Orthodontics

Prep Manual for Undergraduates

THIRD EDITION

Sridhar Premkumar, BDS MDS

Professor, Department of Orthodontics and Dentofacial Orthopaedics
Head, Department of Paediatric and Preventive Dentistry, Tamil Nadu Government Dental
College and Hospital, Chennai, INDIA
Table of Contents

Cover image

Title page

Copyright

Dedication

Preface to the third edition

Preface to the first edition

Acknowledgements
1. Development of a Concept

1. Introduction to orthodontics
Definition and divisions of orthodontics

Need for orthodontic treatment and unfavourable sequelae of malocclusion

Aims, objectives and/or goals of orthodontics

Edward hartley angle

2. Epidemiology of malocclusion
Brief epidemiology of malocclusion

Ideal requirements of malocclusion indices

Various indices used in orthodontics

Index of orthodontic treatment need

Treatment priority index by grainger

2. Growth and Development

3. Concepts of growth and development

Growth and development: Definition and differentiation

Nature of skeletal growth/hyperplasia/hypertrophy/extracellular matrix secretion

Osteogenesis/methods of bone formation

Remodelling

Growth site versus growth centre

Growth movements: Drift versus displacement

Expanding V principle

Pattern of growth

Variability of growth

Safety valve mechanism

Differences between primary and secondary cartilages

Controlling factors in craniofacial growth

Age assessment: Chronological, dental and skeletal age

Role of synchondroses in cranial base growth

Various methods of measuring growth

Craniometry and anthropometry

Vital staining

Implant radiography

Clinical implications of growth and development

Nasal septum

Meckel’s cartilage

4. Theories of growth
Various theories of growth

5. Growth of facial structures

Prenatal growth of maxilla

Prenatal growth of palate

Prenatal growth of mandible

 Postnatal growth of maxilla

Postnatal growth of palate

Postnatal growth of mandible

Condylar growth

Development of tongue

6. Child psychology
Need to study child psychology

Theories of developmental psychology

Correlation of various theories of psychology: Refer table 6.2

Behaviour learning theories

Types of child behaviour

Motivation of a child

Child behaviour management techniques used in orthodontics

Behaviour modification techniques useful in orthodontics

7. Development of occlusion and normal occlusion

Eruption of teeth

Stages of tooth development

Chronology of human dentition

Development of occlusion from birth till 12 years and adolescence

Terminal plane relationship and transition of molar–occlusal relationship from mixed dentition to permanent
dentition

Self-correcting malocclusions/transitional or transient malocclusions

Keys of occlusion

8. Stomatognathics in orthodontics
Stomatognathics: Definition and its various components

Trajectorial theory of bone formation/julius wolff’s law

Trajectories of force/benninghoff’s lines

Buccinator mechanism

Various functions of stomatognathic system

Mastication
 Infantile swallow/retained infantile swallow

Deglutition/adult or mature swallow

Speech and malocclusion

3. Development of Problems

9. Classification of malocclusion
Malocclusion definition

Definition of classification in orthodontics

Methods of recording and measuring malocclusion/various methods of classification of malocclusion

Angle’s classification of malocclusion

Merits and demerits of angle’s classification/validity of angle’s classification

Modifications of angle’s classification

Simon’s classification

Incisor classification/british standard classification of incisor relationship

Ackerman–proffit classification

Quantitative methods of classification of malocclusion

10. Aetiology of malocclusion

Classification of aetiologic factors

Prenatal causes of malocclusion

Role of genetics in malocclusion

Butler’s field theory

Postnatal causes of malocclusion

General causes of malocclusion

4. Diagnosis

11. Case history and clinical examination in orthodontics

Classification of diagnostic aids and various diagnostic methods employed in orthodontics

Importance of case history in orthodontic diagnosis

Clinical evaluation of orthodontic patient

12. Radiographs and related diagnostic aids

 Radiographs used in orthodontics

Role of intraoral radiographs in orthodontics

Panoramic radiography

Facial photograph as a diagnostic tool

Hand–wrist radiographs

Electromyography

Digital radiography

13. Model analysis

Study models/study casts

Classification of model analyses/various methods of model analyses used in orthodontics

Bolton’s analysis/bolton’s ratio

Ashley howe’s analysis

Pont’s index/pont’s analysis

Linderhearth’s analysis

Kesling’s diagnostic set-up

Moyer’s mixed dentition analysis

Tanaka–johnston analysis

Radiographic method of mixed dentition model analysis

Carey’s analysis

14. Cephalometrics
Definition of cephalometrics

Cephalometric radiography

Cephalometric landmarks

Reference planes used in cephalometry

Classification of cephalometric analyses

Steiner’s analysis

Y-axis/growth axis

Tweed’s analysis/tweed’s diagnostic triangle

Wits appraisal/analysis

Ricketts analysis

Mcnamara’s analysis
 Role of cephalometry in orthodontic diagnosis and treatment planning

Visualized treatment objective

5. Biology, Mechanics and Orthodontic Materials

15. Biology of tooth movement

Physiologic tooth movement

Structure of periodontal ligament and its response to physiological force

Theories of tooth movement

Biological tissue reaction to the application of orthodontic force

Stages of tooth movement

Different types of orthodontic force

Orthopaedic force

16. Biomechanics of orthodontic tooth movement

Newton’s laws of motion and its relevance to tooth movement

Terminologies in biomechanics of tooth movement

Types of tooth movement

Definition and classification of anchorage

Sources of anchorage/anchorage sites

Factors affecting anchorage

Anchorage loss

Various types of anchorage with suitable examples

Implant as anchorage units/absolute anchorage/temporary anchorage devices

17. Materials used in orthodontics

Classification of materials used in orthodontics

Wrought alloys/orthodontic metallic materials

Annealing/heat treatment of orthodontic alloys

Archwires used in orthodontics

Desirable properties of orthodontic wires/ideal requirements of orthodontic wire

18–8 stainless steel

Elgiloy wire/cobalt–chromium–nickel wire

 Nitinol wires/superelastic wires/space age wires/shape memory alloys/niti alloy

TMA wires/titanium–molybdenum alloy wire/β-ti wires

Composition and properties of orthodontic wires

Soldering/brazing

Welding in orthodontics

Ceramic brackets in orthodontics

Cements used in orthodontics

Irreversible hydrocolloids/alginate

Orthodontic bonding adhesives

6. Orthodontic Appliances

18. Removable appliances

Definition and classification of orthodontic appliances

Ideal requirements of orthodontic appliances

Advantages and limitations of removable orthodontic appliances

Mechanical principles involved in designing of orthodontic appliances

Components/various parts of removable appliances

Designing of clasps used in orthodontics

Classification of clasps used in orthodontic practice

Free-ended clasps

Continuous clasps

Various active components of removable appliance

Springs used in removable appliance

Canine retractors

Labial bows

Screws

Elastics

Orthodontic pliers

Base plate

Hawley appliance and retainer

Insertion of removable appliance

Failures of removable appliance/unsuccessful removable appliance therapy

 Labial and buccal movements

Lingual movement

Mesiodistal movement

Fabrication of removable appliance

Treatment of various malocclusions by removable mechanical appliances

19. Functional appliances

Definition and classification of functional appliances

History of maxillofacial orthopaedics

Principles of functional appliance therapy

Mechanism of action of functional appliances

Craniofacial response or effects produced by functional appliances

Ideal requirements of functional appliances

Clinical visualized treatment objective

Guidelines for case selection for functional appliances

Advantages and limitations of functional appliances

Bite planes used in orthodontics

Vestibular screens/oral screens

Lip bumper

Activator

Modifications of activator

Bionator

Functional regulators and their types

Indications of functional regulator

Mechanism of action of frankel appliance

Functional regulator (FR) I

Functional regulator III

Clinical management of functional regulators

Differences between activator and functional regulator

Twin block

20. Orthopaedic appliances

Headgears strap/anchorage source
 Reverse-pull headgears or facemask

Chin cup

21. Expansion appliances

Types of expansion

Classification of expansion appliances

Rapid maxillary expansion (RME)/rapid palatal expansion (RPE)

Classification of slow expansion appliances

Removable slow expansion appliances

Fixed slow expansion appliances

Differences between RME and slow expansion

22. Fixed appliances

Various components of fixed appliances

Evolution of various fixed appliance techniques

Bonding techniques in orthodontics

Latex elastics

Management of dental problems during orthodontic treatment

Advantages and limitations of fixed appliances

7. Treatment Planning In Orthodontics

23. General considerations in treatment planning

Treatment planning in orthodontics

Analyses and treatment approach of arch length discrepancy

Principles of growth modification

24. Methods of gaining space

Classification of various methods of gaining space in orthodontics

Proximal slicing

Expansion

Advancement or labial proclination of anterior teeth

Distalization of molars
 Contraindications and complications of molar distalization

Derotation of posterior teeth

Uprighting of tipped tooth

Extractions in orthodontics

8. Early Orthodontic Treatment

25. Preventive orthodontics

Preventive orthodontics: Definition and various preventive orthodontic procedures

Rationale and principles of preventive orthodontics

Non-appliance preventive orthodontic procedures

Classification of space maintainers

Planning for space maintenance and factors for consideration

Ideal requirements, indications and contraindications of space maintainers

Removable space maintainers

Fixed space maintainers

Mouth protectors or guards

26. Interceptive orthodontics

Various interceptive orthodontic procedures

Occlusal grinding/occlusal equilibration

Management of developing anterior crossbite/tongue blade therapy

Incipient malocclusions

Classification of deleterious dentofacial habits

Thumb sucking

Tongue thrusting

Management of lip biting and lip sucking

Bruxism

Mouth breathing and its management

Space regainers/active space maintainers

Serial extraction/guidance of eruption

9. Surgical Considerations in Orthodontics

27. Surgical orthodontics
Various surgical orthodontic procedures

Minor oral surgical procedures in relation to orthodontics

Surgical exposure of impacted canine

Pericision

Corticotomy

Transpositioning of teeth/autotranspositioning/surgical repositioning of teeth

Dentofacial deformities and their management by orthognathic surgery

Diagnosis and treatment planning in surgical orthodontics

Presurgical and postsurgical orthodontics

Model surgery

Surgical procedures for mandibular prognathism and maxillary retrusion/skeletal class III correction

Surgical correction of receding chin/deficient chin

Surgical correction of class II malocclusion

Surgical procedures for vertical malocclusion

Timing of orthognathic surgery

Therapeutic aids in surgical care

28. Cleft lip and palate

Classification of cleft lip and palate

Aetiology, pathogenesis, clinical features and dental management of cleft lip and palate

Orthodontic management of cleft palate

10. Corrective Orthodontics

29. Management of intra-arch problems

Aetiology, clinical features and management of class I malocclusion with crowding

Aetiology and management of class I malocclusion with spacing

Median diastema

30. Management of transverse malocclusions

Definition and types of crossbites

Aetiology, differential diagnosis and management of anterior crossbite

 Aetiology, differential diagnosis and management of posterior crossbite

31. Management of vertical malocclusions

Aetiology, clinical features and management of deep bite

Aetiology, clinical features and management of open bite

32. Management of sagittal malocclusions

Aetiology, clinical features, and diagnostic features of class II division 1 malocclusion

Management of class II division 1 in a growing child (mixed dentition period)

Management of class II division 1 malocclusion in an adult

Incisor edge–centroid relationship/edge–centroid relationship

Class II division 2 malocclusion

Class III malocclusion

Differences between true class III and pseudo-class III

Bimaxillary protrusion

33. Management of problems in adult patients

Adult orthodontics

11. Miscellaneous

34. Retention, relapse and complications

Definition of retention and relapse

Causes for relapse in orthodontics/need for retention after orthodontic treatment

Various schools of thought pertaining to retention in orthodontics

Theorems on retention

Classification and planning of retention in orthodontics

Mechanical aids to retention/retention appliances/retainers

Adjunctive procedures to aid retention and to prevent relapse

Retention with regards to different types of malocclusion

Active retention

35. Digital orthodontics

Digital orthodontics
 Digital panoramic images

Digital cephalometrics

Digital study models

Digital photography

Index
Copyright

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Orthodontics: Prep Manual for Undergraduates, 3e, Sridhar Premkumar
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Dedication

This book is dedicated to the loving memory of my teacher, mentor, guide, friend and
philosopher
Dr. M R Balasubramaniam
Preface to the third edition
Sridhar Premkumar

When the first edition was released, the magnanimous response from the students was
highly motivating to me. It all started with the thought of bridging the gap between
latitudinous concepts and data in orthodontics’ reference books and the practical
difficulties of nascent dentists in comprehending and reflecting in evaluation exams. I
am glad this manual had struck the right chord with the students and had become the
first choice for students in India who appear for theory exams, viva voce and post-
graduate entrance examination preparations.
This red carpet welcome from the readers and forthright interest by the publisher had
resulted in this latest edition with more vibrant presentation. This edition is not just a
face-lift for previous editions, but the entire manual had undergone willing adaptation
based on the international learning strategies. This book manual, from this edition, will
also be known to meet the demands of different styles of learning popular among
students.
The transmission of knowledge had been refreshed and made seamless even without
question and answer format. Apart from enhanced understanding, the point style
format encourages active learning to retain information. The “Advanced Learning” portion
at the end of each chapter favours exploration for independent learning. The simplified
coloured illustrations, flowcharts are imperative for visual learning. The tables, figures
and numerical data used here solely conforms to the international reference books for
analytical learning. The “Accessory Points” given in every chapter can be concretely
depended for factual learning.
I hope this edition too helps students like previous editions and continues to be a
reliable supplementary learning material. Any feedback and suggestion could be
reached to me without hesitation and I always look forward to hear from you.
dr.premsridhar@gmail.com
Preface to the first edition
Sridhar Premkumar

This book is the result of my close interaction with the students. It is written with the
needs of students in mind and their expectations from a book for the purpose of
excelling in the exams. Though written in a question and answer format, this book is
arranged in a logical sequence as in a regular textbook. For the benefit of students,
numerous flowcharts and tables have been provided. Diagrams that are required to be
reproduced by students in exams are included. Important points which will be useful to
write MCQs and face viva-voce are provided in Accessory Points at the end of each
chapter. The book is planned in a meticulous manner for use in dental curriculum so
that the students do not have to refer too many books.
I take this opportunity to remember my postgraduate teacher, Dr S Rangachari who
was instrumental in laying the foundation of my knowledge in the field of orthodontics.
I am also thankful to Dr MR Balasubramanian for imparting clinical knowledge to me,
and Dr KSGA Nasser, Principal, Tamil Nadu Government Dental College and Hospital,
for his constant encouragement.
It is my duty to acknowledge the people who have helped me in bringing out this
book. I would like to thank Dr Asish, MDS for all the help he has provided and Dr VP
Nandhini for her committed and whole hearted support throughout the making of this
book. Dr Mona Mouneswari needs special mention for doing all the artwork in a very
fast and meticulous manner. I also express my sincere thanks to all the people who have
reviewed areas of the manuscript, and finally to all my students who have initiated and
helped me to start and complete this project.
The present book does not aim to replace a textbook, but it can supplement a good
textbook. Students are advised to read the recommended textbook. This book would not
have been possible without reference to major textbooks published, a list of whose are
provided at the end of the book under References.
Students, if any doubt or suggestions can contact me through my e-mail ID:
dr.premsridhar@yahoo.co.in.
Acknowledgements
I owe my hearty thanks to students, friends and colleagues who were instrumental to
the success and steady support for the previous editions of this book.
A special thanks to Dr Poornachitra for her assistance rendered throughout in the
completion of this endeavour.
I thank Nimisha Goswami, Anand Kumar Jha, and the dedicated production and
editorial team at Elsevier for their expertise guidance till the very end.
I acknowledge my Post-graduate teacher Dr S Rangachari for instilling in me the
confidence to pursue a project of this scope, through all the three editions.
Individuals Dr Vinodhini, Dr Tamilselvi and Dr Varun Peter needs to be mentioned
for their inputs and scrupulous proof-reading.
Following the tradition of authors to offer thanks to those who have put up with
neglect, my enduring gratitude and respect to my wife Dr Praveena and to my children
Sriram and Srinidhi.
SECTION I
Development of a Concept
OUTLINE

1. Introduction to orthodontics

2. Epidemiology of malocclusion
CHAPTER 1
Introduction to orthodontics

CHAPTER OUTLINE
❖ Definition and divisions of orthodontics
❖ Need for orthodontic treatment and unfavourable sequelae of malocclusion
❖ Aims, objectives and/or goals of orthodontics
❖ Edward Hartley (EH) Angle
❖ Accessory points
❖ Advanced learning
❖ History of orthodontics
Definition and divisions of orthodontics
In 1922, British Society of Orthodontics defined Orthodontics as, ‘Orthodontics includes
the study of growth and development of the jaws and face particularly, and the body generally, as
influencing the position of the teeth; the study of action and reaction of internal and external
influences on the development, and the prevention and correction of arrested and perverted
development’.

Divisions of orthodontics
Preventive orthodontics defined by Graber is ‘the action taken to preserve the integrity
of what appears to be the normal occlusion at a specific time’.

Interceptive orthodontics is ‘that phase of the science and art of orthodontics employed
to recognize and eliminate potential irregularities and malpositions in the developing
dentofacial complex’ (Graber).

Corrective orthodontics ‘recognizes the existence of a malocclusion and the need for
employing certain technical procedures to reduce or eliminate the problem and the
attendant sequelae’ (Graber).

Surgical orthodontics, as the name denotes, includes the surgical procedures that are
carried out before, during or after active orthodontic treatment.
Need for orthodontic treatment and unfavourable
sequelae of malocclusion
The following are the problems or sequelae of malocclusion:

1. Psychological and social problems

a. Introversion, self-consciousness

b. Response to nicknames like ‘Bugs Bunny’ and ‘Buckteeth’

2. Poor appearance

3. Interference with normal growth and development

a. Crossbites causing asymmetry

b. Overbite and overjet influences

4. Improper or abnormal muscle function

a. Compensatory muscle activities like hyperactive mentalis,

hypoactive upper lip, increased buccinator pressures and
tongue thrust

b. Associated muscle habits like lip biting, nail biting, finger

sucking and bruxism
5. Abnormal deglutition

6. Mouth breathing

7. Improper mastication

8. Speech defects

9. Increased caries activity

10. Predilection to periodontal disease

11. Temporomandibular problems

12. Malocclusion and predilection to trauma

13. Impacted and unerupted teeth leading to cysts and damage to other teeth

14. Prosthetic rehabilitation problems

1. Psychological and social problems

• Irregular and protruding teeth have a negative impact in a

patient’s psychology

• Children with malocclusion become introvert

• Their social behaviour is immature

2. Poor appearance

• Poor appearance due to malocclusion affects a child’s

performance in school as well as in play.

• Treatment should be initiated. Preventive or interceptive

measures should be attempted.
3. Interference with growth and development

• Abnormal finger-sucking habit, a perverted perioral muscle

activity, could cause morphological and functional changes
to the dentition.

• Common effect of abnormal perioral muscle activity is

posterior crossbites.

• Many a time functional aberrations will lead to unilateral

crossbite which, in turn, will cause facial asymmetry.
• Increased deep bite and abnormal lip posture will cause
flattening of mandibular anteriors.

• Anterior occlusal interferences will cause pseudo class III.

• Abnormal tongue posture or mouth breathing will cause

supraeruption of the posterior teeth, thereby increasing the
facial height.
4. Abnormal muscle function

• Abnormal muscle activity could contribute to malocclusion

or sometimes a resultant of malocclusion.

• In the case of lip trap, cushioning of lower lip behind the

proclined upper incisors will aggravate the proclination.
Correction of proclination will correct or eliminate lip trap.
5. Improper deglutition

• In abnormal swallowing, muscles of facial expression are

involved.
6. Mouth breathing

• In many cases, reduction of increased overjet activates upper

lip, makes lip closure possible to establish anterior oral seal
and stimulates nasal breathing.
7. Improper mastication

• Malaligned teeth initiate a different pattern of chewing.

Different patterns of chewing can lead to
temporomandibular joint (TMJ) and periodontal problems.
8. Speech defects

• Malocclusion affects the speech pattern of individuals.

• Effects of cleft lip: Speech problem in cleft patients are due to

velopharyngeal incompetence, naso-oral communication,
abnormal tongue posture and function and lip tissue
inadequacy.
9. Increased susceptibility to caries and periodontal diseases

• Irregular teeth make self-cleansing of oral cavity less

effective.

• This leads to increased susceptibility to caries and

periodontal diseases.

• Loss of tight contacts and abnormal axial inclinations could

lead to uneven distribution of functional stresses. This also
leads to periodontal problems.
10. Predilection to periodontal disease: The systematic review on the effects of a
malocclusion on periodontal health suggests that subjects with a malocclusion have
worse periodontal health than subjects without a malocclusion.

11. Temporomandibular joint disorders

• Malocclusion causes TMJ problems like clicking, pain and

crepitus.
12. Malocclusion and trauma

• One of the most common problems seen in class II division 1

malocclusion is trauma to maxillary anterior teeth.
13. Impacted and unerupted tooth
• Interferes with eruption of the successor or neighbouring
tooth.

• Causes resorption of the roots of the adjacent tooth.

• Creates possibility of development of cysts due to

impacted/unerupted tooth.
14. Prosthetic rehabilitation problems

• Supraeruption of the tooth into opposing edentulous area

and tipping of teeth into adjacent edentulous area cause
space problems for prosthetic rehabilitation.

• Stress distribution in a tipped tooth when taken as an

abutment is not even.
Aims, objectives and/or goals of orthodontics
Orthodontics seeks:

1. To intercept departures from normal development of the masticatory apparatus.

2. To restore conditions to normal development at the earliest when required.

3. To establish as good an occlusion as possible both in functional and aesthetic sense.

In order to achieve the results, use of appliances should be minimal with best possible
outcomes.
The goal of modern orthodontics is to create the best possible occlusal relationship
within the framework of acceptable facial aesthetics and stability of the occlusion.

Jackson’s triad
Jackson has briefly summarized the objectives of orthodontics treatment into three
headings:

1. Establishing functional efficiency: Correction of malocclusion will eliminate all the

unfavourable sequelae of malocclusion. Thus, the functional efficiency of the
masticatory apparatus is restored.

2. Restoring structural balance: A balance between the hard and soft tissues should be
achieved. Failure to achieve structural balance will lead to relapse or loss of correction
achieved. Achieving structural balance maintains stability of the correction.

3. Aesthetic harmony: The single most common reason for the patients to approach an
orthodontist is to improve the facial appearance. Therefore, improvement of the facial
aesthetics is also a prime objective of orthodontic treatment.

All the three objectives put together constitute Jackson’s triad (Fig. 1.1).

FIG. 1.1. Jackson’s triad.

Changing goals in orthodontics

Angle introduced the hard tissue or Angle paradigm, in which the primary goal of
orthodontics is to establish an ideal dental occlusion, followed by jaw relationship as the
secondary goal. Angle was of the opinion that establishing proper dental occlusion
produces an ideal soft tissue, and he was against the extraction concept.
But the ability of the soft tissues to adapt to changes in tooth–jaw relationships is far
narrower than the anatomic limits in correcting occlusal relationships. The physiologic
limits of orthodontic treatment (i.e. the ability of the soft tissues to adapt to changes in
tooth and jaw positions) are far narrower than the anatomic limits of treatment. Thus, in
many ways, analysis of soft tissue effects is the critical step in orthodontic decision-
making. Hence, the concept of soft tissue paradigm as the main goal of orthodontics,
which includes placing jaws and teeth in a functional occlusion within the framework of
ideal soft tissue proportions and adaptation, has become an important factor now.
Thus, there is paradigm shift in giving importance from skeletal and dental
relationships to oral and facial soft tissues.
Edward hartley angle
➤ Edward Hartley (EH) Angle was the person who was responsible in organizing and
systemizing orthodontics.

➤ It was Angle who brought the oldest specialty of dentistry, orthodontics to the
limelight.

History
➤ EH Angle was born on 1st June 1855 in Herrick, Pennsylvania.

➤ He graduated from Pennsylvania College of Dentistry in the year 1878.

➤ Angle’s initial interest was in prosthetics, but later he completely switched to

orthodontics.

➤ In the year 1887, he presented his first scientific paper before the Ninth International
Medical Congress.

➤ In 1892, he became professor of orthodontics at North Western University School of

Dentistry.

➤ He moved to St. Louis in 1895.

➤ In 1900, Angle started his first school of orthodontics in St. Louis.

➤ Under the leadership of Angle, the American Society of Orthodontics was

commenced in the year 1901.

➤ Angle passed away on 11 August 1930.

Contributions of angle to orthodontics

1. Publication of book on orthodontics in 1887.

2. In the same year, he introduced the hypothesis – ‘Key of Occlusion’. Angle

considered the maxillary first molar as the key of occlusion.

3. He introduced ‘Line of Occlusion’ for maxillary and mandibular arches.

4. Combining key of occlusion and line of occlusion, he published the classification of

malocclusion. Angle’s classification (1887) has four classes:
• Normal occlusion

• Class I malocclusion

• Class II malocclusion

• Class III malocclusion

5. Angle’s concept of ‘Occlusion in Orthodontics’ came into light in the year 1890.

6. Appliances developed:

• Angle’s E arch

• Pin and tube appliance

• Ribbon arch appliance

• Edgewise appliance
Owing to his many contributions and inventions in the field of orthodontics, Angle is
aptly called the father of modern orthodontics.
ACCESSORY POINTS
Noyes first defined orthodontics in 1911
The word ‘Orthodontia’ was coined by Le-Foulan, a French man, in 1839
The term ‘Orthodontics’ was coined by Sir James Murray
Pierre Fauchard is known as the father of modern dentistry
Norman Kingsley is known as the father of orthodontics and the first person to use
extraoral force
EH Angle is known as the father of modern orthodontics
Orthodontics is the oldest speciality in dentistry
The first recorded appliance is bandelette by Pierre Fauchard
Jackson’s triad refers to aesthetic harmony, functional efficiency and structural balance
The term ‘malocclusion’ was coined by Guilford
The first recorded method of orthodontic treatment was that of Celsus, by using
finger pressure
Appearance of teeth is the fourth most common target of teasing after height, weight
and hair among children
Advanced Learning
History of orthodontics
Orthodontics as a speciality dates back to the turn of the twentieth century. Many
researchers have made significant contributions to the development of the science and
art of orthodontics. Yearwise historical developments in orthodontics are depicted in
Table 1.1.

Table 1.1.
Yearwise historical developments in orthodontics

Year Name Contribution to orthodontics

1000 BC Greek and Etruscan Skulls Primitive appliances
460–377 BC Hippocrates Writings on crooked teeth
384–322 BC Aristotle Writings on crooked teeth
25 BC Celsus Tooth movement by finger pressure
AD 625–690 Paul of Aegina Mentioned supernumerary tooth as the cause of irregularity and advised extraction of supernumerary tooth
1728 Pierre Fauchard Bandelette appliance, which was similar to expansion arch
1728–1793 John Hunter Vital staining and growth studies
1743 Bunon Used the term orthopaedics for correction of malocclusion
1756 Philip Pfaff Used plaster of Paris for impression
1803 Joseph Fox Wrote the first English textbook on malocclusion correction
1819 Delabarre Condemned deciduous tooth extraction
1825 Joseph Sigmond Recognized habit as a cause for malocclusion
1836 Kneisel Attempted the first classification of malocclusion
1839 Lefoulon Coined the word ‘orthodontia’
1879 Norman Kingsley Introduced bite plate
First to use extraoral force, cleft palate treatment
1887 Angle Presented classification of malocclusion
1888 John Nutting Faraar Textbook on orthodontia
1893 Henry Baker Use of intermaxillary elastics
1823–1903 Emerson C Angel Forerunner of rapid maxillary expansion
1900 Angle Started the first school of orthodontics
1847–1923 Calvin S Case Proposed extraction therapy in orthodontics
1910 Vigo Andresen Activator
1922 Angle Edgewise appliance
1931 Holly Broadbent and Hoffrath Cephalometric radiology
1950 Raymond Begg Begg’s appliance
Differential force
1969–1973 Rolf Frankel Frankel’s appliance
1972 Lawrence Andrews Straight wire appliances and keys of occlusion
CHAPTER 2
Epidemiology of malocclusion

CHAPTER OUTLINE
❖ Brief epidemiology of malocclusion
❖ Ideal requirements of malocclusion indices
❖ Various indices used in orthodontics
❖ Index of Orthodontic Treatment Need (IOTN)
❖ Treatment Priority Index by Grainger
❖ Accessory points
❖ Advanced learning
❖ Peer Assessment Rating (PAR) Index
Brief epidemiology of malocclusion
Definitions
Epidemiology: It is a branch of medical science that deals with the incidence,
distribution and control of disease in a population.

Incidence: This denotes the number of new cases in a particular period of time.

Prevalence: The percentage of a population that is affected with a particular disease at a

given time.

Epidemic: It occurs when an infectious disease affects or tends to affect a

disproportionately large number of individuals within a population, community or
region at the same time.

Introduction
➤ Dental caries has been regarded as the major dental disease throughout the world;
malocclusion is a close runner-up.

➤ Various studies have been conducted to make an epidemiologic registration of

malocclusion.

➤ The most prevalent type of malocclusion in the deciduous dentition is anterior open
bite, tied in with tongue thrust and finger habits, and class II division 1 (mandibular
retrusion) is the next.

➤ In mixed dentitions, crowding is most common, with mandibular retrusion being the
second most common.

➤ The single most common type of malocclusion prevalent in permanent dentition is

crowding.

➤ In permanent dentitions, class II division 1 and crowding are equally distributed.

➤ The characteristics of malocclusion are evaluated using various malocclusion indices.

The percentage of population with excellent alignment decreases as age advances. Only
34% of adults have well-aligned lower incisors.

Midline diastema is often present in childhood (26%), but it decreases to 6% in youth

and adults.
Angle’s class II malocclusion occurs in 23% of children, 15% of youths and 13% of
adults.

Reverse overjet or class III malocclusion affects 1% of children and increases to about
4% in adults.

Severe deep bite (>5 mm) occurs in nearly 20% of children and 13% of adults, while
open bite occurs in 2% of adults.
Ideal requirements of malocclusion indices
➤ Assessment of occlusal status for orthodontic purposes may be undertaken by
subjective assessment or by means of an index of occlusion.

➤ In the orthodontic context, an index is used to describe a rating or categorizing

system that assigns a numeric score or alphanumeric label to a person’s occlusion.

➤ Occlusal indices are used in connection with public health orthodontic programmes
in some countries.

➤ Malocclusion indices have been used to categorize disorders for the purpose of
epidemiology and research in order to allocate patients into categories of treatment
need and to compare the treatment success. It does not provide any information
concerning the prevalence of a given manifestation of malocclusion.

Types of indices
There are five types of indices based on the purpose they are used:

1. Diagnostic index: It is used for the purpose of communication between orthodontists.

An example of this is Angle’s classification.

2. Epidemiologic indices: These indices record every trait in a malocclusion to allow

estimation of the prevalence of malocclusion in a given population, e.g. Summers’
Occlusal Index.

3. Treatment need (treatment priority) indices: According to the level of treatment need,
several indices have been developed to allow the categorization of malocclusion. An
example of this is Grainger’s Treatment Priority Index (TPI).

4. Treatment outcome indices: Assessment of the outcome of treatment or the changes

resulting from treatment is a further potential use of occlusal indices. The Peer
Assessment Rating (PAR) Index is specifically for this purpose.

5. Treatment complexity index: At present, no index has been developed to specifically

measure the treatment complexity.

Ideal requirements of malocclusion index

They are enumerated in Box 2.1.
Box 2.1.
Ideal requirements of an index of occlusion
1. Status of the group is expressed by a single number, which corresponds to a relative
position on a finite scale with definite upper and lower limits; running by progressive
gradation from zero.

2. The index should be equally sensitive throughout the scale.

3. Index value should correspond closely with the clinical importance of the disease
stage it represents.

4. Index value should be amendable to statistical analysis.

5. It should be reproducible.

6. Requisite equipment and instruments should be practicable in actual field situation.

7. Examination procedure should require a minimum of judgement.

8. The index should be facile enough to permit the study of a large population without
undue cost in time or energy.

9. The index would permit the prompt detection of a shift in group conditions, for better
or for worst.

10. The index should be valid during time.

Various indices used in orthodontics
The summary of various indices used in orthodontics is enumerated in Table 2.1. The
other indices are explained in subsequent sections.

Table 2.1.
Summary of important indices used in orthodontics

Massler and Frankel Index (1951) Count the number of teeth displaced or rotated.
Malalignment Index by Vankirk Tooth displacement and rotation are measured.
and Pennell (1959)
Handicapping Labiolingual
Deviations Index by Draker
(1960)
Occlusal Feature Index by
Poulton and Aaronson (1961)
Malocclusion Severity Estimate
by Grainger (1960–1961)
Occlusal Index by Summers
(1966)
Handicapping Malocclusion
Assessment Record by Salzmann
(1968)
Assessment of tooth displacement and rotation is qualitative – all or none.
Tooth displacement defined quantitatively <1.5 mm or >1.5 mm.
Tooth rotation defined quantitatively <45° or >45°.
Measurements include cleft palate (all or none), traumatic deviations (all or none), overjet (mm), overbite (mm), mandibular
protrusion (mm), anterior open bite (mm) and labiolingual spread (a measurement of tooth displacement in mm).
Measurements include lower anterior crowding cuspal interdigitation, vertical overbite and horizontal overjet. Occlusion
features measured and scored according to defined criteria.
Seven weighted and defined measurements: (1) overjet, (2) overbite, (3) anterior open bite, (4) congenitally missing
maxillary incisors, (5) first permanent molar relationship, (6) posterior crossbite and (7) tooth displacement (actual and
potential).
Six malocclusion syndromes were defined:
1. Positive overjet and anterior open bite
2. Positive overjet, positive overbite, distal molar relationship and posterior crossbite with maxillary teeth buccal to
mandibular teeth
3. Negative overjet, mesial molar relationship and posterior crossbite with maxillary teeth lingual to mandibular teeth
4. Congenitally missing maxillary incisors
5. Tooth displacement
6. Potential tooth displacement
Nine weighted and defined measurements: (1) molar relation, (2) overbite, (3) overjet, (4) posterior crossbite, (5) posterior
open bite, (6) tooth displacement, (7) midline relation, (8) maxillary median diastema, (9) congenitally missing maxillary
incisors
Seven malocclusion syndromes were defined:
1. Overjet and open bite
2. Distal molar relation, overjet, overbite, posterior crossbite, midline diastema and midline deviation
3. Congenitally missing maxillary incisors
4. Tooth displacement (actual and potential)
5. Posterior open bite
6. Mesial molar relation, overjet, overbite, posterior crossbite, midline diastema and midline deviation
7. Mesial molar relation, mixed dentition analysis (potential tooth displacement) and tooth displacement
Different scoring schemes and forms for different stages of dental development, deciduous dentition, mixed dentition and
permanent dentition.
Weighted measurements consist of three parts:
1. Intra-arch deviation – missing teeth, crowding, rotation, spacing
2. Inter-arch deviation – overjet, overbite, crossbite, open bite, mesiodistal deviation
3. Six handicapping dentofacial deformities: (1) facial and oral clefts, (2) lower lip palatal to maxillary incisors, (3) occlusal
interference, (4) functional jaw limitation, (5) facial asymmetry and (6) speech impairment
This part can only be clinically assessed on patients.
Index of orthodontic treatment need
➤ In the United Kingdom, the Index of Orthodontic Treatment Need (IOTN) was
developed by Brook and Shaw in 1991.

➤ It was developed in an attempt to rank malocclusion based on the significance of

various occlusal traits for dental health and aesthetic impairment, with the intention
of identifying those who would be most likely to benefit from orthodontic treatment.

The index incorporated two components:

➤ Dental health component derived from occlusion and alignment.

• The dental health component is explained in Box 2.2.

Box 2.2.
Dental health component of IOTN
Grade 1: No treatment is required. Extremely minor malocclusions, including
displacements <1 mm.
Grade 2: Little

(a) Increased overjet >3.5 mm but ≤6 mm (with competent lips)

(b) Reverse overjet >0 mm but ≤1 mm

(c) Anterior or posterior crossbite with ≤1 mm discrepancy between retruded contact

position and intercuspal position

(d) Displacement of teeth >1 mm but ≤2 mm

(e) Anterior or posterior open bite >1 mm but ≤2 mm

(f) Increased overbite ≤3.5 mm (without gingival contact)

(g) Pre-normal or post-normal occlusions with no other anomalies. Includes up to half a

unit discrepancy

Grade 3: Borderline need

(a) Increased overjet >3.5 mm but ≤6 mm (incompetent lips)

(b) Reverse overjet >1 mm but ≤3.5 mm

(c) Anterior or posterior crossbites with >1 mm but ≤2 mm discrepancy between the
retruded contact position and intercuspal position

(d) Displacement of teeth >2 mm but ≤4 mm

(e) Lateral or anterior open bite >2 mm but ≤4 mm

(f) Increased and incomplete overbite without gingival or palatal trauma

Grade 4: Treatment required

(a) Increased overjet >6 mm but ≤9 mm

(b) Reverse overjet >3.5 mm with no masticatory or speech difficulties

(c) Anterior or posterior crossbites with >2 mm discrepancy between the retruded
contact position and intercuspal position

(d) Severe displacements of teeth >4 mm

(e) Extreme lateral or anterior open bites >4 mm

(f) Increased and complete overbite with gingival or palatal trauma

(g) Less extensive hypodontia requiring pre-restorative orthodontics or orthodontic

space closure to obviate the need for a prosthesis

(h) Posterior lingual crossbite with no functional occlusal contact in one or more buccal
segments

(i) Reverse overjet >1 mm but ≤3.5 mm with recorded masticatory and speech
difficulties

(j) Partially erupted teeth, tipped and impacted against adjacent teeth

(k) Existing supernumerary teeth

Grade 5: Treatment required

(a) Increased overjet >9 mm

(b) Extensive hypodontia with restorative implications (more than one tooth missing in
any quadrant requiring pre-restorative orthodontics)

(c) Impeded eruption of teeth (apart from third molars) due to crowding, displacement,
presence of supernumerary teeth, retained deciduous teeth and any pathological
cause
(d) Reverse overjet >3.5 mm with reported masticatory and speech difficulties

(e) Defects of cleft lip and palate

(f) Submerged deciduous teeth

Aesthetic component of IOTN

Aesthetic component derived from comparison of the dental appearance to standard
photographs.

The aesthetic component was developed from a standardized continuum of aesthetic

need and comprises a scale of 10 anterior intraoral photographs showing different
levels of dental attractiveness.

➤ The score is derived from a patient’s answer to ‘Here is a set of photographs showing
a range of dental attractiveness. No. 1 is most and no. 10 is least attractive (Figure 2.1).
Where would you put your teeth on the scale?’

Photographs 1–4 represent no need for treatment.

Photographs 5–7 represent borderline need for treatment.

Photographs 8–10 represent need for treatment.

 FIG. 2.1. Aesthetic component of IOTN; score is derived from patient’s answer about
attractiveness after showing the photographs. Grade 1 most aesthetic arrangement of the
dentition; Grade 10 least aesthetic arrangement of the dentition. Grade 1–4, little or no
treatment required; Grade 5–7, borderline or moderate treatment required; Grade 8–10,
treatment required.

Advantages of IOTN
➤ Facial appearance and psychosocial considerations are used in addition to dental
characteristic when parents’ judge treatment need or dentists decide to recommend
treatment.

➤ IOTN grades seem to reflect clinical judgements better than earlier methods.

➤ Although IOTN was developed for treatment prioritization, before and after
treatment scores may be compared as a somewhat crude assessment of outcome.

Disadvantage of IOTN
One shortcoming of the aesthetic scale is the poor stability.
Treatment priority index by grainger
TPI was introduced by Grainger in the year 1967. It is a method for evaluating the
severity of the malocclusion.

➤ Patients are rated or ranked according to the severity of malocclusion.

➤ Measurements are made clinically or from study casts.

➤ TPI is a valid epidemiologic indicator of malocclusion (Table 2.2).

Table 2.2.
TPI scores

Score Criteria
0 Near ideal occlusion
1–3 Mild malocclusion
4–6 Moderate malocclusion
>6 Severe or very severe

Prerequisites for determining orthodontic handicap:

1. Unacceptable facial aesthetics

2. Drastic reduction in masticatory function

3. Speech problems

4. Unstable occlusion

5. Occlusal trauma predisposing to tissue damage

6. Gross defects

Criteria taken for measurement of malocclusion:

1. Upper anterior segment overjet

2. Lower anterior segment overjet

3. Overbite of upper anterior over lower anterior

4. Anterior open bite

5. Congenital absence of incisor

6. Distal molar relation

7. Mesial molar relation

8. Posterior crossbite (maxillary teeth buccal to normal)

9. Posterior crossbite (maxillary teeth lingual to normal)

10. Tooth displacement

11. Gross anomalies

Grainger defined seven malocclusion syndromes:

1. Maxillary expansion syndrome

2. Overbite

3. Retrognathism

4. Open bite

5. Prognathism

6. Maxillary collapse syndrome

7. Congenitally missing incisor

Disadvantages
1. Inadequate for assessing deciduous dentition occlusion.

2. Inadequate for assessing mixed dentition occlusion.

3. TPI has not included mixed dentition analyses.

4. TPI values recorded in the transitional dentition do not predict the future severity of
malocclusion.

5. TPI records only occlusal features.

ACCESSORY POINTS
➤ ICON stands for Index of Complexity, Outcome and Need

➤ Class I malocclusion is the largest single group of malocclusion

➤ Crowding is the single most common type of malocclusion

➤ Patients with overjet greater than 7 mm are more likely to be teased about their facial
appearance

Advanced Learning
Peer assessment rating (PAR) index
➤ The PAR Index, introduced in the year 1992, is a British occlusal index that measures
the severity of dental malocclusion and has been used in several investigations that
have evaluated the effectiveness of orthodontic treatment provision in Europe.

➤ The PAR Index was validated for malocclusion severity, by using the opinions of a
panel of 74 dentists and orthodontists.

➤ This is a measure of occlusal change that allocates scores to (1) alignment of the
dentition (including impactions), (2) buccal segment relationship, (3) overjet, (4)
overbite and (5) midline discrepancy.

➤ It is applied to pretreatment and post-treatment dental casts, and the change in PAR
scores thus reflects the treatment effect on the dental occlusion and alignment.

➤ A scoring system was developed and a ruler was designed to allow the analysis of a
set of study casts in approximately 2 min.

➤ Individual scores for the components of alignment and occlusion are finally summed
to calculate an overall score. Thus, a score of zero would indicate perfect alignment
and occlusion, and higher scores (rarely beyond 50) indicate increasing levels of
irregularity.

The index is applied to both the start and the end of treatment study casts, and the
change in the total score reflects the success of treatment in achieving overall alignment
and occlusion.
SECTION II
Growth and Development
OUTLINE

3. Concepts of growth and development

4. Theories of growth

5. Growth of facial structures

6. Child psychology

7. Development of occlusion and normal occlusion

8. Stomatognathics in orthodontics
CHAPTER 3
Concepts of growth and development

CHAPTER OUTLINE
❖ Growth and development: definition and differentiation
❖ Nature of skeletal growth/hyperplasia/hypertrophy/extracellular matrix secretion
❖ Osteogenesis
❖ Endochondral ossification
❖ Membranous ossification
❖ Remodelling
❖ Growth site versus growth centre
❖ Growth movements: drift versus displacement
❖ Expanding V principle
❖ Pattern of growth
❖ Cephalocaudal growth
❖ Scammon’s growth
❖ Variability of growth
❖ Wetzel’s grid
❖ Differential growth
❖ Growth spurts
❖ Safety valve mechanism
❖ Differences between primary and secondary cartilages
❖ Controlling factors in craniofacial growth
❖ Age assessment: chronological, dental and skeletal age
❖ Chronological age
❖ Dental age
❖ Skeletal age/skeletal maturity indicators
❖ Role of synchondroses in cranial base growth
❖ Various methods of measuring growth
❖ Craniometry and anthropometry
❖ Vital staining
❖ Implant radiography
❖ Clinical implications of growth and development
❖ Nasal septum
❖ Meckel’s cartilage
❖ Accessory points
❖ Advanced learning
❖ Puberty/adolescence
❖ Growth rotations of mandible
Growth and development: Definition and
differentiation
Definition
Growth: Craniofacial growth is a complex and beautiful phenomenon. Growth has been
described in so many terms:

➤ Todd defines growth as ‘increase in size’.

➤ Krogman: Increase in size and change in spatial proportion over time.

➤ Huxley: Self-multiplication of the living tissues.

➤ Moss defines growth as any change in morphology which is within measurable

parameter.

➤ Meredith defines growth as the entire series of anatomic and physiologic changes
taking place between the beginning of prenatal life and the close of senility.

➤ Moyer defines growth as the biologic process by which living matter gets larger.

Development: In simple words, ‘progression towards maturity’.

➤ The definition given by Melvin Moss is ‘development can be considered as a

continuum of causally related events from the fertilization of ovum onwards’.

Differences between growth and development

➤ The basic difference between growth and development is that growth can be
considered an ‘anatomic phenomenon’ whereas development is a physiological and
behavioural phenomenon.

Growth
Growth is quantitative, i.e. it is a measurable aspect of biologic life. The units of growth
are inches per year or grams per day.

➤ Characteristically, growth is equated with enlargement. But sometimes there are

instances in which there is decrease in size during growth, e.g. thymus gland after
puberty.

➤ Growth highlights the normal dimensional changes over a period of time.

➤ Growth might cause change in form or proportion, increase or decrease in size and
change in texture or complexity.

➤ In simple words, growth is change or difference in quantity.

Development
➤ Includes all the changes in life of a subject from his/her origin as a single cell till
death.

➤ Comprises sequential events from fertilization till death.

➤ Development: Growth + differentiation + translocation, where differentiation means

change in quality and translocation means change in position.

Differences in growth and development are depicted in Table 3.1.

Table 3.1.
Growth versus development: differentiating features

S.
Growth Development
no.
1. Todd defines growth as ‘increase in size’ Development is defined as ‘progression towards maturity’
2. It is an anatomic phenomenon It is a physiological and behavioural phenomenon
3. It is quantitative and the units of growth are inches per year or grams per day It includes growth + differentiation + translocation
4. Growth highlights the normal dimensional changes over a period of time It comprises sequential events from fertilization till death
5. Growth might cause change in form or proportion, increase or decrease in size, It includes all the changes in life of a subject from his/her origin as
change in texture and complexity a single cell till death
Nature of skeletal
growth/hyperplasia/hypertrophy/extracellular
matrix secretion
There are three basic mechanisms by which growth takes place at the cellular/tissue
level:

1. Hyperplasia: Growth due to increase in the number of cells.

2. Hypertrophy: Growth due to increase in the size of cells.

3. Extracellular matrix secretion: In this process, there is an increase in size because of the
secretions of the cells into the extracellular matrix. The secretions contribute to increase
in size.

• In soft tissues, growth takes place by both hyperplasia and

hypertrophy. These growth changes are carried out in all the
nook and corner of the tissues. The resultant growth is
called interstitial growth. By interstitial growth, it is meant
that there is growth at all the points within the tissue.

• Growth in soft tissue is primarily by hyperplasia,

hypertrophy and the resultant interstitial growth.

• Growth by extracellular matrix secretion is secondary.

• Uncalcified cartilage behaves like a soft tissue.

• Hard tissue: In hard tissues like bone and teeth, the

extracellular matrix gets mineralized.

• Because of the mineralization, interstitial growth is not

possible in a hard tissue.

• Hyperplasia, hypertrophy and extracellular matrix secretion

 all occur only on the surface.

• New cell formation takes place in the periosteum, the soft

tissue membrane that covers the bone.

• Therefore, bone growth takes place only by ‘surface

deposition of bone’. There is addition of fresh bone to the
surface of existing bone.

• Differences between soft tissue growth and skeletal growth

are depicted in Table 3.2.

Table 3.2.
Differences between soft tissue and skeletal growth

S.
Soft tissue
no.
1. It is primarily by hyperplasia and hypertrophy
and resultant interstitial growth
2. Uncalcified cartilage behaves like soft tissue
3. Growth by EC matrix secretion is secondary
Hard tissue
Hyperplasia, hypertrophy and extracellular matrix (ECM) secretion occur only on the surface. The ECM
gets mineralized and so interstitial growth is not possible in hard tissues
The new cell formation takes place in periosteum, the soft tissue membrane that covers the bone
Growth in hard tissues takes place by surface deposition in bone
Osteogenesis/methods of bone formation
Bone formation takes place by two basic methods, namely:

1. Endochondral ossification

2. Membranous ossification

Endochondral ossification/cartilaginous
ossification/indirect ossification
➤ Endochondral bone formation involves production of bone in areas where there are
high levels of compression. Thus, it is seen in the cranial base and in movable joints.

➤ During endochondral bone formation, the first step is the differentiation of

mesenchymal cells into chondrocytes.

➤ These chondrocytes form a rough model which is enclosed by perichondral cells.

➤ Cartilage mass grows both by interstitial growth and by apposition.

➤ Cartilage cells hypertrophy and their matrix begins to get calcified.

➤ During this time, blood vessels penetrate the cartilage mass from the perichondrium.

➤ These penetrating blood vessels carry undifferentiated mesenchymal cells along with
them, which get converted into osteoblasts.

➤ Osteoblasts subsequently deposit bone and bone spicules are formed.

➤ Gradually, the cartilage mass is replaced by bone.

➤ Endochondral bone is not formed directly from cartilage; osteoblasts invade cartilage
and replace it.

Importance of endochondral ossification

➤ Cartilage behaves like a soft tissue and growth takes place both by interstitial growth
and appositional growth. In bone, interstitial growth is not possible.

➤ Cartilage unlike bone is a pressure-adapted tissue and can grow in heavy pressure
areas, e.g. cranial base.

➤ Direction of growth is not unidirectional like bone. Linear growth takes place
allowing lengthening of bone.
➤ The entire process of endochondral ossification is continuous and repetitive, one
zone transferring into the next. Note in Fig. 3.1 zone b changes into zone c (arrow 1),
zone d into zone e (arrow 2) and zone e into zone f (arrow 3).

FIG. 3.1. The diagram shows the various zones of cartilage: (a) zone of reserve cells, (b) zone
of hyperplasia, (c) zone of hypertrophy, (d) zone of matrix calcification, (e) penetration of blood
vessels and (f) calcified cartilage matrix.

Membranous ossification/intramembranous
ossification/direct ossification
➤ Membranous ossification or bone formation occurs on the outer surface of bone
(periosteum), inner surface (endosteum), sutures, etc.

➤ Undifferentiated mesenchymal cells in the mesenchymal tissue differentiate into

osteoblasts.

➤ Osteoblasts secrete osteoid (fibrous bone matrix).

➤ The original blood vessels are retained in close proximity to the formative bony
trabeculae.

➤ As bone deposition continues, some of the osteoblasts get enclosed by their own
deposits and become osteocytes.

➤ Intramembranous ossification is the major mode of growth in the skull (Fig. 3.2).
 FIG. 3.2. Intramembranous ossification. In a centre of ossification, (A) the cells and matrix of
the undifferentiated mesenchymal cells (1) undergo changes to osteoblasts (2) and lay down
the first fibrous bony matrix. In stage (B) fibrous bony matrix gets mineralized. Original blood
vessels are retained in close proximity to the bony trabeculae (3). Some of these cells get
enclosed by their own deposits and become osteocytes (4). The outline of an early bony
spicule (5) and new osteoblasts (6) are shown in stage (C). In stage (C) blood vessels (3) get
enclosed in the fine cancellous space.

Importance of membranous ossification

➤ Membranous ossification or growth is seen in areas of tension.

➤ Growth takes place outward or externally.

Remodelling
➤ Remodelling can be defined as the process of reshaping and resizing at each level
within a growing bone (Fig. 3.3).

➤ A craniofacial bone does not simply grow in size by deposition and resorption.
Instead, bone grows by a process of remodelling.

➤ Remodelling takes place by selective deposition and resorption of bone. So, bone not
only increases in size, but there is a constant reshaping of bone also.

➤ Remodelling is a basic part of the growth process which provides both regional
changes in shape and also produces regional adjustments that adapt to the changing
function of the bone.

➤ The mandible remodels differently in directions that are predominantly posterior

and superior. The shape of the bone as a whole is maintained. This is a highlight of
the remodelling process.

FIG. 3.3. Remodelling causes reshaping and relocation of parts of the bone.

Types of remodelling
There are four different types of remodelling:

➤ Biochemical remodelling: Involves constant deposition + removal of ions to maintain

blood calcium.
➤ Haversian remodelling: Involves secondary reconstruction of bone by haversian
systems and rebuilding of cancellous bone.

➤ Regeneration and reconstruction: Takes place during pathology and trauma.

➤ Growth remodelling: Constant remodelling of bone during active growth period and
childhood.
Growth site versus growth centre
The terms ‘growth sites’ and ‘growth centres’ were coined by Baume. A proper
understanding of the terms ‘growth site’ and ‘growth centre’ will help to clarify the
differences between theories of growth. Differences between growth site and centre are
tabulated in Table 3.3.

Table 3.3.
Growth site versus growth centre

Growth site Growth centre/growth field

• Is a location or place where growth takes place
• Is a region of periosteal or sutural bone formation and remodelling resorption adaptive
to environment
• Sites of growth when transplanted to another area do not continue to grow
• Marked response to external influences
• They do not cause growth of the whole bone, instead they are simply places where
exaggerated growth takes place
• All growth sites are not growth centres
• Theories of growth are not based on growth site
• Growth sites do not control the overall growth of the bone
• Is a location or place where genetically controlled growth takes
place
• Is place of ossification with tissue separating force
• Centres of growth when transplanted to another area continue
to grow
• Less response to external influence. More response to functional
needs
• Cause growth of the major part of the bone
• All growth centres are growth sites
• Various theories of growth are based on the place where growth
centre is expressed
• Growth centre controls the overall growth of the bone

Various theories and growth centres

The various growth theories and their growth centres are as follows:

Sutural theory by Sicher sutures, periosteum and endosteum

Cartilaginous theory cartilages, synchondroses

Functional matrix theory soft tissues

Growth movements: Drift versus displacement
Two basic kinds of skeletal movements take part in growth of craniofacial bone, namely
drift and displacement.

Drift
Drift/cortical drift is growth movement of an enlarging portion of a bone by the
remodelling of its own osteogenic tissues.

➤ Drift occurs due to a combination of deposition and resorption (Fig. 3.4).

➤ Movement of bone takes place as there is bone deposition on one side of the cortical
plate and resorption on the opposite side.

➤ Because of constant deposition on one side and resorption on the other side, drift
usually takes place in the direction of bone deposition.
 FIG. 3.4. Diagrammatic representation of drift.

Displacement
Physical movement of the whole bone as a unit either because of its remodelling action
or because of growth of adjacent tissue or bone (Fig. 3.5).
 FIG. 3.5. Diagrammatic representation of Displacement.

Displacement can be primary or secondary (Table 3.4).

Table 3.4.
Primary and secondary displacement

Primary displacement Secondary displacement

• Movement of the bone as the bone enlarges is called primary displacement (Fig. 3.6) • Movement of the whole bone caused by enlargement of other bones
which are present nearby or quite distant is called secondary
displacement
• Movement can be either in the direction of bone deposition or in the direction of • Increase in size of middle cranial fossa causes the maxilla to be
bone resorption displaced anteriorly and inferiorly
• As the bone enlarges, it is carried away from other bones • This is independent of the growth and enlargement of the maxilla
itself
• Growth remodelling takes place to maintain contact, e.g. condyle grows upwards
and backwards to maintain contact with fossa as the mandible is displaced
downwards
• Similarly, maxilla is displaced downwards and forwards. To maintain contact bone
deposition takes place in upwards and backwards direction
FIG. 3.6. Primary displacement.
Expanding V principle
➤ This concept was put forward by Enlow.

➤ Most of the cranial and facial bones have a V-shaped configuration (Fig. 3.7).

➤ Bone deposition takes place on the inner aspect of the V.

➤ Resorption takes place on the external surface of the V.

➤ Continuous deposition on internal aspect and resorption on the external causes the V
to move from position A to B.

➤ Simultaneously with the movement, the V also increases in size.

➤ The increase in size and the simultaneous movement of the bone in the shape of
expanding V is called ‘Expanding V principle’.

➤ Movement of the bone is towards the end of V.

➤ Growth movement of most of the craniofacial bones including mandible, maxilla and
palate (Fig. 3.8) takes place in this expanding V shape.

FIG. 3.7. V principle.

FIG. 3.8. V principle in palate.
Pattern of growth
➤ The word ‘pattern’ literally means definite arrangement of designs in a definite
proportional relationship.

➤ In growth, pattern can be defined as a proportional relationship over time.

➤ Patterns are the controlling or restricting mechanisms to preserve the integration of

parts of the body under varying conditions or through time.

Contributors to pattern
➤ Cephalocaudal growth and Scammon’s growth are predictability the contributors to
pattern.

Cephalocaudal growth (fig. 3.9)

There is an axis of increased growth gradient extending from head towards the feet.
This is called ‘cephalocaudal growth’.

➤ As shown in Fig. 3.9, in fetal life, head constitutes 50% of total body length. The
cranium is large and limbs are primitive (30%).

➤ At birth, head constitutes 25–30% and there is increased and faster growth of body
and limbs.

➤ In an adult, the head constitutes only 12%, while limbs take up 50%.

FIG. 3.9. Cephalocaudal growth.

 The above mentioned changes on pattern of growth are because of cephalocaudal
growth.

Cephalocaudal growth in face

➤ At birth, jaws and face are less developed when compared to skull.

➤ Maxilla being closer to head grows faster and growth is completed before
mandibular growth.

➤ Mandible being away from the brain grows more and growth completes later than
maxilla.

Scammon’s growth
Human body comprises four major tissues: (1) neural, (2) somatic/General – includes
muscles and bones, (3) lymphoid and (4) genital/sexual tissue. These different tissues
grow at different time and at different rates (Fig. 3.10).

➤ Neural tissue growth completes by 6–7 years of age.

➤ General body tissues follow an S-shaped pattern. Slowing of growth during childhood
and acceleration at puberty is seen.

➤ Lymphoid tissue attains peak growth and grows beyond adult amount during late
childhood.

• Undergoes regression at puberty or when genital growth

acceleration takes place.
➤ Genital: Secondary sexual characteristics begin to appear during puberty.

• Reaches peak by 20 years of age.

 FIG. 3.10. Scammon’s growth curves: Diagram showing four types of growth curves.

Effect of scammon’s growth in facial region

Mandible:

➤ It follows somatic growth pattern.

➤ Long time growth until about 18–20 years in male.

Maxilla:

➤ Follows neural growth pattern.

➤ Growth ceases earlier.

➤ So skeletal problems of the maxilla should be treated earlier to mandible, e.g. ideal
age for giving reverse pull headgear is 6 years.

Predictability
Predictability denotes the predictable sequences of changes in growth proportions for
an individual.
Variability of growth
Variability of growth is the law of nature. No two individuals are exactly alike, and no
two individuals grow in the same pattern. The reasons for variability of growth are:

Wetzel’s grid
➤ Variations within normal range could be studied using the Wetzel’s grid.

➤ The height and weight of the individual are plotted against the age over a period of
time.

➤ The resultant curve is compared with normal range.

➤ Any unexpected growth pattern changes should be evaluated and investigated for
growth abnormality.

Other factors affecting variability

➤ Heredity: There is genetic control on the rate of growth and onset of menarche.

➤ Nutrition: Malnutrition retards growth and certain parts of the body may be affected.

➤ Racial differences: It could account for differences in skeletal maturity.

➤ Climate and seasonal effects: People living in cold places have more of fat or adipose
tissue.

➤ Exercise: It causes increase in muscle mass and physique.

➤ Socioeconomic factors

➤ Psychological factors

➤ Size of family

➤ Hormonal Changes

Differential growth
➤ Growth of craniofacial bones is not a steady and uniform process of addition,
wherein all parts of the body enlarge at the same rate and increment over the period
of time.

➤ Instead different bones grow at different rates and at different times as per the
functional needs. This is called ‘differential growth’.

➤ Reasons for differential growth include cephalocaudal growth and Scammon’s

growth.

Order of completion of growth

Growth is a three-dimensional phenomenon. The order of completion of growth is
different in the three dimensions. The order of completion of growth is as follows. In the
cranium, width completes first, followed by height and depth. In face also, width
completes first, followed by depth and height.

Amount of growth
When the amount of growth or increment of growth is considered, this also shows
variation. In the cranium, growth in the anteroposterior dimension (depth) is the
greatest followed by width. Height has the least amount of growth increment in
cranium.
In face, height has got the maximum increment, followed by depth. Width has got the
least increment of growth.

Timing of growth
Occurrence of the same events at different times for different individuals is called
timing variations in growth.
Timing variation in growth is because of the following reasons:
Sex differences: There is variation between boys and girls in onset of menarche and
rate of growth.

➤ In girls, there is early onset of menarche, and growth completes faster before boys of
the same age.

➤ In boys, there is delayed onset of puberty and growth occurs over a longer period.

Growth spurts
➤ Growth sites are responsible for a greater increment of growth.

➤ Many growth sites may be active at one particular period of time than other.

➤ This uneven or sudden activity of growth site is responsible for growth to occur as
spurts.

➤ This is called growth spurts/growth peaks. The different types of growth spurts are
depicted in Table 3.5.

Table 3.5.
Types of growth spurts

Spurt Female (in years) Male (in years)

Childhood 3 3
Juvenile 6–7 7–9
Pre-pubertal 11–12 13–15

Clinical implications:

➤ These growth spurts can be utilized for growth modulation treatment.

➤ During pubertal growth spurts, there is change in growth direction from vertical to
horizontal.

➤ Safety valve mechanism comes into play.

Safety valve mechanism
➤ Safety valve mechanism is nature’s attempt to maintain proper occlusion.

➤ The maxillary intercanine width serves as a safety valve to compensate for the
horizontal growth in mandible.

Mandible
➤ In mandible, intercanine width is completed at 9 years of age in girls.

➤ In boys, it is completed at 10 years of age.

Maxilla
➤ Intercanine width is completed by 12 years in girls.

➤ In boys, it is completed at 18 years of age.

➤ The delay in growth of maxillary intercanine arch width serves as a ‘safety valve’ for
pubertal growth spurts in mandible.

➤ There is no equal amount of horizontal growth in maxilla while the mandible grows
horizontally.

➤ Maxillary intercanine width adjusts to the mandible dentition as it is brought

forward.

➤ This is called ‘safety valve mechanism’.

➤ The sequence of safety valve mechanism is explained by the following flowchart.

Differences between primary and secondary
cartilages
Characteristic features of primary and secondary cartilages are depicted in Table 3.6.

Table 3.6.
Primary vs secondary cartilage features

Primary cartilage Secondary cartilage

• Derivative of primordial cartilage • Secondary cartilage formation on membrane bone
• In primary cartilage, chondroblast divides and synthesizes intercellular matrix • No intercellular matrix
• Dividing chondroblasts are surrounded by cartilaginous matrix • Not surrounded by cartilaginous matrix
• Cells arranged in columnar fashion • Cells arranged in haphazard manner
• Since surrounded by cartilaginous matrix, not influenced by local environmental factors, • Affected by external influences which will stimulate growth of
e.g. epiphyseal cartilages and, synchondroses cartilage, e.g. condylar cartilage
• Growth is interstitial. Hence three-dimensional growth • Peripheral growth
• Considered to be a genetic pacemaker for growth • Contributes only to regional adaptive growth
Controlling factors in craniofacial growth
Controlling factors in craniofacial growth have been classified into two ways:

➤ Moyer’s classification of controlling factors

➤ Von Limborgh’s classification of controlling factors

Von Limborgh’s controlling factors

S. no. Factors Definition/explanation

1. Intrinsic genetic factor Genetic factors inherent to the craniofacial skeletal tissues
2. Local epigenetic factor (capsular matrix) Genetically determined influences originating from adjacent structures and spaces (brain, eyes, etc.)
3. General epigenetic factor Genetically determined influences originating from distant structures (sex hormones)
4. Local environmental factor (periosteal matrix) Local non-genetic influences from external environment (muscle force and local external pressure)
5. General environmental factors General non-genetic influences originating from the external environment (oxygen supply and food)
Age assessment: Chronological, dental and
skeletal age
Chronological age
➤ Chronological age is the measured amount of time since birth.

➤ Chronological age has little place in the assessment of maturational status of an

individual.

➤ It is not a good indicator of a person’s growth status.

Dental age
It is assessed with the following three characteristics:

➤ Which teeth have erupted?

➤ Amount of root resorption of primary teeth.

➤ Amount of permanent teeth development.

Dental ages
At birth (radiographic finding): Mandibular central incisors and lateral incisors show
calcification about half of the crown. Cusps of canine and deciduous molars are seen.
At 2 years: Majority of children have 20 teeth clinically present. By 2½ years of age, deciduous dentition is usually complete.
At 6 years: First stage of eruption of permanent teeth. Common sequence of eruption is mandibular central incisors, mandibular first molars and maxillary
first molars.
At 7 years: Maxillary central incisors and mandibular lateral incisors erupt.
At 8 years: Maxillary lateral incisors erupt. After 8 years, there is no further eruption of any teeth for the next 2–3 years.
At 11 Group of teeth erupts simultaneously. Mandibular canines, mandibular first premolars and maxillary first premolars.
years:
At 12 Mandibular second premolars, maxillary second premolars and maxillary canines are seen erupting. Maxillary and mandibular second molars
years: also erupt.

Clinical implications
➤ Dental age usually correlates with chronological age, but the correlation is weak.

➤ Sequence of eruption and timing of eruption are genetically determined.

➤ Teeth eruption is advanced in girls than boys.

➤ Calcification of mandibular canine coincides with puberty.

Skeletal age/bone age/skeletal maturity indicators
Skeletal maturity
➤ Assessing the skeletal maturity status of an individual helps in knowing whether
he/she will grow appreciably in the treatment period. This has important implications
in the treatment planning and response to treatment.

➤ The position of the patient in the facial growth curve is important while planning
orthopaedic therapy, functional appliance therapy and orthognathic surgery.

➤ The orthopaedic or functional appliance treatment during the periods of accelerated

growth can contribute significantly to correction of dentofacial deviations leading to
an improvement in the facial appearance.

➤ The physical maturity of an individual is not related to chronological age.

➤ Physical maturity can be assessed by the skeletal maturity or skeletal age. The other
parameters like peak height velocity (PHV), secondary sexual changes and dental age
are inferior to skeletal age in estimating physical maturity.

➤ The bones mature at different rate and follow a reasonable sequence in doing so.
Hence, the developmental status of a child can be estimated by determination of
degree of completion of facial skeleton.

The skeletal maturity indicators commonly used are:

1. Hand–wrist radiographs 2. Cervical vertebrae cephalogram
3. Pelvis radiographs 4. Canine calcification intraoral radiographs

Hand–wrist radiographs
➤ There are numerous small bones in the hand–wrist region. They follow a pattern in
ossification and union hand and wrist of left side"? of epiphysis with diaphysis.

➤ Carpal bones were first named by Lyser in 1683.

➤ The left hand–wrist is used by convention and a postero-anterior (PA) view is taken
to register the hand–wrist region (Fig. 3.11).
 FIG. 3.11. Anatomy of hand–wrist region.

Hand–wrist region: Anatomy

Each hand–wrist area has 8 carpals, 5 metacarpals and 14 phalanges which make a total
of 27 bones. Distal ends of radius and ulna also appear in the hand–wrist radiograph.
Radius and ulna are the long bones of the forearm. Ulna lies in the medial aspect and
radius in the distal aspect when the palm is facing front.
The carpal bones are arranged in two rows:

➤ Distal row: Trapezium, Trapezoid, capitate, and hamate

➤ Proximal row: Scaphoid, lunate, triquetral, and pisiform

These small irregular bones lie in between the long bones of forearm and the
metacarpals.
Metacarpals are long bones. Each of the five metacarpals has a base, shaft and head.
They lie between the carpals and phalanges forming the skeletal framework of the
palm.
Each finger has a proximal phalanx, middle phalanx and distal phalanx. Middle
phalanx is absent in the thumb. The small round bone located in the thumb embedded
in the tendons is called the sesamoid bone. The phalanges have a pattern of ossification
which can be divided into three stages (Fig. 3.12).
 FIG. 3.12. Ossification pattern of phalanges.

Bjork divided the skeletal development in the hand–wrist area into eight stages. Each
of the stages represents a particular level of skeletal maturity (Table 3.7).

Table 3.7.
Stages of skeletal development in hand–wrist region

Hagg and Taranger noted that stages of ossification of middle phalanx of third finger
(MP3) follow pubertal growth spurt. The stages of ossification are outlined from stage F
to stage I.

➤ Stage F: The epiphysis is as wide as the metaphysis. About 40% of the individuals are
before PHV. Very few are at PHV.

➤ Stage FG: The epiphysis is as wide as the metaphysis, and there is a distinct medial or
lateral (or both) border of the epiphysis forming a line of demarcation at right angles
to the border. About 90% of the individuals are one year before or at PHV.

➤ Stage G: The sides of the epiphysis are thickened, and there is capping of the
metaphysis, forming a sharp edge distally at one or both sides. About 90% of the
individuals are at or one year after PHV.

➤ Stage H: Fusion of the epiphysis and metaphysis has begun. About 90% of the girls
and all the boys are after PHV but before the end of the pubertal growth spurt.

➤ Stage I: Fusion of the epiphysis and metaphysis is completed. All individuals except a
 few girls have ended the pubertal growth spurt.

Cervical vertebrae maturation as an indicator of skeletal maturity

➤ Use of cervical vertebrae for assessing skeletal growth was introduced by Hassel and
Farman.

➤ Certain levels of bone development are associated with change in the shape of
cervical vertebrae.

➤ The various stages are tabulated and depicted in Table 3.8 and Fig. 3.13.

Table 3.8.
Stages in assessing skeletal growth

Stages Name Changes observed

Stage 1 Initiation • Marks the beginning of adolescent growth
• Lower borders of C2, C3 and C4 will be flat and wedge-shaped
• Upper borders are tapered
• 80–95% of growth is left
Stage 2 Acceleration • Acceleration of growth takes place
• Depressions are seen in lower borders of C2 and C3 and the body is rectangular in shape
• Lower border of C4 will be flat
• 65–85% of growth is left
Stage 3 Transition • Acceleration of growth to PHV
• Marked depressions are seen in lower borders of C2 and C3 and the body is rectangular in shape
• Depression in the lower border of C4 is seen; 25–65% of growth is left
Stage 4 Deceleration • Deceleration of adolescent growth spurt
• Marked depressions are seen in C2, C3 and C4 in their lower borders
• Shape of C3 and C4 is square
• 10–25% of growth is left
Stage 5 Maturation • Final maturation of vertebrae takes place
• More accentuated depressions are seen in lower borders of C2, C3 and C4
• C3 and C4 are square in shape
• 5–10% of growth is left
Stage 6 Completion • Adolescent growth is almost complete
• More accentuated depressions are seen in lower borders of C2, C3 and C4
• Shape of C3 and C4 is square with more vertical height

FIG. 3.13. Cervical vertebrae maturation: stages.

Role of synchondroses in cranial base growth
Introduction
➤ Synchondroses are the remains of the primary cartilaginous skeleton of the cranial
base. They are predominantly seen in the cranial base.

➤ The cranial base is the template by which the face develops.

➤ The bones of the base of the skull are initially formed in cartilages which are later
transformed by endochondral ossification to bone.

➤ ‘Synchondroses’ are defined as the bands of cartilage present between bones.

➤ These synchondroses form important growth sites in the base of skull.

➤ Cranial base grows by cartilaginous growth in the synchondroses which later gets
calcified (Fig. 3.14).

FIG. 3.14. Mid-sagittal section of the cranial base.

Types of synchondroses
Synchondroses can be classified into four subtypes (Table 3.9).

➤ Spheno-occipital synchondroses are responsible for most of the lengthening of

cranial base between foramen magnum and sella turcica.
➤ Spheno-occipital synchondrosis is the major contributor of endochondral growth till
20 years.

➤ Elongation of synchondroses in combination with drift and remodelling contributes

to cranial base lengthening.

Table 3.9.
Types of synchondroses

S. no. Synchondroses Age of fusion

1. Intersphenoidal synchondroses At birth
2. Intraoccipital synchondroses 3–5 years
3. Spheno-occipital synchondroses 20 years
4. Spheno-ethmoidal synchondroses Exactly not known

Advantages of cartilaginous growth (fig. 3.15)

➤ Cartilage behaves like a soft tissue and growth takes place both by interstitial growth
and appositional growth. In bone, interstitial growth is not possible.

➤ Cartilage unlike bone is a pressure-adapted tissue and can grow in heavy pressure
areas, e.g. cranial base.

➤ Direction of growth is not unidirectional like bone. Linear growth takes place
allowing lengthening of bone as shown by the arrows in Fig. 3.15.

FIG. 3.15. Cartilaginous growth. Arrows depict linear lengthening.

Clinical implications
➤ Abnormal growth of cranial base can result in severe dentofacial deformity, e.g.
achondroplasia and craniofacial dysostosis.

➤ An obtuse cranial base angle increases the depth of maxilla and causes mandible
retrognathism.
Various methods of measuring growth
The various methods of measuring growth are:
Craniometry and anthropometry
Craniometry: It is the art of measuring skulls to discover their specific differences.
Precise measurements can be made with craniometry.

Anthropometry: It is the measurement of skeletal dimensions on living individuals.

Table 3.10 depicts the information obtained from craniometry and anthropometry.

Table 3.10.
Craniometry and anthropometry

Information Craniometry Anthropometry

Site of growth Cannot be elicited Cannot be elicited
Amount of growth Cannot be elicited Little information
Rate of growth No To some extent
Direction of growth To some extent Relatively accurate
Type of study Cross-sectional Longitudinal
Drawbacks Unknown sample Soft tissue restricts accuratemeasurements

No previous record

Clinical uses
➤ Index is the ratio of a smaller to a larger linear measurement expressed by means of
percentage.

➤ Two important indices used in orthodontics are cranial index and facial index.

➤ Maximum cranial breadth ‘is the measured distance between the two most
prominent points on either side of the head’.

➤ Maximum cranial length ‘is the measured distance from glabella to opisthocranion,
the most prominent point of the occipital bone in the midline’.

➤ The values for different head types are:

• Dolichocephalic (long narrow skull):  70.0–74.9

• Mesocephalic (middle type):      75.0–79.9

• Brachycephalic (short and round):   80.0–84.9

➤ Facial height is the measured distance from nasion to

gnathion.

➤ Zygomatic breadth is the distance between two zygomas.

➤ The values for different face types are:

• Euryprosopic (broad and round):  80–84.9

• Mesoprosopic (middle type):    85–89.9

• Leptoprosopic (high and narrow):  90–94.9

Vital staining
➤ Vital staining is an experimental method of measuring growth.

➤ Vital staining was introduced by John Hunter in the eighteenth century.

Procedure
➤ Method consists of injecting dyes that stain the mineralizing tissues.

➤ These dyes get deposited in the bones and teeth.

➤ Animals are sacrificed and tissues studied histologically.

Dyes used for vital staining

➤ Alizarin S ➤ Tetracycline
➤ Radioactive tracers ➤ Trypan blue
➤ Fluorochrome

Information elicited
➤ This cross-sectional study gives a detailed analysis of site and amount of growth.

➤ Rate of growth can also be elicited.

➤ Disadvantage: It is not a longitudinal study, i.e. repeated data of the same individual
cannot be obtained.
Implant radiography
Implant radiography is an experimental method to study physical growth.

➤ Human implant radiograph for growth measurement was introduced by professor

Bjork.

Procedure
➤ Inert metal pins are placed in the mandible.

➤ Tantalum inert pins of length 1.5 mm and diameter 0.5 mm are used.

➤ These metal pins get fused to the bone. These osseointegrated implants serve as
reference points.

➤ Serial cephalometric radiographs are taken repeatedly over a period of time and
compared.

➤ Rotation of jaw bones was estimated using implant radiography only.

Site of implants
Implant sites are depicted in Table 3.11 and Fig. 3.16.

Table 3.11.
Sites of implants

Bone Site
Mandible 1. Symphysis in the midline below roots
2. Right side body of mandible – one below first premolar and second below first molar
3. Outer surface of ramus on the right side in level with occlusal plane
Hard palate 1. Behind canines
2. Front of first molar in the junction between alveolar process and palate
Maxilla 1. Inferior to anterior nasal spine
2. Bilaterally in the zygomatic process
 FIG. 3.16. Mandibular sites for implant placement.

Information obtained from implant radiography

Site of growth : Very accurate information
Amount of growth : Very accurate information
Rate of growth : Relatively accurate
Direction of growth : Very accurate
Type of study : Longitudinal study
Drawbacks : Two-dimensional study of three-dimensional process and radiation hazard.
Clinical implications of growth and development
Introduction
Craniofacial growth is a complex and beautiful phenomenon.

➤ A thorough knowledge of the normal pattern of growth and normal variations will
help in identifying the problems and utilizing the normal growth as advantage in
treatment.

➤ Clinical implications of growth and development can be studied under the following
headings:
1. Growth pattern 2. Variability
3. Timing variations 4. Differential growth
5. Safety valve mechanism

Combine answers to questions from page 21 to 28.

Nasal septum
➤ Nasal septum appears to be the primary factor in the displacement of nasomaxillary
complex.

Nasal septum in fetal life

➤ In prenatal life, nasal septum cartilage lies behind the cranial base cartilages (Fig.
3.17).

➤ In front and below, it is attached to premaxillary bone.

➤ Lower edge to vomer.

➤ Posteriorly with mesethmoid cartilage.

FIG. 3.17. Cross-section of nasal cartilage.

Postnatal development
➤ Perpendicular plate of ethmoid ossifies from mesethmoid cartilage at birth.

➤ At about 3 years, this perpendicular plate of ethmoid fuses with cribriform plate of
ethmoid which is from nasal capsule.
➤ With this, the cranial components are fused with facial bony elements.

➤ Anterior part of the nasal septum remains cartilaginous throughout life.

➤ Nasal septum has little effect on the facial growth after union of cranial and facial
bony components.
Meckel’s cartilage
➤ The cartilage of the first branchial arch is called Meckel’s cartilage.

➤ Meckel’s cartilage appears bilaterally as cartilaginous bars (Fig. 3.18).

➤ Anterior aspect of these two cartilages approaches each other near the midline, but
they do not fuse.

➤ Posteriorly, they terminate in a bulbous structure called malleus.

➤ Malleus and incus are derivatives of Meckel’s cartilage.

➤ The part of the cartilage extending from the region of the middle ear to mandible
disappears, but its sheath forms the ‘anterior ligament of the malleus’ and the
‘sphenomandibular ligament’.

➤ Evidence shows that the contact point of malleus and incus is the primary
articulation of the lower jaw for the first 20 weeks of prenatal life.

➤ Condylar cartilage develops as a mesenchymal condensation lateral to Meckel’s

cartilage.

➤ Then the temporomandibular joint, the articulation of condyle to temporal fossa,

which is the secondary joint becomes functional.

FIG. 3.18. Meckel’s cartilage.

ACCESSORY POINTS
Size increase
➤ Prenatal period: Height increases by 5000 times
➤ Postnatal period: Height increases by 3–4 times

➤ Prenatal period: Weight increases by 6.5 billion-fold

➤ Postnatal period: Weight increases by 20-fold

Stages of growth
➤ Period of ovum: 0–14 days

➤ Period of embryo: 14–56th day (8th week)

➤ Period of fetus: 56th day till birth (270 days) (9th week to 9th month)

➤ Period of neonate: Birth to 2 weeks

➤ Period of infancy: 2 weeks to 1 year

Methods of bone formation

➤ Only membranous: Frontal, zygomatic, parietal, palatal, maxilla, vomer, lacrimal

➤ Only endochondral: Ethmoid, nasal concha

➤ Mixed: Mandible, occipital, temporal

Bony joints
➤ Suture: A type of fibrous joint in which the opposed surfaces are firmly united

➤ Symphysis: Two bony surfaces are firmly united by a plate of fibrocartilage

➤ Synostosis: Union of adjacent bones by osseous matter

➤ Syndesmosis: Fibrous junction in which the intervening fibres forms a interosseous

membrane

➤ Synchondrosis: A cartilaginous joint that is usually temporary and gets converted into
bone in adult life

Facial bones
➤ At birth, skull consists of 45 bones

➤ Reduced to 22 in adults

➤ Fourteen of them are in the face

➤ Remaining eight form the cranium

➤ Ratio between cranium and face in newborn is 8:1

➤ Face makes up one-fourth of entire height at birth

➤ In adult, head makes up 12%

Growth completion
➤ Order of completion – face: width, depth, height

➤ Maxillary growth completes first usually. But in width, maxillary width completes
after mandibular width – safety valve mechanism

➤ Mandibular intercanine width completes by 9 years

➤ Maxillary intercanine width completes by 12 years in female and 18 years in male

➤ Which side of the face is usually larger at birth? – left side

Tweed’s growth trends

➤ Type A: Maxilla and mandible grow in unison both downwards and forwards; ANB
shows no change since both maxilla and mandible grows equally.

➤ Type B: Maxilla grows more rapidly than mandible; ANB angle increases

➤ Type C: Mandible grows faster than maxilla; ANB angle decreases

Hellmann standards
➤ Stage 1: Period of infancy before completion of deciduous dentition

➤ Stage 2: Period of late infancy at the completion of deciduous dentition

➤ Stage 3: Period of childhood when first permanent molars are erupting or have taken
their position

➤ Stage 4: Period of pubescence when second molars are erupting or have taken their
position

➤ Stage 5: Period of adulthood when the third molars are erupting or have taken their
position

➤ Stage 6: Period of old age when the occlusal surfaces of molars are worn off to the
extent of obliterating the pattern of grooves
➤ Stage 7: Period of senility

➤ Growth of the anterior cranial base completes at 8–10 years

➤ Premaxilla is formed by medial nasal process

➤ The point of merging of the first and second branchial arches is identified as foramen
caecum

➤ The blood vessels which proliferate into the cartilage mass before ossification begins
are derived from perichondrium

➤ Functional cranial component theory was first proposed by Van der Klaauw

➤ The basic maxillary skeletal unit is infraorbital nerves and vessels

➤ Salivary gland is a good example of neurovisceral trophism

➤ Natural bite openers in the phenomenon of physiological bite raisers is the pad of
tissue overlying the permanent molars as they erupt

➤ The initial sign of sexual maturation in boys is fat spurt

➤ Growth rotation of jaws was demonstrated by implant studies of Professor Bjork

➤ The most accepted reason for lower incisor crowding occurring in late teens or early
twenties is late mandibular growth

➤ The process of compressing a 15-year study to 3-year study is called overlapping study

➤ The angle of mandible at birth is (approximately) 130°

➤ The most constant portion of the mandible is the arc from foramen ovale to mandibular
foramen to mental foramen

➤ Hand–wrist radiographs are used to predict the timing of growth

➤ Meckel’s cartilage is essential for growth of mandible because it is a template for bone
deposition

➤ Differential growth means different tissues grow at different rates, amount and at
different time

➤ Condylar cartilage is a secondary cartilage

➤ Independent or genetically controlled growth occurs at growth centres

Advanced Learning
Puberty/adolescence
➤ ‘Puberty is the period where there is maturation of gonads, development of
secondary sexual characteristics and acceleration of somatic growth’.

➤ It is the intermediate period between childhood and adulthood.

➤ Occurrence of puberty or adolescence is because of the maturation of the sex organs,

which in turn release the sex hormones, initiating the onset of puberty.

➤ Puberty generally occurs earlier in girls than in boys by nearly 2 years.

Biological control of puberty

Mechanism of biological control of puberty is depicted in Fig. 3.19.

FIG. 3.19. Biological control of puberty.

Stages of puberty in males

Stage 1

➤ At about 11 years of age, testicular enlargement is the first sign of puberty.

➤ Initially, testes produce oestrogen which causes the ‘fat spurts in boy’. Boys gain
weight and look chubby due to feminine fat distribution.

Stage 2
➤ One year after stage 1, the penis enlarges and pubic hair begins to appear.

➤ Height increase is just starting.

➤ Decrease in feminine fat distribution.

Stage 3

➤ 8–12 months after stage 2.

➤ PHV is achieved.

➤ Axillary hair appears and pubic hair has reached its final stage.

➤ Facial hair above the upper lip or moustache begins to grow.

➤ Spurt in muscular growth takes place.

Stage 4

➤ 1½–2 years after stage 3.

➤ Voice change takes place during this stage.

Stages of puberty in females

Stage 1

➤ Occurs at the beginning of growth spurt.

➤ Appearance of breast buds takes place.

➤ Early stages of pubic hair development are seen.

Stage 2

➤ Occurs one year after stage 1.

➤ PHV occurs during this stage.

➤ Noticeable breast development and widespread pubic hair growth is seen.

➤ Axillary hair growth is visible.

Stage 3

➤ Happens 1–1½ years after stage 2.

➤ There is completion of growth spurt.

➤ Hip broadening takes place.

Clinical implications
➤ Growth of the jaws correlates with the physiologic event of puberty.

➤ Mandible and maxilla show pubertal growth spurt.

➤ Cephalocaudal growth is remarkably expressed. More growth occurs in mandible.

➤ There is acceleration of mandibular growth when compared to maxilla.

➤ Convexity of the face decreases.

➤ Chin prominence increases.

➤ Girls show ‘juvenile acceleration’ 2 years before adolescent growth spurt. This
should be utilized for orthodontic purpose. Treatment should not be delayed for girls.

➤ In boys, juvenile acceleration is not very intense as compared to girls.

Timing of puberty/assessment of skeletal maturity can be assessed by the following

methods:

➤ Hand–wrist radiograph

➤ Cervical vertebra maturation

➤ Voice change and menarche

Growth rotations of mandible

Rotations of mandible depend upon the direction of growth (Fig. 3.20) and upon
location of growth (Fig. 3.21).
Rotation depending upon the direction of growth (Schudy)
 FIG. 3.20. Flowchart depicting growth rotations of mandible depending upon direction of
growth.

FIG. 3.21. Flowchart depicting rotation depending on location of growth (Proffitt).

Rotation depending upon location of growth by proffitt ( figs 3.22 and

3.23)
The core and surface parts of mandible are shown in Fig. 3.22. Matrix and intramatrix
types of internal rotation are explained in Fig. 3.23.
 FIG. 3.22. Core and surface parts.

FIG. 3.23. (A) Matrix and (B) intramatrix rotation.

CHAPTER 4
Theories of growth

CHAPTER OUTLINE
❖ Various theories of growth
❖ Genetic theory
❖ Sicher’s sutural dominance theory or hypothesis
❖ Nasal septal cartilaginous theory or Scott’s hypothesis
❖ Moss’ functional matrix theory or hypothesis
❖ Neurotrophism
❖ Servo system or cybernetic theory
❖ Accessory points
❖ Advanced learning
❖ Clinical implications of functional matrix theory
❖ Growth equivalents concept or Enlow’s counterpart
principle
Various theories of growth
➤ The various theories of craniofacial growth are based on the expression of intrinsic
genetic potential.

➤ Depending upon where the growth centre is expressed, we have:

• Genetic theory by Brodie

• Sutural dominance theory by Sicher

• Cartilaginous theory by Scott

• Functional matrix theory by Melvin Moss

➤ Various other concepts/hypotheses related to craniofacial growth are:

1. Von Limborgh’s compromise theory

2. Hunter and Enlow’s growth equivalent concept

3. Petrovic’s cybernetic theory

Genetic theory
➤ This theory was put forward by Brodie in 1941.

➤ Brodie stated that the persistent pattern of facial configuration is under tight genetic
control.

➤ Genes determine the overall growth control.

➤ This theory is more of an assumption and is not proved.

➤ Primary genetic control determines only certain features and does not have complete
influence on growth.

Sicher’s sutural dominance theory or hypothesis

Introduction
➤ Sutural theory was put forward by Sicher.

➤ Sicher said that bone growth within the various craniofacial units is the result of
growth taking place in sutures.

Theory

➤ According to Sicher, the growth of the skull tissue is controlled by its own genetic
potential.

➤ All bone forming elements like cartilage, sutures and periosteum are growth centres,
according to Sicher.

➤ But this theory is also called sutural dominance theory because proliferation of
connective tissue and its replacement by bone in the suture is considered to be the
primary event.

➤ Growth in the sutures which attach maxillary complex to the cranium drives the
midface down.

Drawbacks of sutural theory

➤ Suture is a tension-adapted tissue and any unusual pressure on suture initiates bone
resorption and not bone deposition.

➤ Subcutaneous transplantations of zygomaticomaxillary suture in guinea pigs did not

grow. This clearly shows sutures lack intrinsic genetic growth.

➤ Extirpation or removal of facial sutures had no effect on the growth of skeleton.

➤ Shape of the sutures varies depending upon the functional needs.

➤ Differences in development of skull in microcephaly and hydrocephaly are not in

 accordance with the size of the sutures.

Conclusion
➤ Sutures do not act as primary growth centres.

➤ Growth in the sutural area is secondary in response to functional needs.

➤ Evidence in favour of secondary role of sutural growth is more.

Nasal septal cartilaginous theory or scott’s hypothesis

Introduction
➤ Nasal septal cartilaginous theory was put forward by Scott.

➤ This theory is based on the principle that cartilage is a pressure-adapted tissue and
growth of cartilage in nasal septum provides force that displaces maxilla downwards
and forwards.

Theory

➤ Scott said that intrinsic growth potential is present in cartilage and periosteum.
Hence cartilage and periosteum are growth centres.

➤ Sutural growth is passive and secondary to cartilaginous growth.

➤ Nasal septum is the major contributor in maxillary growth.

➤ In mandible, condylar cartilage is considered to be the growth centre present

bilaterally with the U-shaped mandible in between.

Experimental evidences
➤ Extirpation of septal cartilage in rats and rabbits resulted in deficient snout of these
animals.

➤ In nasal septum and cranial synchondroses, endochondral ossification is present.

➤ Transplantation of epiphyseal plate and synchondroses results in growth in the

transplanted area.

Conclusion/contemporary view regarding cartilaginous theory

➤ Epiphyseal cartilages and cranial synchondroses can act as independent growth
centres.

➤ Nasal septum acts as centre to a limited extent.

➤ Condylar cartilage growth is secondary and not primary.

Moss’ functional matrix theory or hypothesis

Definition
The functional matrix theory claims that the origin, growth, form, position and
maintenance of all skeletal tissues and organs are always secondary, compensatory and
obligatory responses to temporally and operationally prior events or processes that
occur in specifically related nonskeletal tissues, organs or functioning spaces (functional
matrices).

Components of functional matrix hypothesis (fig. 4.1)

FIG. 4.1. Components of functional matrix.

Theory
Functional matrix hypothesis was put forward by Melvin Moss. It is based on the work
of Van der Klaauw. Simply, the theory states, ‘There is no direct genetic influence on the
size, shape or position of skeletal tissues, only the initiation of ossification. All
skeletogenic activities are primarily upon the functional matrices’.

Functional cranial component

➤ According to Moss, head is a structure which carries out many functions like
respiration, neural integration, digestion, hearing function, etc.

➤ Each one function is carried out by tissues and spaces in the head.

➤ The tissues and spaces together, which are responsible for a single function, are
called ‘functional cranial component’.

➤ Functional cranial component is divided into two components:

• Functional matrix: Any function actually is performed by the

functional matrix.

• Skeletal unit: It provides the biomechanical role of protection

and support to the functional matrix.
Functional matrix
➤ The totality of the soft tissues associated with a single function is termed the
functional matrix.

➤ There are two distinct types of functional matrices:

Periosteal matrix

• Periosteal matrix influences the bone directly through the

periosteum.

• All periosteal matrices act by the process of bone deposition

and resorption.

• Examples for periosteal matrices are temporalis muscle,

 teeth, blood vessels, nerves and glands.

• Periosteal matrices form the local environmental factors

which affect the growth.

• The influence of periosteal matrix is restricted to part of a

bone, i.e. it affects the ‘microskeletal unit’.

Capsular matrix

• Capsular matrix includes the capsule that surrounds masses

and spaces.

• For example, the neural mass is contained within the capsule

of scalp and dura mater.

• Orbital mass is surrounded by the supporting tissues of eye.

• The oronasal–pharyngeal spaces are surrounded by a variety

of tissues that form their capsule.

• Neurocranial capsular matrix is formed by the brain,

leptomeninges and cerebrospinal fluid.

• Orofacial capsular matrix pertains to functioning spaces and

tissues in respiration and deglutition.

• Capsular matrix forms the local epigenetic factor which

controls growth.

• There is genetically determined volumetric expansion of the

capsular matrix.

• Volumetric expansion of the capsular matrix causes spatial

 translation of the whole bone or macroskeletal unit.

• Capsular matrix causes growth of the whole bone.

Skeletal unit
The totality of all the skeletal tissues associated with one function is called a skeletal unit
(Fig. 4.2). There are two types of skeletal units: microskeletal and macroskeletal.

FIG. 4.2. Skeletal unit. Interaction of skeletal unit and functional matrices and the resultant
growth.

Interaction of functional matrix and skeletal unit

Periosteal matrix Microskeletal unit

Temporalis muscle Coronoid process
Tooth Alveolar bone
Masseter and medial pterygoid Angle of mandible

Capsular matrix and Macroskeletal unit interactions

Capsular matrix Macroskeletal unit

Nasal mass Cranium
Eye mass Orbit
Orofacial capsule Core of mandible and maxilla

Neurotrophism
➤ Moss functional matrix theory states that soft tissues regulate the skeletal growth
through functional stimuli.

➤ The process by which the functional stimulus is transmitted to the skeletal unit
interface involves neurotrophism.

➤ Neurotrophism is a nonimpulse transmitive neurofunction involving axoplasmic

transport, providing for the long-term interactions between neurons and innervated
tissues which homeostatically regulate the morphological, compositional and
functional integrity of those tissues.

➤ There are three types of neurotrophism:

• Neuroepithelial trophism

• Neurovisceral trophism

• Neuromuscular trophism
Neuroepithelial trophism
➤ There is growth after intimate neuroepithelial contact, e.g. amphibian limb
regeneration. This is called neuroepithelial trophism.

➤ Few patients with facial hypoplasia and cleft palate exhibit concurrent sensory
deficits which clearly show neuroepithelial trophism.

Neurovisceral trophism
➤ Salivary glands are regulated by neurotrophism.

➤ Hyperplasia and hypertrophy of the gland cells seem to be under neurotrophic

control partially.

Neuromuscular trophism
➤ Moss says that nerve influences the gene expression of the cell.

➤ The periosteal muscular functional matrices regulate the size and shape of the
microskeletal units through neuromuscular trophism.

➤ Similar trophic influences probably exist for capsular matrix which passively controls
the position of macroskeletal unit.
Servo system or cybernetic theory
➤ Servo system theory was put forward by Alexandre Petrovic.

➤ Servo system theory is based on the cybernetic principles.

➤ Cybernetic theory states that everything affects everything and living organisms
never operate in an open-loop mechanism.

➤ In an open-loop mechanism, input/stimulus leads to a response. There is no feedback

or regulation.

➤ Closed-loop mechanism will operate in the following way:

➤ When a given physiological system is designed for maintaining in spite of

disturbance, a specific correspondence between input and output, it is called a closed-
loop system.

➤ There are two types of closed-loop system:

a. Regulator: In this system, the main input is constant.

b. Servo system: It is also called the follow-up system. In this

system, the main input is not constant but varies.
➤ Servo system is a type of closed-loop mechanism through which growth of mandible
can be explained.

Elements of servo system

Elements and organization of servo system are depicted in Figure 4.3.

➤ Command is a signal established independently of the feedback system under

scrutiny. It affects the controlled system without being affected by the consequences
of this behaviour, e.g. growth hormone, testosterone and oestrogen.
➤ Reference input elements: They establish the relationship between the command and
reference input, which includes septal cartilage, septopremaxillary ligament and
labionarinary muscles.

➤ Reference input is the signal established as a standard of comparison – sagittal

position of maxilla.

➤ The confrontation between the position of the upper and lower dental arch is the
comparator of the servo system.

➤ Activity of the retrodiscal pad and lateral pterygoid muscle constitutes the actuating
signal. The elastic meniscotemporal and meniscomandibular frenums of the condylar
disc form the retrodiscal pad.

➤ Controlled system is between the actuator and controlled variable, e.g. growth of
condylar cartilage through the retrodiscal pad stimulation.

➤ Controlled variable is the output signal of the servo system. The best example is
sagittal position of mandible.

FIG. 4.3. Elements and organization of servo system.

Explanation of theory
➤ According to this theory, the influence of somatotrophic hormone on the growth of
cartilages of nasal septum, spheno-occipital synchondrosis and other synchondroses
follows that of a cybernetic form of command pattern.

➤ The growth in secondary cartilages like condyle corresponds to local and

environmental factors (epigenetic control).
➤ Upper dental arch is the constantly changing reference input.

➤ Lower arch constitutes the controlled variable.

➤ Whenever there is disturbance or confrontation between the respective positions of

upper and lower arch, which is the peripheral comparator, it sends actuating signals
through the stimulation of retrodiscal pad and lateral pterygoid muscles.

➤ This affects the output signal. The output signal is the final sagittal position of
mandible. The sagittal position of mandible depends on the modification of condylar
growth by the activity of retrodiscal pad and lateral pterygoid muscle stimulation.

ACCESSORY POINTS
➤ Bone remodelling theory of craniofacial growth was put forward by Brash (1930)

➤ The concept that ‘form follows function’ was first proposed by Van der Klaauw (1948–
52)

➤ Growth relativity hypothesis was put forward by John C Voudouris, in 2000

➤ The basal tubular portion of the mandible serves as a protection for the mandibular
canal and follows a logarithmic spiral in its downward and forward movements from
beneath the cranium. This is called unloaded nerve concept

➤ Unloaded nerve concept is also called protected nerve concept

➤ Servo system theory of growth was put forward by Alexander Petrovic

➤ The four components of functional matrix revisited by Melvin Moss are:

1. The role of mechanotransduction

2. The role of an osseous connected cellular network

3. Genetics, epigentics and causation

4. The epigenetic antithesis and the resolving synthesis

Advanced Learning
Clinical implications of functional matrix theory
➤ Orthodontic correction of malocclusion is done either by intraoral and/or extraoral
appliances.

➤ Force application by these appliances tends to alter the functional matrix.

➤ Alteration of periosteal functional matrix produces changes in microskeletal unit.

➤ Alteration of capsular functional matrix produces changes in macroskeletal unit.

Orthodontic treatment that modifies functional matrix

1. Rapid palatal expansion: This causes widening of palatal sutures. It is a form of
orofacial orthopaedics.

2. Repositioning maxillary segments in cleft patients: These procedures alter the

macroskeletal unit.

3. Condylectomy: In ankylosis, condylectomy restores function and allows further

development of mandible.

4. Upper anterior inclined planes: They hold the mandible to stimulate growth of condyle.

5. Activator: To stimulate the growth of condyle.

Distraction osteogenesis: This provides simultaneous expansion

of the functional soft tissue matrix, referred to as distraction
histogenesis.
6. Functional regulator: Stimulation of both periosteal matrix through lip pads, buccal
shields and capsular matrix by altering oropharyngeal spaces.

7. Distraction osteogenesis

8. Adjuncts used with fixed appliances like class II elastics, interarch coil springs, Herbst
appliances and extraoral appliances like headgear, facemask or chin cup have direct
effect on functional matrices, primarily because of alteration of muscle and space.
Growth equivalents concept or enlow’s counterpart principle
➤ This is a concept in which the certain facial and cranial parts are compared with each
other to see how they fit.

➤ The vertical or horizontal size of one given part is compared with its specific
counterparts.

➤ A dimensional balance exists, if both of them match.

➤ Imbalances can result in either protrusion or retrusion of the part of the face.

Different counterparts or growth equivalents

➤ Nasomaxillary complex elongation is the counterpart for elongation of anterior
cranial fossa.

➤ Lengthening of spheno-occipital region is the growth equivalent of the underlying

pharyngeal region and the increasing length of ramus.

➤ Combined vertical lengthening of the clivus and mandibular ramus is the growth
equivalent to total vertical nasomaxillary region.

➤ Maxilla and mandible corpus are mutual counterparts.

CHAPTER 5
Growth of facial structures

CHAPTER OUTLINE
❖ Prenatal growth of maxilla
❖ Prenatal growth of palate
❖ Prenatal growth of mandible
❖ Postnatal growth of maxilla
❖ Postnatal growth of palate
❖ Postnatal growth of mandible
❖ Condylar growth
❖ Development of tongue
❖ Accessory points
❖ Advanced learning
❖ Growth of maxilla with regard to various theories of
growth
❖ Growth of mandible with regard to various theories of
growth
❖ Effect of continuous growth on occlusion and stability
of treatment/late mandibular growth/late incisor crowding
Prenatal growth of maxilla
Introduction
Maxillae, a pair of bones on either side of the middle third of the face, is formed by
intramembranous bone formation, i.e. bone ossifies by deposition of bone substance
over the connective tissue membrane. Mechanism of prenatal growth of maxilla is
depicted in Fig. 5.1.

FIG. 5.1. Mechanism of prenatal growth of maxilla.

Maxilla is ahead of mandible in growth generally due to its more cranial location; it
has the advantage of being close to the neural structures and follows the cephalocaudal
gradient of growth. Growth of maxilla closely follows the neural growth curve in the
Scammon’s curves.

Stages of prenatal growth

➤ The prenatal craniofacial growth develops in three stages:
 a. The period of the ovum for the first two weeks from
fertilization.

b. The period of embryo from 2nd to 8th week.

c. The period of fetus from the 9th week till birth.

➤ The tissues of the face, both hard and soft tissues, are of neural crest cell origin. The
neural crest cells are derived from the margins of the crests of the neural folds, which
is the infolding of the neural plate. The neural crest cells have great migration capacity
and though they are of ectodermal origin, they exhibit properties of mesenchymal
tissues. They are thus called ectomesenchyme.

➤ The neural crest cells give rise to diverse structures both near the site of their origin
and at remote sites. In the head and neck region, the neural crest cells give rise to the
facial processes, the branchial arches and their cartilages, the bone cells (osteoblasts)
for the membranous bones of the skull, ganglia of the autonomic nervous system,
leptomeninges, etc.

➤ In the early formative stages, the head of the fetus is occupied by the developing
forebrain. The head occupies about half of the entire length of the fetus.

➤ There are surface thickenings on the ectoderm of the forebrain that form the optic
vesicles. They later form the lens placode.

Frontonasal process (fig. 5.2)

➤ At around 21 days after conception, the head begins to take shape. The migrating
neural crest cells form two streams when they encounter the lens placode. The
anterior stream of cells forms the mesenchyme of the frontonasal process (Fig. 5.2) and
the posterior stream migrates to form the structures of the branchial arches.

➤ Between 3rd and 8th week of intrauterine life (IUL), most of the development of the
face takes place. At around 4th week of IUL, the branchial arches begin to develop.

➤ The developing forebrain, the prosencephalon, forms downward projection called the
frontonasal process which overhangs the primitive oral cavity or the stomodeum.

➤ The stomodeum at this stage is not opened to the environment but closed by a
bilaminar membrane called the buccopharyngeal or oropharyngeal membrane. This is a
temporary structure which is formed by the mucosa of the pharynx on the inside
(endoderm) and mucosa of the mouth on the outside (ectoderm). This is one of the
two sites where there is no intervening mesoderm; the other site being the cloacal
 membrane.

➤ The buccopharyngeal membrane ruptures at about 28th day of IUL. This establishes
the continuity of passage between the mouth and pharynx.

FIG. 5.2. Processes of the face.

Branchial arches
➤ The branchial arches, developing during the late somite period, are formed from the
mesoderm of the ventral foregut. The mesoderm segments to form five bilateral
mesenchymal swellings.

➤ There are five pairs of branchial arches, the fifth being transitory. The branchial
arches are separated by four branchial grooves on the external aspect and
corresponding five pharyngeal pouches on the internal aspect of the gut.

➤ The first arch is the mandibular arch and the second arch is the hyoid arch. The jaws of
the face, e.g. maxilla and mandible, are derived from the first arch.

➤ In the meanwhile, the frontonasal process of the forebrain just above the stomodeum
develops bilateral thickenings called nasal placode. In the middle, there is invagination
of the placode to form nasal pits.

➤ On both sides of the nasal pits, there are elevations, which are medial and lateral nasal
processes.

Maxillary process (fig. 5.3)

➤ By about 4th week of IUL, facial process arises from the first arch which corresponds
to the mandibular processes. Later, the mandibular processes give two more
swellings, which grow ventromedially. These are the maxillary processes.

➤ By about 6th week, the processes of the face are easily discernible. The stomodeum is
bound by the frontonasal process above, the mandibular process below and the sides
being occupied by the maxillary processes. The stomodeum is very wide at this stage
but as the development of the various processes proceeds, it narrows and forms the
mouth.

➤ The maxillary process grows ventromedially towards the nasal processes. The
maxillary process fuses with the lateral nasal process and migrates medially to
contact the inferolateral side of the medial nasal process.

➤ The maxillary and the medial nasal processes are initially separated by the epithelial
nasal fin, which soon degenerates so that the mesenchyme of the two processes can
fuse. The maxillary and mandibular processes fuse at the sides to form the cheek
tissue.

➤ The lateral nasal process forms the alae of the nose. The medial nasal process of both
sides fuses to form the globular process in the middle which gives rise to the tip of the
nose, columella, the philtrum, the labial tuberculum of the upper lip, the frenulum
and the entire primary palate.

➤ The maxillary process forms the alveolus, which bears teeth distal to the canines and
the secondary palate.

➤ The area of fusion of the maxillary and mandibular processes forms the
commissures/corners of the mouth. As the two processes grow towards the fellow of
the opposite side, the stomodeum is narrowed.
 FIG. 5.3. Maxillary process.

Ossification centres of maxilla

➤ Maxilla develops by intramembranous ossification. A primary ossification centre
appears at about early 8th week at the termination of the infraorbital nerve just above
the canine tooth lamina. There are two centres for each maxilla.

➤ Secondary cartilages appear at the end of the 8th week in the regions of the
zygomatic and alveolar processes that ossify and fuse with the primary centre.

➤ Two ossification centres appear in the region of the premaxilla on each side in the 8th
week. The centres rapidly merge with the primary centres and are overshadowed by
the growth of the primary centres.

➤ The ossification proceeds by the spread of the trabeculae of bone along the
mesenchyme of the facial processes.

Developmental defects
➤ The most prominent defect in the development of maxilla is the cleft lip either
unilateral or bilateral. The cleft lip is the result of the failure of the fusion of maxillary
and medial nasal processes. The most common is unilateral left side cleft lip (1 in 800
births). Bilateral cleft lip produces a protuberant, free hanging middle part of the lip.
The midline cleft, the ‘true hare lip’, which is theoretically due to the failure of fusion
of the medial nasal processes, is exceedingly rare. The cleft lip can be complete or
partial.

➤ Lateral facial cleft or oblique facial cleft is occasionally seen in condition of failure of
fusion of lateral nasal process with the maxillary process.

➤ The line of fusion of the maxillary and lateral nasal processes is the site of
nasolacrimal groove, which houses the nasolacrimal duct. In some instances, there
may develop a cyst in the duct.

➤ Cleft lip/palate and other facial clefts develop during the period of formation of
organ systems in the stages of the craniofacial development. This approximates to
about 28–55 days of IUL.

➤ Over fusion of the maxillary and mandibular processes leads to small mouth called
microstomia and the opposite of this condition is macrostomia. Globulomaxillary cyst
is the medial cyst in the line of fusion of globular and maxillary processes.
Prenatal growth of palate
Introduction
The closure of the palatal shelves marks the formation of separate oral and nasal
cavities which were previously single chamber opening to the outside through the
stomodeum. The palate is formed of three parts: two lateral maxillary palatal shelves
and the primary palate of the globular process.

Stages of development
➤ Even as the maxillary processes are forming, they give lateral outgrowths on the
inside of the primitive oral chamber.

➤ At that time, the palatal shelves are vertical, just lateral to the developing tongue one
on either side.

➤ In the meantime, the globular process that is formed by the fusion of the medial nasal
processes forms the primary palate. The primary palate grows in the oral chamber.

➤ All this happens within 6 weeks of IUL. At the 7th week of IUL, size of the tongue
enlarges and tongue occupies a huge volume of the oronasal chamber with the down
growing palatal shelves on both sides.

➤ During the late 7th week, the elevation of the vertical palatal shelves to horizontal
takes place (Fig. 5.4A). The process of elevation takes only few hours.

➤ The palatal shelves after becoming horizontal start fusing (Fig. 5.4B). The process of
fusion is very organized and starts only at a particular site and is not random. Fusion
starts at the site of future incisive foramen and proceeds both anteriorly and posteriorly
from there.

➤ The primary palate fuses with the two lateral shelves starting from the incisive
foramen and the line of fusion is evident in the adult by a shallow fissure. The region
is the anterior palate, which is the region anterior to the canine area and bears all the
incisor teeth.

➤ There is initial contact of the epithelium of the two processes that meet. The epithelial
layers fuse to form a single layer and disintegrate to permit fusion of the
mesenchyme. There is programmed cell death of the epithelial cells at the leading
edges of fusion.

➤ This programmed cell death or apoptosis of the intervening epithelial cells seems to
be an essential prerequisite for the fusion of the mesenchyme.
➤ There is also fusion along the dorsal surfaces of the fusing palatal processes and the
lower edge of the midline septum of the nose.

FIG. 5.4. (A) Horizontal palatal shelves and (B) at 10th week, fusion is evident.

Elevation of the palatal shelves

➤ Many theories have been proposed to reason out the start of elevation of the palatal
shelves:

(a) The most accepted theory is that as the tongue grows, it

comes to occupy a huge part of the oral volume and at
this point there is elevation of the head from the heart
prominence. This frees the mandible to grow forward and
increases the intraoral volume. The huge tongue descends
and moves forward in the new found space, mouth
opening reflexes start, and there is formation of pressure
difference in the oral chamber due to the movement of the
tongue; all of these cause the palatal shelves elevate from
a vertical to a horizontal position.

(b) There is a biochemical transformation in the physical

consistency of the connective tissue matrix of the palatal
shelves.

(c) There is a variation in the vasculature and blood flow to

 these structures.

(d) Rapid differential mitotic growth may cause rapid

elevation of the palate.

(e) The palatal shelves elevate due to an intrinsic shelf force.

(f) Muscular movements may be a reason for the elevation

of the palate.
➤ During the initial stages of fusion, the lateral palatal shelves seem to overlap the
anterior primary palate. This can be appreciated by the sloping path of the incisive
neurovascular canal.

➤ The junction of the three processes is marked by the incisive foramen and the fusion
area of the lateral maxillary processes can be ascertained by the midpalatal raphe in
the adult.

➤ In the initial stages after fusion, the palate is unarched and flat.

Ossification centres
➤ The ossification of the palate proceeds rapidly during the 8th week of IUL. There is
spread of bone through the mesenchyme of the fused lateral shelves.

➤ Ossification also proceeds from the centres in the anterior primary palate. Trabeculae
of bone appear from the primary palate and spread posteriorly. The presence of a
separate ossification centre in the primary palate is not accepted any more. The new
theory is that the trabecular migration is from the primary centre of the maxilla,
which is near the future infraorbital foramen, one on each side.

➤ Posteriorly, the hard palate ossification is from the bone from the single ossification
centre of palatine bones. The palatal ossification starts at the 8th week and is almost
completed at the 12th week save for the midpalatal suture and the soft palate.

➤ In the most posterior region, ossification does not occur, forming the soft palate.

➤ The muscles of the soft palate are formed by the mesenchyme of the first and the
fourth branchial arches.

➤ Midpalatal structures are evident from the 10½ weeks of IUL.

➤ In the early prenatal life, the palate grows in length rapidly between 7th and 18th
 week in utero and from 4th month onwards the width of the palate increases rapidly
by growth at the midpalatal suture. By birth, the length and breadth are almost equal.

Anomalies
➤ Cleft of the palate is the most common anomaly in this region. The cleft palate occurs
due to the failure of fusion of the connective tissues of the mesenchyme. After shelf
approximation, the presence of epithelium at the leading edges of fusion contributes
to failure of fusion. The failure of fusion may be due to mistiming of the critical
events that may be precipitated by environmental or genetic factors.

➤ Cleft palate varies in degrees. The least severe form is the bifid uvula where there is
failure of fusion of the posterior most parts of the palatal shelves. In contrast to the
direction of normal fusion, the cleft palate in its most severe form always involves the
posterior part, proceeding anteriorly with increasing severity.

➤ In its most severe form, there is bilateral cleft of the anterior maxilla with the free
hanging premaxilla and the cleft extending the whole length of the palate, with the
cleft lip on both sides. In the less severe form, the cleft is confined to one side of the
premaxilla. Sometimes there is isolated cleft palate without involvement of the
premaxillary region.

➤ Elevation and fusion of the palatal shelves start few days earlier in males than
females. This is the reason for the appearance of isolated cases of cleft palate in female
infants.

➤ The complete cleft palate involves the premaxilla and the cleft passes between the
lateral incisor and canine teeth. The lateral incisor, which is in the region of the cleft,
is malformed or missing. There is varying degrees of speech difficulties. The nasal
septum fuses with either the right or left palatal shelf in cases of bilateral cleft.

➤ Other anomalies are the presence of epithelial pearls in the region of the midpalatal
raphe. These are epithelial entrapments called the Epstein’s pearls.

➤ Dental lamina cysts, Bohn’s nodules (mucous gland retention cyst along the buccal
and lingual alveolar borders), are other anomalies.
Prenatal growth of mandible
Introduction
Mandible is the only movable bone of all the bones of the face. Mandible is a horseshoe-
shaped bone with the following parts:

a. Body of the mandible

b. Ramus

c. Condylar process consisting of the head and neck; the head articulates with the
glenoid fossa for the formation of the temporomandibular joint (TMJ)

d. Coronoid process

e. Alveolar process

Mandible is derived from the first branchial arch, which is called the mandibular arch.
The branchial arches start developing at about 4th week in utero.

Stages of development
Branchial arches and their components
➤ Branchial arches are bilateral mesodermal swellings that develop at around 4th week
in utero. The mesodermal core of each arch is surrounded by invasion of the
ectomesenchymal tissue that augments it.

➤ There are five branchial arches in total; the fifth being transitory. The first arch is the
mandibular arch and the second arch is the hyoid arch.

➤ The branchial arches are separated by the four branchial grooves on the external
aspect and five pharyngeal pouches in the inner aspect of the foregut.

➤ Each branchial arch has the following components:

• A central cartilage rod that forms the skeleton of the arch.

• A muscular component called the branchiomere.

• A vascular component, consisting of an aortic arch artery

 running around the pharynx from the ventrally located
heart to the dorsal aorta.

• A nervous element, consisting of sensory and special visceral

motor fibres of one or more cranial nerves supplying the
mucosa and the branchial muscle arising from that arch.
➤ The cartilage of the first arch is called Meckel’s cartilage developing at about 41st to
45th day in utero. The Meckel’s cartilage provides a template for the development of
mandible.

Derivatives of first arch cartilage

➤ The following are the derivatives of the Meckel’s cartilage:

• Ear ossicles: malleus and incus

• Spine of sphenoid

• Anterior ligament of malleus

• Sphenomandibular ligament
➤ The musculatures derived from the first arch are:

• Muscles of mastication

• Mylohyoid muscle

• Anterior belly of digastric muscle

• The tensor tympani

• The tensor veli palatini

All the muscles are supplied by the mandibular division of the

 trigeminal nerve, which is the nerve of the first arch.
➤ The mandible starts its development as a swelling, which grows ventromedially to
approach the fellow of the opposite side.

➤ In the mean time, it gives off a bud for the maxillary arch. By the time the
mandibular swelling is developing, the downward growth of the forebrain can be
visualized as the frontonasal process, which overhangs the stomodeum or the
primitive oral cavity. The floor of the stomodeum is covered by the buccopharyngeal
membrane.

➤ By the 5th week of IUL, the mandibular processes of both sides approach each other
and are fused. The Meckel’s cartilage extends from the area of future ear to the
midlines of the fused mandibular processes (see Fig. 3.23).

➤ At about the 6th week, the cartilaginous rods begin to chondrify which is continuous
from the malleolus region to the future symphysis. The rods are separated in the
midline. The rods support the forming skeletal framework of the mandible.

➤ The part of mandible mesial to the mental foramen undergoes endochondral

ossification, whereas lateral to the mental foramen undergoes intramembranous
ossification.

➤ The process of ossification proceeds anteriorly and posteriorly. Posterior

intramembranous ossification forms the rest of the body and the ramus of the
mandible.

Development of condyle and coronoid processes (fig. 5.5)

➤ The formation of condylar process starts only at the 10th week; hence, till such time
malleus and incus function as a temporary joint with the glenoid fossa of the
temporal bone to permit mandibular movements.

➤ The Meckel’s cartilage is replaced largely by bone, and the remnant of it is left as the
bones malleus and incus and the soft tissue part sphenomandibular ligament.
Ossification centre is present at the site of future mental foramen.

➤ The condylar cartilage is a secondary cartilage and its origin is unrelated to the
Meckel’s cartilage, which is a primary cartilage. The condyle arises as a separate
mesenchymal condensation that is cone-shaped at about 10th week of IUL.

➤ The process of ossification does not start till 14th week. The cartilage is replaced by
bone except the region of the tip of the head of the condyle superiorly which is
maintained till teens for future growth.
➤ Now that condyle is established, the TMJ is shifted anteriorly.

➤ The growth of the mandible at about 7th week to permit elevation of the palatal
shelves is largely contributed by the growth of the Meckel’s cartilage.

➤ The ossification of the ramus proceeds and the condyle is soon fused to the mandible
at about 16 weeks.

➤ Coronoid process develops from secondary cartilage that arises at about 10th–14th
week in utero. Soon the growing intramembranous ossification fuses the coronoid
process to the ramus.

➤ One or two cartilaginous fragments in the region of the mental foramen ossify and
become fused with bone at 7th month of IUL.

➤ The ossification centre is at the site of future Meckel’s cartilage, one on either side.
Ossification proceeds anteriorly and posteriorly from here and stops at the site of
future lingula.

FIG. 5.5. Formation of condyle and coronoid processes.

Anomaly
The failure of fusion of both the mandibular processes from both sides leads to a
midline cleft. This is rare occurrence.
Postnatal growth of maxilla
Introduction
➤ Maxilla is a membranous bone and the development/growth of maxilla is completed
early when compared to the mandible.

➤ According to the cephalocaudal gradient of growth, growth does not proceed

proportionately in the human.

➤ The best example of this phenomenon is the growth of head which being cranial part
of the body occupies about 50% of the body length in utero but during birth it is
reduced due to the growth of the other caudal structures and in adult life head
occupies only 8% of the body length.

➤ The rationale is that head completes its growth early while all other structures, like
trunk and limbs, catch up later.

➤ So is the case of maxilla, it completes its growth early in life in certain aspects,
relative to the mandible.

➤ The maxilla (especially width) also follows closely the neural growth curve more
than the general growth curve in the Scammon’s curve.

Mechanisms of bone growth

The growth of any bone follows certain basic processes like remodelling and growth
movements caused by drifts and displacements. Maxilla cannot be considered a separate
bone. It has to be the nasomaxillary complex because of the close association or
attachment of maxilla to the cranial base. Mechanism of postnatal growth of maxilla is
depicted in Fig. 5.6.
 FIG. 5.6. Mechanism of postnatal growth of maxilla.

Remodelling
➤ Remodelling is the differential growth activity necessary for bone shaping. It is not a
uniform process. The process of remodelling is differential, e.g. if deposition takes
place on the outer/periosteal surface of bone then resorption takes place in the
endosteal surface.

➤ Remodelling is the basic growth process providing regional changes in the shape,
dimensions and proportions of bone.

➤ It also performs regional adjustments in the bone to the changing functional

demands.

Growth movements
Two types of growth movements occur during the enlargement of the cranial bones –
drift and displacement.

➤ Drift: It is the movement of the bone surface caused by deposition and resorption
towards the depository surface. It is otherwise called transformation.

➤ Displacement (Fig. 5.7): It is the growth of the bone as a whole unit so that the bone is
taken away from its articulation with other bones. It is otherwise called translation.

➤ Displacement is of two kinds: (i) primary or active, in which the movement is due to
the growth of the bone itself, e.g. growth of maxilla at tuberosity region, and (ii)
secondary displacement, which is the movement of one bone due to the growth of other
 bones or translation within the capsule. It is passive, e.g. growth of maxilla due to
growth at the spheno-occipital synchondrosis.

FIG. 5.7. Displacement of maxilla.

Growth of maxilla
Growth of maxilla occurs by the following processes:

I. Connective tissue proliferation at the sutures

The maxillae articulate with the surrounding bone with the

help of sutures. The zygomaticomaxillary, frontomaxillary,
pterygopalatine and zygomaticotemporal sutures to name a
few.

According to Sicher, growth at these paired parallel sutures

will move the maxilla downwards and forwards. It is only
secondary and not a primary mechanism.
II. Translation

Translation of a bone is the process by which specific local

areas come to occupy new actual positions in succession as
the entire bone enlarges. Translation may be active or
 passive.

• Passive translation takes place when maxilla grows

downwards and forwards by the growth of the spheno-
occipital synchondrosis or the cranial base/growth of the
nasal septum.

• Passive translation also takes place when the maxillary bone

is translated in space by the growth of the corresponding
capsular matrices. There are three capsules with regard to
the nasomaxillary complex. They are the orbital, nasal and
the oral capsules.

• Active translation takes place when the growth at the

tuberosity of the maxilla pushes the maxilla forward.
III. Remodelling

Simultaneous resorption and deposition moves the surfaces of

the maxilla while maintaining the integrity and basic shape
of the bone. Maxillary growth matures first in width
followed by the depth and length. It would be easier to
discuss the growth of maxilla in that order.
Maxillary width
➤ Midpalatal suture is active till 15 years but it cannot be generalized. There is gender
difference in the fusion of the suture. There is bone fill in the midpalatal area due to
sutural growth and resorption in the lateral aspect.

➤ In the maxillary sinus, as the sinus enlarges there is resorption on the inner surface
and apposition on the outer surface.

➤ In the zygomatic process and the zygomatic arch, it is more complex. There is
apposition on the posterior and lateral aspect and resorption in the anterior and
medial surface. There is posterior and lateral movement of the arch.
Nasal cavity
➤ The nasal part of the maxilla inside the nasal cavity faces in an anterior, lateral and
superior direction. The growth proceeds in the same direction. There is surface
removal of bone from the periosteum lining the inner aspect of the nasal cavity and
deposition takes place in the endosteal surface. This allows expansion of the nasal
cavity.

Orbital part of maxilla

➤ The orbital floor similarly faces laterally, anteriorly and superiorly. Growth proceeds
in this direction by deposition and resorption on the lateral surface of the orbital rim.

Anteroposterior/depth
➤ Zygomatic bone moves posteriorly and laterally by deposition in the posterior and
lateral surface and resorption in the medial surface.

➤ In the anteroposterior direction, there is growth by apposition in the posterior

tuberosity area so that there is increased space for the permanent teeth. As maxilla
moves forward, there is resorption of the anterior surface of the periosteum from the
anterior nasal spine to the alveolar margins of the incisors. This makes the anterior
portion more concave. There is concomitant apposition in the endosteum. Deposition
occurs in the anterior nasal spine to make it more prominent.

➤ The zygomatic bone moves in a posterior direction to keep its relation with the
maxilla. This happens by resorption in the anterior surface and deposition in the
posterior surface.

Maxillary height
➤ In the vertical direction, the maxillary bones increase in height by apposition along
the alveolar process. This increase is seen as long as the teeth erupt. This contributes
to early increase in the height of maxilla and also makes up for about 40% increase in
the maxillary height. Growth in height by alveolar growth also expands the maxilla
due to divergence of the alveolus as it grows.

➤ There is resorption along the nasal floor and deposition along the palatal roof. There
is a shift of the palate in a downward direction.

➤ The premaxilla also undergoes a downward shift by resorption along the periosteal
surface of the labial cortex and deposition along the endosteal side of the cortex and
the periosteal surface of the lingual cortex.

Conclusion
The remodelling of the maxillary complex is found to be under neurotrophic influence.
The remodelling takes place in such a way that the basic shape of the bone is
maintained. In other words, the infraorbital neurovascular triad acts as the basic skeletal
unit of the maxilla that protects the trigeminal nerve.
There is maintenance of the constant position of the neurovascular triad in space
despite growth by various remodelling processes.
Postnatal growth of palate
Introduction
Postnatal growth of the palate follows the concept of expanding ‘V’ by Enlow. Many of the
cranial bones have a V-shaped configuration. The process of growth by this concept
does not follow the arbitrary rule of apposition on one surface and resorption on the
other. It is more complex.

Growth at the midpalatal suture

Growth at the suture by bone fill-in contributes more to the increase in width of the
palate than remodelling. The growth of width of the palate also increases by the growth
of the alveolar process which diverges out.

‘V’ principle of enlow

The growth of the palate is one of the best examples of the expanding V principle by
Enlow (see Fig. 3.8).

➤ Many bones or parts of a bone are in the form of V. Bone deposition takes place on
the inner side of V and resorption takes place on the outer surface.

➤ V moves from one position to another and also increases in overall dimensions. The
direction of growth is towards the wide end of the V. A simultaneous growth
movement and enlargement of the bone occurs.

➤ If the outer surface of the expanding V is taken, then the periosteal surface can be
found to be lined with osteoclasts, and the endosteal surface is found to be lined with
osteoblasts.

➤ There is noncomitant resorption and apposition of bone so that the endosteal surface
is found to be occupied by periosteal bone. This is best illustrated by implant studies
where implants placed in the periosteal surface on the narrower part of the V become
subsequently released from the bone by resorption on that surface.

➤ The implants placed in the wider part of the V also become released but not fully
because the bone is expanding in this region.

Palate as ‘V’
➤ In the young child, the maxillary arch and the nasal floor are very close to the inferior
orbital rim. By deposition on the palatal periosteal surface and resorption on the nasal
 floor, the palate comes to occupy a lower position.

➤ When viewed in the cross-section, the deposition of the bone occurs along the whole
of the periosteal surface of the palate in such a way that the bone expands in a lateral
direction and also downwards.

➤ The nasal floor due to resorption increases in volume and descends down from the
level of infraorbital rim.

➤ In conjunction with the V principle, half of the external surface involved in this
growth is depository and half resorptive; thus, half of the bone tissue of the palate is
endosteal and half is periosteal.

➤ Even in the anteroposterior growth of the palate/midsagittal section of the palate, the
same concept is seen. There is deposition on the palatal surface and resorption along
the anterior surface/incisor area and superior surface, expanding the palate like a V.
Postnatal growth of mandible
Mandible at birth
Mandible at birth is much smaller in size and there is slight variation in shape from the
adult form. The infant mandible has a short more or less horizontal ramus with obtuse
gonial angle. The condyles are low and at the position of the occlusal plane. The
symphyseal suture has not ossified.

Functional matrices of mandible

Mandibular growth in the postnatal life shows the integration of the periosteal and
capsular matrices of functional matrix theory by Moss. Capsular matrix involves the
oropharyngeal functional spaces and the mandible grows according to the functional
needs of the particular functional system. The process of surface remodelling usually
involves the activity of the periosteal matrix (muscle fibres).

Growth in the first year

➤ The growth of mandible in the first year of life involves growth at the symphyseal
suture and lateral expansion in the anterior region to accommodate the erupting
anterior teeth. The mental foramen is directed at right angle to the surface of the
corpus.

➤ There is increased deposition in the posterior surface of the ramus of the mandible.

➤ The infant mandible is suited for the suckling activity since the condyle and the
glenoid fossa is flat, which helps in the anteroposterior movement of the mandible.

Mandible in the adult/concept of V

➤ Mandible in the adult is different from the mandible of an infant. The ramus is longer
and the gonial angle is less obtuse. The bone is larger on the whole and the condyle is
well developed.

V principle of growth: Mandible

➤ All these changes take place with the growth of the mandible in the form of an
expanding V (Fig. 5.8). It is easier to visualize mandible as the V-shaped bone than
the maxilla because of its horseshoe shape.
 FIG. 5.8. V principle of growth in mandible.

Length
➤ The growth of the mandible in length anteroposteriorly is by the deposition of bone at
the posterior surface of the ramus and resorption of the leading edge of the anterior
surface (Fig. 5.9). This helps to lengthen mandible so that the anterior part of the
ramus is occupied by the posterior part of the body in the future and to accommodate
the developing permanent molars.

➤ As the mandible grows posteriorly, it is displaced anteriorly because the articulation

of the condyle to the glenoid fossa is constant and the change in length can take place
only by the anterior displacement. As the mandible grows anteriorly, the opening of
the mental foramen faces backwards so that the neurovascular bundle leaves the
foramen directed backwards.

➤ There is corresponding surface remodelling at the anterior border with deposition in

the posterior surface of the symphysis and resorption in the superior part of the
anterior surface and deposition in the inferior aspect.
 FIG. 5.9. Mandible: sites of bone deposition (+) and resorption (–).

Width
➤ There is deposition on the lateral surface of the ramus and resorption on the lingual
surface below the mylohyoid ridge.

➤ In contrast, the coronoid process, which looks almost like an extension of the ramus
in the anterior border, undergoes apposition at the medial surface and resorption at
the lateral surface. This expands the mandible like a V.

➤ The condyle undergoes reduction of bone on the lateral aspect of neck and
deposition corresponding to the V principle, which makes the condyle longer at the
neck.

➤ Thus, the interramal distance is efficiently increased by the growth of mandible

following the V principle. This helps the mandible to keep pace with the growth of
the cranial base.

➤ The alveolar bone increases the height of the bone by filling the intermaxillary space.

➤ The mandible, which is often retrognathic in the newborn, assumes an orthognathic

relation with the maxilla during adulthood due to the growth of the bone in length.

➤ Contrary to the old belief, it is now found that the condylar cartilage contributes
little, if any, to the growth and does not act as primary growth centre. In patients with
ankylosis of the TMJ, mandible is found to grow to normal length.

➤ The muscular processes of the mandible, like the angle, coronoid and condylar
processes, are under the influence of the periosteal matrix.
Height
➤ Alveolar process height correlates well with the eruption of teeth.

➤ Bone deposition taking place in the lower border of mandible also contributes to
increase in height of the mandible (Fig. 5.9).

Unloaded nerve concept

➤ The body of the mandible, which forms a basal tubular portion in the form of an arc
from the foramen ovale through the mandibular to the mental foramen, is the most
constant portion of the mandible. This portion of the mandible is in the form of a
logarithmic spiral form, the foramen ovale to mental foramen protecting the
mandibular nerve.

Rotation of mandible
➤ Bjork used implants to study the growth pattern of mandible. He found that
mandible undergoes growth rotation in the form of intramatrix and matrix rotation
when the body of the mandible is considered the matrix. It was found that though
mandible undergoes rotation, the effects seen are minimal due to external
compensation.

➤ The mandible may be absent in some cases; this condition is called agnathia.
Macrognathia, a condition of prognathic mandible, is seen in hyperpituitarism.
Micrognathia is seen in Pierre Robin syndrome, defective mandible is seen in Treacher
Collins syndrome, Down syndrome, etc.
Conclusion
The growth of mandible is largely influenced by the functional matrices and condylar
cartilage has little influence in its overall growth.
Condylar growth
Prenatal growth
➤ The condylar cartilage develops from mesenchymal cells unrelated to the first
branchial arch.

➤ It is, therefore, referred to as secondary cartilage, since its formation is secondary to the
original primordial cartilage.

➤ Condylar cartilage formation starts at 8 weeks of IUL when it is separated from the
rest of the mandible.

➤ Later, it fuses with the mandibular ramus at about 16th week of IUL.

➤ Initially, the condylar cartilage appears as cone or carrot-shaped, the large end of the
cone assuming the position of future condyle (see Fig. 5.5).

➤ By 20th week, the wedge of cartilage is connected to bone except for a thin layer of
articular surface.

Postnatal growth
➤ Condylar cartilage covers the surface of the mandibular condyle at the TMJ.

➤ The individual condyle remodels according to the expanding V principle.

➤ Condylar cartilage can be visualized as being positioned on the inner aspect of the
expanding V.

➤ Neck of the condyle is lengthened by the reduction of the bone situated on the side of
the V, away from the direction of the growth (Fig. 5.10).
 FIG. 5.10. Growth at the condyles following the V principle.

Condylar growth and functional matrix

➤ Mandible exists within a functional matrix.

➤ Growth of mandible is entirely secondary.

➤ Mandible exists within a capsule formed by the soft tissues of the face.

➤ Therefore, expansion of the functionally related tissues is the primary event in

condylar growth. Proliferative and subsequent endochondral ossifications of the
condylar cartilage are secondary compensatory mechanisms.

➤ Growth of the facial viscera translates the entire mandible in space.

➤ As a result, the TMJ articulation will be lost as the condyles are disengaged.

➤ Condylar growth takes place in posterosuperior direction in order to preserve the

functionally important TMJ.
Development of tongue
Introduction
Tongue is a unique organ because it develops from more than one branchial arches. The
tongue is composed of base, body and tip.
It has two surfaces – dorsal and ventral and two lateral borders. The dorsal surface of
the tongue is divided into anterior two-thirds and posterior one-third by the sulcus
terminalis, which is a V-shaped groove. In the centre of the V is the foramen caecum.

➤ The tongue arises from the ventral wall of the primitive oropharynx from the lining
of the branchial arches.

➤ The tongue develops from the first, third and the fourth arches. At about 4th week in
utero, paired lingual swellings appear in the mesenchyme of the first branchial arch
(Fig. 5.11).

➤ From the third arch, behind the lingual swellings arise the tuberculum impar, a median
swelling.

➤ Behind the tuberculum impar is a pit called the foramen caecum that marks the site of
origin of the thyroid diverticulum. It extends into the pharynx to form the major
portion of the thyroid gland.

➤ The lingual swellings grow and fuse with each other and growing over the
tuberculum impar to form the anterior two-thirds of the tongue.

➤ The ventral parts of the second, third and forth arches fuse to form the copula in the
midplane. The posterior portion of the eminence forms the hypobranchial eminence.

➤ The circumvallate papillae along the sulcus terminalis form at about 2–5 months in
utero. Fungiform papillae develop at 11 weeks in utero.

➤ Muscles are derived from the occipital somites and are supplied by the hypoglossal
nerve.

➤ The tongue grows rapidly at 6–7 weeks in utero such that the whole oronasal cavity
before the elevation of the palatal shelves is occupied by the tongue. The lateral
palatal shelves are on either side of the tongue.

➤ Mandible is retrognathic at this juncture. The head rests on the heart prominence and
hence the mandible cannot grow. The withdrawal of the head of the fetus from the
heart prominence is followed by the anterior growth of mandible and anterior
displacement of the tongue. The tongue descends to occupy a lower position in the
 increased oral volume and allows the palatal shelves to elevate.

➤ The sensory supply of the anterior two-thirds of the tongue is by the lingual nerve
and the gustation is by chorda tympani nerve. The posterior one-third is supplied by
the glossopharyngeal nerve and posterior most part by the vagus nerve.

➤ In the infant stage of life, tongue is an important organ because it helps in the process
of suckling. The tongue is placed between the gum pads to create an oral seal.

➤ The position of the tongue is always anterior in the infants and the contact of the
tongue to the lower lip is very important. It reinforces the suckling action. The tongue
is found to follow the lower lip, if the lip is retracted at this stage.

➤ The tongue attains adult size at about 8 years of age. The size of the tongue is almost
double when the size of the newborn and adult tongue is compared.

FIG. 5.11. Development of tongue.

Anomaly
➤ Conditions of abnormally large tongue called macroglossia is common in
hyperpituitarism. The lateral borders of the tongue are found to have crenations in
macroglossia. The condition is also seen in Down syndrome.

➤ The smaller size of the tongue is called microglossia. Absence of the tongue, aglossia,
is rare.

ACCESSORY POINTS
Growth sites in maxilla
1. Maxillary tuberosity area

2. Nasal septum

3. Sutures

4. Alveolar process

5. Lateral walls

Growth sites in mandible

1. Condyle

2. Coronoid process

3. Alveolar process

4. Ramus – posterior surface

5. Lower border of mandible

Size of embryo at different stages

➤ 1.5 mm: 2 weeks; 5 mm: 4 weeks

➤ 14.5 mm: 7 weeks; 20 mm: 8 weeks

➤ 60 mm: 12 weeks; 69 mm: 14 weeks

Neural crest cell migration is completed by 4 weeks

Fusion of maxillary process occurs at 7th week of IUL

➤ 8–12 weeks (eyelids and nostrils are formed, marked acceleration of mandibular
growth is seen)

➤ 11 weeks (papilla of tongue is formed)

➤ 12 weeks (tastebuds are formed; form of malleus, incus and stapes are completed)

➤ Fusion of condylar cartilage with the mandible takes place at 4 months of IUL

Ossification centres
➤ Maxilla: One above canine fossa and two for premaxilla

➤ Mandible: One each in the area of future mental foramen

➤ Ossification of mandible stops at future lingual

Behrent’s finding on adult growth

➤ Craniofacial size and shape changes are seen even after 17 years of age

➤ Adult growth continues in the same direction as adolescent growth

➤ Skeletal changes are mainly because of localized remodelling

➤ Sexual dimorphism exists in adult growth. Men tend to grow more

➤ Women show increased rate of growth during pregnancy

➤ The quantity or amount of growth is not sufficient for growth modulation treatment

Advanced Learning
Growth of maxilla with regard to various theories of growth
Introduction
➤ Maxillae, a pair of bones on either side of the face, form an important component of
the midface.

➤ The growth of maxilla cannot be discussed with regard to a single bone but must be
viewed as the growth of maxillary complex.

➤ The process of remodelling takes place in such a way that apposition in one bone is
accompanied by resorption in other bones or other surfaces of the same bone.

➤ Hence, the nasomaxillary complex as a whole grows downwards and forwards.

➤ Growth of the complex can be explained with various theories of growth.

1. Sutural dominance theory

• Sicher proposed the sutural theory in which he hypothesizes

that it is the proliferation of the connective tissues in the
suture that created enough force to separate the bones.
There is subsequent bone filling at the separated site, thus
growth of the bone ensues.

• Sicher pointed out that the nasomaxillary complex is

 composed of paired, parallel and oblique sutures.

• Connective tissue growth at these sutures would result in

apposition of bone at the sutural ends.

• The nasomaxillary complex as a whole grows downwards

and forwards.

• The sutures involved are as follows:

- Zygomaticomaxillary suture

- Zygomaticofrontal suture

- Frontomaxillary suture

- Frontonasal suture

- Intermaxillary suture
2. Cartilaginous theory

• Cartilaginous theory by Scott proposes that the cartilage acts

as growth centres, in other words inherent growth potential
resides in the cartilage.

• With regard to maxillary complex, nasal septum is seen as

the important growth centre.

• In many parts of the body, it is seen that it is the cartilage

that grows while bone merely replaces it. Nasal septum by
its growth pushes the nasomaxillary complex downwards
and forwards.
• Nasal septum has been proved to have some growth
potential in transplantation experiments. Experiments in
which nasal septum were removed in animals showed that
there was midface deficiency and retarded growth.
3. Functional matrix hypothesis

• The functional matrix hypothesis by Moss claims that the

growth of any skeletal component is only secondary,
compensatory and mechanically obligatory process in
response to prior events and changes that take place in the
related soft tissue functional spaces.

• Moss divides the whole craniofacial skeleton into various

functional cranial components.

• Functional cranial component is the sum of soft tissue and

skeletal elements performing a single function.

• He divided the functional cranial component into functional

matrix and skeletal unit.

• Functional matrix again is divided into periosteal matrix and

capsular matrix.

• The capsular matrix for maxillary growth is nasal and oral

capsules. Volumetric expansion of these capsules causes
translation of maxillary complex. Facial bones are passively
carried downwards and forwards.

• There is also the growth of sinuses and functional spaces in

the nasal maxillary complex which causes growth of the
bones.
• The periosteal matrices are the teeth (growth of the
alveolus), muscles and arteries.

• Periosteal matrices through their function influence growth

of the bone by remodelling.

Growth of mandible with regard to various theories of growth

The growth of mandible can be explained with various theories as follows.
Sutural dominance theory and cartilaginous theory
➤ Though Sicher’s theory is called sutural dominance theory, Sicher gives equal
importance to cartilage, periosteum in par with the sutures. Both the sutural and
cartilaginous theories consider condylar cartilage to be the primary centres of growth
for the mandible.

➤ Growth of condylar cartilage causes downward and forward growth of mandible.

➤ Condylar cartilage is a secondary cartilage. In transplantation experiments, it was

revealed that the condylar cartilage does not have any inherent growth potential.

Functional matrix hypothesis

➤ Functional matrix hypothesis by Moss proclaims the dominance of the soft tissue
growth over the skeletal growth.

➤ According to Moss, the function of the soft tissue related to the skeleton influences its
growth.
➤ Functional cranial component is the sum of the skeleton and soft tissue associated
with a single function.

➤ Functional cranial component comprises functional matrix and skeletal unit.

➤ Functional matrix is the soft tissue functioning component which is divided into
periosteal and capsular matrix.

➤ Mandible represents the integrity of the activity of periosteal and capsular matrices.

➤ Skeletal unit is divided into microskeletal and macroskeletal units (Fig. 5.12). Growth
of microskeletal unit is associated with periosteal matrix, and of macroskeletal unit is
associated with capsular matrix.

➤ The mandibular matrix consists of

• All muscles attached to mandible

• Neurovascular triads

• Associated salivary glands

• Teeth

• Fat, skin and connective tissues

• Tongue

• Oral and pharyngeal matrix

 FIG. 5.12. Core of the mandible (blue stippled part) is the macroskeletal unit and the
remainder part is the microskeletal unit in mandible.

➤ Mandible is passively translated in space (growth) through the expansion of the oral
and pharyngeal spaces.

➤ Coronoid and condylar processes, angle of the mandible, are the microskeletal units.
They are associated with periosteal matrices like temporalis, masseter and medial
pterygoid muscles. Activities of these muscles regulate the growth of these regions by
remodelling.

➤ Mandibular growth is the sum of translation caused by expansion of capsular matrix

plus the changes in form by the activity of periosteal matrix.

Effect of continuous growth on occlusion and stability of treatment/late

mandibular growth/late incisor crowding
➤ Malocclusion is a combination of skeletal and dental problem.

➤ Continuous growth in undesirable pattern could affect both the dental and skeletal
bones.

Effect on lower incisors crowding: There is a tendency for lower incisors crowding to
develop after teen age.

Late incisor crowding:

Three reasons are attributed:

1. Lack of normal attrition

2. Third molar eruptive force

3. Late mandibular growth
There are three stages:

1. Lack of normal attrition

• Intake of refined foods by the present day children leads to

lack of normal interproximal attrition or wear.

• During growth, shortening of arch length and mesial

migration of teeth occur.

• This shortening is compensated by the reduction in width of

the tooth material by interproximal attrition.

• Interproximal attrition takes place with coarse diet only.

• Since there is too much of intake of refined foods, there is

lack of interproximal reduction which causes crowding in
the lower arch.

• Though this theory seems to explain the delayed crowding,

the concept is not accepted, as crowding is not always
present even in individuals who take refined food.
2. Force from third molars

• Late incisor crowding coincides with the time of eruption of

third molars.

• So one school of thought says that the pressure from the

erupting third molars is the reason for late incisor crowding.

• But amount of pressure from third molars is not sufficient to

cause pressure effect and changes in lower incisors.
• Hence, this theory is also not foolproof.
3. Late mandibular growth

• Mandibular growth continues even after cessation of

maxillary growth.

• When mandible grows continuously and since mandible is a

contained arch, the mandibular incisor teeth tend to move
lingually.

• As a result of the mandibular growth, the dentoalveolar

portion reacts in such a way that any one of the following
reactions take place:

• Mandible is displaced distally and causes TMJ problems.

• Maxillary incisors are proclined and spaces are created in

maxillary anterior region.

• Lower incisors move distally and get crowded.

• The third reaction is the most common occurrence followed

by TMJ problem. Spacing in the maxillary incisors is the
least frequent.

Contemporary view of late incisor crowding

➤ Incisor crowdingn moves distally due to late mandibular growth.

➤ If there is space distal to the third molar, crowding will not occur.

➤ If there is lack of space, extraction of third molars allows the teeth to shift distally
and prevent crowding.
CHAPTER 6
Child psychology

CHAPTER OUTLINE
❖ Need to study child psychology
❖ Theories of developmental psychology
❖ Psychoanalytical theory
❖ Psychosocial theory/Erikson’s theory
❖ Cognitive theory
❖ Correlation of various theories of psychology
❖ Behaviour learning theories
❖ Classical conditioning
❖ Operant conditioning
❖ Observational learning/modelling
❖ Types of child behaviour
❖ Frankel’s rating
❖ Wright’s classification
❖ Lampshire’s classification
❖ Motivation of a child
❖ Child behaviour management techniques used in orthodontics
❖ Accessory points
Need to study child psychology
➤ Psychology is described as the science of behaviour.

➤ Psychology seeks to understand the abilities, motives, thinking processes and actions
of people.

Reasons for studying child psychology

➤ A good knowledge of psychology makes it possible to meet the specific needs of the
patient according to age and maturation.

➤ Helps in understanding the reaction of children undergoing treatment as well as the

best ways in nealing with them.

➤ Makes it possible to understand deviations from expected behaviour.

➤ Makes it possible for the orthodontist to adjust his/her own reactions and behaviour
in treatment session.

➤ Makes it possible for the orthodontist to see through the eyes of the child or patient.

➤ Increased knowledge of mental health, emotional problems and the psychology of

the patient permits an orthodontist to deal more effectively and efficiently with
his/her patient and improve patient compliance.
Theories of developmental psychology
The various theories of psychology are depicted in Fig. 6.1.

FIG. 6.1. Theories of psychology.

Psychoanalytical theory
➤ Psychoanalytical theory was put forward by Sigmund Freud (1856–1939).

➤ Freud’s theory emphasized the interplay of surroundings and society in emotional

development (Fig. 6.2).

➤ This theory lays emphasis on innate behaviour, mainly sex urge.

➤ According to Freud, within each individual, there are three systems.

➤ These are called id, ego and superego.

▸ The personality or behaviour of an individual is based on the interaction of these three

systems.
 FIG. 6.2. Psychoanalytical theory.

The id (fantasy)
➤ It is the source of all pleasures and gratification.

➤ It represents the unconscious, instinctive urge which motivates the behaviour.

➤ It operates on pleasure principle.

➤ Id aims at immediate satisfaction of libidinal urges.

➤ It is illogical, immoral and lacks purpose.

➤ The inner urges of the id can find satisfaction through external sources.

The ego (reality)

➤ The ego makes interaction with the social world and permits the need of the id to be
satisfied.

➤ At the same time, ego responds to the reality principle.

➤ Ego plays the role of mediators, controls the tendency of id and modifies or excludes
the tendencies that are in conflict with the reality.

➤ Ego serves to control the id’s pleasure-seeking tendency.

The superego (idealistic)

➤ Superego plays the role of conscience.
➤ It is the superego which makes judgements on the individual’s actions.

Interaction between id, ego and superego

➤ According to Freud, a child is born with only id.

➤ The ego and superego develop later under the training and influence of
environment.

➤ Superego makes value-based judgements about the individual urges and impulses.

➤ The mind embodies value system, ideals and concepts of what is right or wrong.

➤ In a person’s character, there is always a conflict between ego and superego.

➤ If it exceeds a certain level, some individuals develop personality disorder.

➤ Ego develops defence mechanisms to hide from superego the fact that id impulses
are being satisfied. Some of the defence mechanisms are depicted in Table 6.1.

Table 6.1.
Defence mechanisms

Defence mechanism Explanation

Suppression Intentional exclusion of material from consciousness
Projection Blaming others for their own behaviour and limitations
Identification Identifying oneself with powerful or famous persons
Rationalization Justifying one’s behaviour
Fantasy Imagining success

Freud’s stages of development

Oral stage ( 0–1.5 years)

➤ Mouth is the most important organ of the body during infancy.

➤ Child seeks satisfaction of his/her needs through the mouth.

➤ Manipulation of the mouth, lips and tongue on the bottle and breast brings
happiness and satisfaction for the child.

➤ Problems in this stage can lead to abnormal habits like thumb sucking.

➤ Passive aggression and sarcasm are features of this stage.

Anal stage (1.5–3 years)

➤ Egocentric behaviour is the characteristic feature of this stage.
➤ Toilet training takes place in this stage.

➤ Pressures of accumulated waste in the lower digestive tract results in the individual
to seek relief from discomfort through defaecations.

➤ Anal zone becomes the main area of pleasure.

➤ Stubbornness, strong and contradictory feelings are features of this stage.

➤ Overemphasis by adults on toilet training results in compulsion, obstinate and

perfectionist behaviour in later life which is called anal personality.

Phallic stage (3–5 years)

➤ Child focuses attention on the genitals.

➤ Child starts understanding the sex differences.

➤ Child attributes more importance to anatomic differences.

➤ Electra complex in girls and Oedipus complex in boys develop at this stage.

➤ Electra complex: The girl child develops attraction to the father. In Greek mythology,
Electra kills the lover of her father to win her father’s love. That is why it is named as
Electra complex.

➤ Oedipus complex: The male child gets attached to mother and starts thinking his father
as enemy. Male child wants to rival his father for his mother’s attention.

Latent stage (6–12 years)

➤ No bodily organ predominates this stage.

➤ Child is less ego centric.

➤ School friends and adults outside home are important.

➤ Child starts adapting to difficult situations.

➤ Maturation of ego and mastery of skills take place.

Genital stage (13–19 years)

➤ Signifies the onset of puberty.

➤ Attraction towards members of the opposite sex.

➤ Focus is on reproduction and mutual pleasure between partners.

➤ Dependence on parents is reduced.

➤ Tries to achieve individual identity.

Psychosocial theory/erikson’s theory

Introduction
➤ Erik Erikson’s work is actually an extension of Freud’s psychoanalytical theory.

➤ But it represents a great departure from psychosexual concept.

➤ The society in which a child grows up has been accorded greater significance by
Erikson.

➤ His eight stages of man represent a progression through a series of personality

development (Figs 6.3 and 6.4).

➤ Erikson says psychosocial development proceeds by critical steps, which means with
turning points.

➤ Chronological age may not correlate with developmental age.

1. Development of basic trust (0–18 months)

• In this stage, a basic trust or lack of trust develops.

• Successful development of trust depends on a caring mother

who meets both physiologic and emotional needs of the
child.

• A strong bond must develop between the mother and child.

This helps to develop basic trust in the child.

• Physical growth can also be affected, if there is lack of

maternal affection (maternal deprivation syndrome).

• Since there is a tight bond between the child and parent, it is

a must that during treatment parent should be with the
 child.

• Child who does not develop trust will be frightened and

becomes an uncooperative patient in the future.
2. Development of autonomy (18 months–3 years)

• In this stage, child moves away from the mother and

develops a sense of autonomy.

• This stage is called ‘terrible two’s stage’.

• Child will be uncooperative during this period.

• Typically you can see a child doing what he/she likes. The
child runs away from parents, but in times of distress comes
back to the parents for dependence.

• At this stage, enforcement of limits on behaviour allows the

child to develop trust in a predictable manner.

• Failure to develop proper sense of autonomy in a child

results in the development of doubts in the child’s mind
about his/her capacity to stand alone.

• Parents should accompany the child at this stage.

• Child should be made to understand that whatever the

doctor does is as per the child’s wish.
3. Development of initiative (3–6 years)

• This is a continuation of autonomy that, in addition, the

child plans and pursues vigorously in various activities.
• At this stage, child’s talent should be channelized to
manageable tasks, so that the child succeeds and initiative is
reinforced.

• Opposite is guilt. If the child continuously fails in his/her

attempt, a sense of guilt develops.

• This is the stage when most of the children visit dentist for
the first time.

• Child is intensely curious in dental office and tolerates

separation from mother.
4. Mastery of skills (7–11 years)

• Child acquires mastery of skills – both at academic and

social level.

• Child learns the rule by which the world is organized.

• Child develops industriousness to enter the competitive

world.

• Parent’s influence on the child decreases while that of the

friends increases.

• Inferiority develops when the child is not able to prove

themselves.

• Orthodontic treatment begins at this stage and it involves

wearing of removable appliance.

• Success of orthodontic treatment depends on child’s

understanding of the orthodontic problem and also of the
 friends’ attitude.

• Acceptance by the friends increases the motivation.

5. Development of personal identity (12–17 years)

• This is the period of adolescence in which intense physical

and hormonal changes take place.

• Child also develops personal identity.

• Sense of identity includes a sense of belonging to a large

group usually friends and a feeling that they can exist
outside the family.

• Academic responsibilities, career planning, physical ability,

changes and sexual attraction, all mark this stage.

• Seen more with friends than with family.

• Parental authority is rejected by the children. Therefore,

internal motivation is necessary for successful orthodontic
treatment.
6. Development of intimacy (young adult)

• There is establishment of intimate relationship with others.

• Appearance as one of the important factor in development of

a relationship is given more importance.

• Many young adults come for orthodontic correction, if they

feel there is something wrong with their facial appearance.
7. Guidance of next generation (adults)
• Establishment and guidance of the next generation is the
important responsibility of a mature adult.

• Responsibilities, like good parenting, service to the

community, group and nation, come into play.

• Negative personality is self-centred and self-indulgent.

8. Attainment of integrity (late adult)

• Last stage of this theory is attainment of integrity.

• Integrity is the feeling that one has made the best of his/her
life’s situation.

• Opposite character is despair – experiencing disgust and

unhappiness on a large scale.

FIG. 6.3. Stages 1–4 of psychosocial theory.

 FIG. 6.4. Stages 5–8 of psychosocial theory.

Cognitive theory
➤ This theory deals with the development of intellectual capabilities.

➤ This theory was proposed by Jean Piaget.

➤ According to Piaget, development of intelligence is because of a process called

biologic adaptation.

Adaptation is divided into two processes: assimilation and

accommodation.
➤ Assimilation: Initially the child assimilates events within the environment into mental
categories called cognitive structures, e.g. child will say bird for all flying objects. The
child cannot differentiate between kites, insects and birds.

➤ Accommodation: Intelligence develops because of accommodation. Accommodation

takes place when the child changes the cognitive structure to better differentiate with
the environment, e.g. child differentiates between birds, kites and insects.

➤ Intelligence develops because of the interplay between assimilation and

accommodation.
➤ The stages in development according to Piaget are as follows:

Sensorimotor period (0–2 years)

• The child is entirely dependent upon reflex activities in this

stage.

• Rudimentary concepts of objects are developed in this stage.

• Interpretation of sensory data by the child is negligible.

• This stage represents the beginning of thinking process.

Preoperational period (2–7 years)

• Children learn to use words and this stage marks the

beginning of symbolic activity.

• There are two important features in this stage: ego centrism

and animism.

Ego centrism: Child has a feeling that the world is created for
him/her. The child is incapable of understanding other
person’s view. Child gives importance only to his/her
thinking.
Animism: This is a thought process wherein the child gives life
to all inanimate objects. This animism can be used to the
dental surgeon’s advantage by giving names to the
instruments that are being used.

Concrete operation period (7–11 years)

• Child’s thinking process is more logical.

• Complex mental procedures, like addition and subtraction,

can be performed by the child.

• Child becomes flexible and reasonable.

• Animism declines.

• Instructions to this group of patients should be concrete.

Formal operation period (11 years–adult)

• Child’s thought process resembles that of the adult.

• Child should be treated as an adult as the child is able to

understand health concepts.

• In adolescents, children feel that they are being constantly

observed and criticized. They give a lot of importance to
their bodies, actions and feelings. Children feel that they are
on stage and everybody is watching them. This imaginary
thinking phenomenon is called imaginary audience by David
Elkind.

• Another phenomenon observed in this stage is personal fable.

As per this phenomenon, teenagers feel that they are being
 observed by everybody. This leads adolescents to think or
feel that they are unique individuals. Because of this feeling,
they feel that they will not be subjected to dangerous
consequence like other people. The personal fable is a
powerful motivator that allows us to cope in dangerous
world.

• Cooperation of the patient depends upon the friends’

motivation.

• It is sort of external motivation at this stage which prompts

the individual to seek orthodontic treatment.
Correlation of various theories of psychology:
Refer table 6.2
Table 6.2.
Theories of psychology: Correlation
Behaviour learning theories
Behavioural responses are learned by the following three mechanisms:

➤ Classical conditioning by Ivan Pavlov

➤ Operant conditioning by BF Skinner

➤ Observational learning by Bandura (Fig. 6.5)

FIG. 6.5. Behaviour learning theories.

The three behaviour learning theories and their salient features are provided in Fig.
6.5.

Classical conditioning
➤ Ivan Pavlov, the Russian physiologist, first described classical conditioning.

➤ Pavlov discovered that unassociated stimuli could evoke reflexes.

Pavlov’s experiment

Pavlov gave food to a dog every time with ringing of bell. After many days, ringing
of bell as itself caused increased stimulation.
Ringing of bell gets associated with food presentation.
Classical conditioning works by the association of one stimulus with another.
Therefore, it is also called learning by association.

➤ Classical conditioning occurs in a dental clinic in the following way:

Initial visit

Subsequent visit

The whole atmosphere of hospital get associated with pain and the child starts crying
the moment he/she enters the clinic in the above mentioned way.

Types of responses
Conditioned reflexes could lead to three types of response: (i) generalization, (ii)
extinction and (iii) discrimination.

Generalization: Child visits the clinic. Painful procedure is carried out on successive
visits. Reinforcement or generalization occurs. Child will get a feeling that every time
he/she visits the clinic only painful changes happen.

Extinction: Association between conditioned and unconditioned stimuli is not

reinforced. Child visits a clinic. No painful procedures are carried out. There is
extinction of association between conditioned and unconditioned stimulus.

Discrimination: By this process, the child learns to differentiate between places where
painful things do not happen. Continuous discrimination leads to erasing of
 generalization process.

Operant conditioning
Introduction
➤ Operant conditioning theory can be considered as an extension of classical
conditioning by Pavlov.

➤ This theory was put forward by BF Skinner.

➤ Skinner gives more importance to unconscious determination of behaviour.

Theory
➤ Skinner states that the consequence of a behaviour will itself act like a stimulus
which can affect the future behaviour.

➤ Consequence which follows a response to the stimulus will itself act as a stimulus.

➤ Based on the nature of consequences, Skinner described four types of operant

conditioning (Table 6.3).

Table 6.3.
Operant conditioning: Types

Probability of response increases Probability of response decreases

Pleasant stimulus (S1) I III
S1 presented (positive reinforcement/reward) S1 withdrawn (omission/time-out)
Unpleasant stimulus (S2) II IV
S2 withdrawn (negative reinforcement/escape) S2 presented (punishment)

Positive reinforcement
➤ If a pleasant consequence follows a response, positive reinforcement occurs.
➤ Child is likely to behave in the same good manner in next visit also, e.g. child
rewarded with a toy for good behaviour in the dental clinic.

Negative reinforcement
In this, the unpleasant stimulus is withdrawn because of the behaviour of the child.

Omission
It is also called time out. In this, a pleasant stimulus is removed, so that child will
cooperate.

Punishment

Clinical applications
➤ Positive reinforcement is used in clinical practice for child management.
➤ Negative reinforcement can be used when circumstances permit, e.g. making the
child understand that the procedure has been shortened so that he/she cooperates in
future visits also.

➤ Omission and punishment should not be used frequently.

Observational learning/modelling
➤ The theory was put forward by Albert Bandura.

➤ According to this theory, behaviour is acquired through imitation of behaviour

observed by the child.

➤ There are two stages in observational learning: (i) acquisition and (ii) performance.

Acquisition: Child acquires the potential to perform an act only by observing.

Performance: Once the child acquires the skill then he or she actually performs the act.

➤ Performance depends on factors like whether he/she likes to do it or not.

➤ If he/she likes, then he/she imitates them, e.g. role models.

➤ Another factor is the consequence of a behaviour. If the consequence is not pleasant,

the probability that a child may do a particular act is less.

Clinical applications
➤ Observational learning is an important tool in management of dental treatment.

➤ When a young child sees an older child undergoing treatment, he/she is likely to
cooperate by imitating the older child.
Types of child behaviour

Frankel’s behaviour rating

Advantage
It is a short-hand form used for recording children’s behaviour.

Disadvantage
This rating does not communicate sufficient clinical information regarding
uncooperative children, no categorization of the child’s reaction.

Wright’s classification
Types of cooperative behaviour Types of uncooperative behaviour
• Cooperative behaviour: Child is cooperative, relaxed with less apprehension Obstinate
Tense cooperative
• Potentially cooperative: Refuses to cooperate because of fear Timid
Whining
• Lacking in cooperation: Mentally retarded and very young children Stoic behaviour

Lampshire’s classification
• Cooperative Cooperates fully for the treatment; child is relaxed
• Tense cooperative Tensed but cooperative child
• Apprehensive Initially avoids treatment; later accepts treatment
• Fearful Constant support and pursuance is required to treat a fearful child
• Stubborn Resists treatment
• Hypermotive Agitated child and resists treatment
• Handicapped Mentally or physically handicap child
• Immature child Emotionally immature
Motivation of a child
➤ Motivation can be defined as the driving force which causes a person to act or behave.

➤ There are two methods of classification:

I. Classification 1

• Internal motivation: It is provided by the individual’s own

desire for treatment to correct the defect.

• External motivation: It is pressure from others, mostly parents

or friends.

II. Classification 2

• Achievement motivation: It is the motivation characterized by

striving for success in any situation in which standards of
excellence apply.

• Affiliation motivation: A hypothetical situation of seeking

orthodontic care for the purpose of improving dentofacial
aesthetics in order to facilitate association with other people.

• Attribution motivation: Motivation for perceiving the causes of

success or failure. Thinking that facial appearance is
responsible for not scoring well in interview and seeking
orthodontic treatment.
Child behaviour management techniques used in
orthodontics
Behaviour management is defined as the means by which the dental team effectively and
efficiently performs treatment for a child and at the same time instills a positive
attitude.

Objectives of behaviour management

➤ To establish effective communication with the child and for management of the
child.

➤ Gain the confidence of the child as well as the parents.

➤ Gain acceptance for dental treatment.

➤ To provide comfortable and relaxed environment to the child.

➤ To teach the child preventive and interceptive aspects of orthodontics.

Fundamentals of behaviour management

• Positive approach • Team attitude
• Organization • Truthfulness
• Tolerance • Flexibility
Behaviour modification techniques useful in
orthodontics
Useful modification techniques:

1. Communicative management

• It is the basic method of behaviour management technique.

• An effective communication technique is to look into the

eyes of the patients before looking into their mouths.

• Conversation should be on a personal note.

• Good communication should be honest and two-way also.

• Patient should be allowed to ask doubts.

• Usage of euphemisms in young children.

• Proper communication improves patient compliance.

• The important points in improving patient compliance:

a. Verbally praising the patient.

b. Discussing treatment goals with the patient.

c. Educating the patient about proper use of elastic,

headgear, etc.

d. Educating the patient about consequences of poor

compliance.
 e. Communication should be at the patient’s level.
2. Classical conditioning

• Conditioned reflexes could lead to three types of response:

(i) generalization, (ii) extinction and (iii) discrimination (see
Behaviour Learning Theories section for details).
3. Reinforcement

• Positive and negative reinforcements are used.

• Omission and punishment are to be avoided.

4. Modelling

• Observational learning is an important tool in management

of dental treatment.

• When a young child sees an older child undergoing

treatment, he/she is likely to cooperate by imitating the
older child.
5. Tell–show–do

• This technique can be used for removable appliance therapy.

ACCESSORY POINTS
Objective fears arise from direct physical stimulation of the sense organ
Subjective fears are based on feeling and attitudes that have been suggested to the
child by others without the child having had the experience personally
Psychoanalytical theory: Sigmund Freud
Psychosocial theory: Erik Erikson
Cognitive theory: Jean Piaget
Classical conditioning: Ivan Pavlov
Operant conditioning: BF Skinner
Observational learning: Bandura
➤ According to Freud, the id represents fantasy, ego represents reality and superego
represents idealistic

➤ Electra complex and Oedipus complex are seen during phallic stage

➤ Thought process wherein the child gives life to all inanimate objects is called animism

➤ Ego centrism develops during the preoperational stage of cognitive theory

➤ The best form of motivation is internal motivation

CHAPTER 7
Development of occlusion and normal
occlusion

CHAPTER OUTLINE
❖ Eruption of teeth
❖ Stages of tooth development
❖ Chronology of human dentition
❖ Development of occlusion from birth till 12 years and adolescence
❖ Pre-dental jaw relationships
❖ Face and jaws
❖ Gum pads
❖ Deciduous dentition period
❖ Sequence of eruption
❖ Chronology of eruption
❖ Features of deciduous dentition
❖ Mixed dentition period
❖ Early mesial shift
❖ Incisal liability
❖ Ugly duckling stage & its clinical significance
❖ Normal sequence of eruption of permanent teeth
❖ Replacement of canine and primary molars as second
transitional stage
❖ Leeway space of Nance
❖ Terminal plane relationship and transition of molar–occlusal relationship from
mixed dentition to permanent dentition
❖ Features of normal occlusion in permanent dentition
❖ Self-correcting malocclusions/transitional or transient
malocclusions
❖ Keys of occlusion
❖ Andrew’s keys of static occlusion
❖ Roth’s keys of functional occlusion
❖ Accessory points
❖ Advanced learning
❖ Forces of occlusion
❖ Key of occlusion and Angle’s concept of normal
occlusion
Eruption of teeth
Definition
➤ Eruption can be defined as the movement of the tooth from its site of origin to its
occlusal position.

Theories of eruption
➤ The exact mechanism by which the tooth erupts is still not clear

➤ Crosslinking of the maturational fibres of periodontal ligament provides the force for
eruption. This seems to be the contemporary view.

➤ The other theories of eruption:

• Pulp theory

• Root elongation theory

• Genetic theory

• Hammock ligament theory

• Vascular theory

• Alveolar bone growth theory

• Follicular theory

Stages of eruption
➤ The nature of eruption of primary and permanent teeth is the same.

➤ Only difference is the resorption of primary tooth when the permanent tooth erupts.

➤ According to William R Proffit, teeth erupt in two principal stages, namely

preemergent eruption and postemergent eruption stages.
Pre-emergent eruption
This stage consists of movement taking place from the site of origin of tooth till it
pierces the gingiva.

➤ There are two mechanisms involved in this stage.

➤ First is the resorption of the bone and overlying roots of primary tooth.

➤ Resorption is the rate-limiting factor in preemergent eruption.

➤ In cleidocranial dysostosis, failure of eruption occurs due to deficient resorption.

➤ Secondly, the erupting tooth has to be guided into the path created by resorption of
bone.

➤ Normally, both the mechanisms go hand in hand.

➤ In condition called primary eruption failure syndrome, resorption takes place but the
erupting tooth does not follow the path that has been created.

Post-emergent eruption
Post-emergent eruption consists of three stages:

1. Post-emergent spurt: This is the phase in which there is rapid tooth movement after the
tooth penetrates the gingiva till it reaches the occlusal level.

2. Juvenile occlusal equilibrium:

• This is a slow process, during which teeth erupt to

compensate the vertical growth of the mandibular ramus.

• When the mandible grows vertically, it moves away from

 maxilla creating space into which the teeth grow.

• Significance of juvenile occlusal equilibrium is best

understood when a tooth is ankylosed.
3. Adult occlusal equilibrium:

• This is the final phase of tooth eruption. It occurs after the

pubertal growth spurt ends.

• Tooth continues to erupt when its antagonist is lost and also

because of wear of the tooth structure.
Stages of tooth development
➤ Nolla has divided the development of tooth into 10 stages (Fig. 7.1).

➤ Tooth eruptive movements begin during the sixth stage when the crown formation is
complete.

➤ After 2–3 years, with two-thirds of root formation complete, tooth erupts into the
oral cavity.

FIG. 7.1. Stages of tooth development. Radiograph of the patient is compared with the
drawings, and each tooth is given a suitable developmental stage.
Chronology of human dentition
➤ The chronology of deciduous and permanent dentition is depicted in Table 7.1.

➤ Table 7.1 provides details regarding the beginning of tooth formation, eruption time
and time taken for completion of roots.

Table 7.1.
Chronology of the human dentition
Development of occlusion from birth till 12 years
and adolescence

Definition
Occlusion in dentistry can be defined as the changing interrelationship of the opposing
surfaces of the maxillary and mandibular teeth which occurs during movements of the
mandible and terminal full contact of the maxillary and mandibular dental arches
(Salzmann).

Pre-dental jaw relationships (0–6 months)

Face and jaws
➤ The face and jaws in a newborn are positioned distally when compared to adult
position.

➤ With the initiation of function, a change in relationship occurs.

➤ Face and jaws grow forwards, downwards and laterally.

Gum pads

Maxillary gum pads (fig. 7.2)

➤ Definition: The alveolar arches at the time of birth are called gum pads.
➤ They are firm and pink.

➤ Maxillary gum pads develop in two parts, namely labiobuccal and lingual.

➤ Labiobuccal portion grows fast. It is divided into 10 segments by transverse grooves

which correspond to the deciduous tooth sac.

➤ The groove between the canine and deciduous first molar is called lateral sulcus.

➤ Lingual portion remains smooth throughout.

➤ Labiobuccal and lingual parts are demarcated by the dental groove. The dental groove
passes from the incisive papilla, runs laterally and joins with the gingival groove at
the lateral sulcus area. From there, it runs distally and buccally to the first molar
crypt.

➤ Gingival groove demarcates the palate from gum pads.

FIG. 7.2. (A) Gingival groove, (B) dental groove and (C) lateral sulcus.

Lower gum pads (fig. 7.3)

➤ Lower gum pads are U-shaped.

➤ Anteriorly, the lower gum pad is everted.

➤ Gum pad is divided into 10 segments by transverse grooves. The segments are less
defined when compared to maxillary gum pad.
 FIG. 7.3. Lower gum pad.

Relationships
➤ Gum pads’ relationship is arbitrary. They do not have definite relationship.

➤ Upper lip appears short.

➤ Tongue is interposed between the lips.

➤ Maxillary gum pad is wider than mandibular gum pad, and there is total
overlapping of maxillary gum pads anteriorly and posteriorly.

➤ Lower lateral sulcus is distal to upper lateral sulcus.

➤ Vertical gap exists in between the upper and lower lip pads in the anterior region.

➤ The gum pads grow rapidly during the first year of life, and the amount of growth is
more in the transverse direction.

➤ Length of the gum pad also increases, mostly posteriorly to accommodate the
deciduous first and second molars.

Deciduous dentition period (6 months–6 years)

The salient points to be studied during deciduous dentition period:
1. Sequence of eruption of primary teeth:

• Eruption of primary teeth starts 6 or 7 months after birth.

• Delay in eruption by 4–10 months is considered normal.

• Mandibular teeth usually precede the maxillary teeth.

• The order of eruption is as follows:

2. Chronology of eruption: Chronological order of eruption of deciduous dentition is

depicted in Table 7.2.

3. Features of deciduous dentition:

a. Spaced dentition or open dentition: Primary dentition in

which interdental spaces are present is called open
dentition or spaced dentition. There are two types of
spacing: (i) physiologic/developmental/generalized and
(ii) primate.

Developmental (physiologic/generalized) spaces:

• These are present throughout the primary dentition.

• The reason for developmental space is anteroposterior

growth of the jaws.

• Spaced dentition is preferable because the chances for

crowding in the permanent dentition are very minimal.
• Developmental space is on an average 4 mm in maxillary
arch and 3 mm in mandibular arch.

Primate spaces (Fig. 7.4): These are also called simian spaces or
anthropoid spaces because they are usually seen in
monkeys.

• They are present in both maxillary and mandibular

arches of primary dentition.

• Primate space presents between deciduous lateral incisor

and canine in the maxillary arch.

• In the mandibular arch, it is present between primary

canine and primary first molar.

• Primate spaces are used in early mesial shift.

b. Closed dentition/nonspaced dentition: Primary teeth

without any spaces are called closed dentition. Lack of
space could be either due to wider primary teeth or
reduced arch length. Closed dentition invariably leads to
crowding in the permanent dentition.

c. Deep bite: When the primary incisors erupt, the overbite

is deep. This could be due to vertical inclination of the
primary incisors. Over a period of time, this deep bite
reduces due to two reasons:

• Eruption of primary molars

• Rapid attrition of incisors

• At about six years of age, there may be an edge–edge

 relationship.

d. Overjet: Overjet is more initially in primary dentition.

Overjet decreases with the movement of the whole dental

arch anteriorly. The average overjet in primary dentition
is 1–2 mm.

e. Terminal plane relationships: Baume classified the

relationships of the primary teeth into three categories: (i)
straight or flush terminal plane – seen in 76%, (ii) mesial
step – seen in 14% and (iii) distal step – seen in 10%.

Table 7.2.
Chronology of eruption of deciduous dentition

Deciduous teeth Age of eruption (months)

Lower central incisor  7
Upper central incisor  9
Upper and lower lateral incisors 11
First molars 15
Canines 18
Second molars 26

FIG. 7.4. Primate space.

Baume’s classification of primary teeth is based on the relationship of upper and

lower primary second molars in the sagittal direction (Fig. 7.5).

➤ A line is drawn along with the distal surface of maxillary and mandibular second
primary molars.
➤ If it is straight, it is called flush terminal plane relationship, otherwise mesial step or
distal step.

FIG. 7.5. Primary teeth relationship: (A) straight or flush terminal plane, (B) mesial step and
(C) distal step.

General features of deciduous dentition

➤ Dental arches are normally ovoid in shape.

➤ Deep bite present initially which changes to edge-to-edge relationship.

➤ Developmental spaces present

➤ Shallow intercuspal contact

➤ Straight or vertical inclination of incisors

➤ Flat curve of Spee

➤ Minimal overjet

➤ Absence of crowding

Mixed dentition period (6–12 years)

Transition from the primary dentition to the permanent dentition begins at 6 years of
age with the eruption of permanent first molars and permanent incisors. Mixed
dentition stage is the period during which both primary and permanent teeth are
present in the mouth. Mixed dentition period consists of three periods, namely first
transitional period, intertransitional period and second transitional period (Fig. 7.6).
 FIG. 7.6. Mixed dentition: stages.

Eruption of first permanent molar

Early mesial shift:

➤ In patients with spaced primary dentition and flush terminal plane relationship,
when the permanent mandibular first molars emerge or erupt at about 6 years, they
close the primate space distal to canine.

➤ Thereby, the flush terminal plane gets converted into mesial step.

➤ This allows the permanent maxillary first molars to erupt into a class I molar
relationship.

➤ This process is called as early mesial shift (Fig. 7.7).

➤ In a closed dentition, this is not possible.

FIG. 7.7. Early mesial shift. Closure of primate space in mandible and mesial movement of
lower permanent first molar as depicted by arrows.

Replacement of incisors/incisal liability

➤ The mesiodistal width of the permanent incisors is larger than the mesiodistal width
of the primary incisors.

➤ The erupting permanent incisors require more space for proper alignment.
➤ This difference between the amount of space needed for the incisors and the amount
available for them is called the incisor liability.

➤ Incisor liability was described by Warren Mayne in 1969.

➤ A favourable incisal liability exists when the primary dentition is an open dentition.

➤ An unfavourable situation exists in closed dentition.

The incisal liability is about 7.6 mm in maxillary arch and 6 mm in mandibular arch.
The space discrepancy is compensated by three mechanisms (Fig. 7.8).

1. Increased intercanine width: During the period of permanent incisor eruption,

significant amount of increase in the intercanine arch width occurs. It is about 3–4 mm.

2. Interdental spacing: Spacing present in primary dentition helps in alignment of

incisors. The primate space present in the upper arch mesial to primary canine is also
used.

3. Labial eruption of incisors: Primary incisors stand upright. The permanent incisors,
which replace them, are labially proclined placing them in a wider arch (Fig. 7.9).

FIG. 7.8. Replacement of incisors.

 FIG. 7.9. Labial eruption of incisors.

Ugly duckling stage

Synonyms: Broadbent’s phenomena or physiologic median diastema
Ugly duckling stage is a transient form of malocclusion wherein midline diastema is
present between the maxillary central incisors.

➤ Ugly duckling stage is seen between 7 and 11 years of age.

➤ During the eruption stages of canine, canine will be impinging on the roots of lateral
incisors.

➤ This pressure causes the lateral incisor to erupt into the oral cavity with divergence
of crown distally.

➤ Even after the lateral incisor fully erupts, this pressure effect from the erupting
canine persists.

➤ This pressure is transmitted to the central incisors also, which causes the crowns to
diverge and roots to converge towards midline.

➤ This bilateral effect causes a midline diastema, which is temporary.

➤ This temporary spacing that occurs between the central incisors and sometimes
between central and lateral incisors gets closed automatically as the canine comes into
occlusion.

➤ This stage is called ugly duckling stage because it represents a metamorphosis from an
unaesthetic phase to an aesthetic phase (Fig. 7.10).

FIG. 7.10. Ugly duckling stage.

Clinical significance
➤ As a guideline, maxillary midline diastema up to 2 mm closes spontaneously.
➤ Total closure of a median diastema greater than 2 mm is unlikely.

➤ Any attempt to close the median diastema during ugly duckling stage will be
hazardous.

➤ Apex of the lateral incisors will be damaged.

➤ Canine may be deflected from its normal path of eruption.

Normal sequence of eruption of permanent teeth

Figure 7.11 depicts normal sequence of eruption of permanent maxillary and
mandibular teeth.

FIG. 7.11. Sequence of eruption of permanent teeth.

Replacement of canine and primary molars as second

transitional stage
Leeway space of Nance (Fig. 7.12): The combined mesiodistal width of the deciduous
canine and first and second primary molars is greater than the combined mesiodistal
width of the permanent canine and first and second premolars. This is called leeway
space of Nance.

➤ In the maxillary arch, it is about 0.9 mm on one side, totalling to 1.8 mm.
➤ In the mandibular arch, it is about 1.7 mm on one side, totalling to 3.4 mm.

➤ When the primary second molars are lost, there is an adjustment in the occlusion of
the permanent first molar teeth.

➤ There is decrease in arch length in both maxillary and mandibular arches as the first
molars shift mesially.

➤ This shift of molars is more in the mandible, which accounts for the establishment of
full cusp class I molar relation from flush terminal plane relationship in deciduous
dentition. This shift is called late mesial shift of molars (Fig. 7.13).

FIG. 7.12. Leeway space of Nance. AB—Combined mesiodistal width of permanent canines,
first and second premolars. AB represents in maxillary arch. CD—Combined mesiodistal width
of deciduous canines, first and second molars. C’D’ represents in maxillary arch. AC–
Represents leeway space of Nance. A’C’ represents leeway space in maxilla.
FIG. 7.13. Late mesial shift. Leeway space of Nance is utilized.
Terminal plane relationship and transition of
molar–occlusal relationship from mixed dentition
to permanent dentition
Terminal plane relationship: See Fig. 7.5 and related text for this.

Transition of molar–occlusal relationship from mixed

dentition to permanent dentition
There are two important contributors to the molar transition:

1. Late mesial shift of molar: After the shedding of primary second molar, first permanent
molar shifts mesially. This mesial shift of lower molar is more when compared to upper
molar because of the more amount of leeway space.

2. Differential growth of mandible relative to maxilla: This is the second contributor. Because
of the cephalocaudal growth, mandible grows more than maxilla.

The possible effects on molar transition from mixed dentition to permanent dentition
are depicted in Fig. 7.14.

FIG. 7.14. Transition of molar–occlusal relationship. DG, differential growth; LS, late mesial
shift.

Features of normal occlusion in permanent dentition

1. Overlap: In normally occluding dentition, the maxillary teeth are labial or buccal to
mandibular teeth.
2. Angulations: Permanent teeth will have buccolingual and mesiodistal angulations.

3. Occlusion: With the exception of mandibular central incisors and maxillary third
molars, each permanent tooth occludes with two teeth.

4. Arch curvature:

• Anteroposterior curvature in the mandibular arch is called

curve of Spee.

• Corresponding curve in the maxillary arch is called

compensating curve.

• Buccolingual curvature from one side to the other side is

called Monson’s curve.
5. Overbite: Normal is 10–30%.

6. Overjet: 1–3 mm.

7. Molar relationship: Class I molar – mesiobuccal cusp of maxillary first permanent

molar occludes in the mesiobuccal groove of the permanent mandibular first molar.
Self-correcting malocclusions/transitional or
transient malocclusions
Transient malocclusions are those conditions which will look like malocclusion at some
particular time. But with normal growth, the condition gets corrected on its own
without any treatment. The transient malocclusions are seen in all stages of occlusal
development (Tables 7.3–7.5).

Table 7.3.
Predental jaw relation stage

S. no. Transient malocclusion Reason for correction

1. Retrognathic mandible Corrects with cephalocaudal growth and differential growth of mandible
2. Complete overlap of maxillary gum pad Transverse growth of mandibular gum pad

Sagittal growth of mandibular gum pad

3. Anterior open bite Eruption of primary incisors

4. Infantile swallow With initiation of function at about 18 months of age

Table 7.4.
Primary dentition

S. no. Transient malocclusion Reason for correction

1. Deep bite (i) Eruption of primary molar and (ii) attrition of incisal edges
2. Increased overjet More forward growth of the mandible
3. Flush terminal plane Early mesial shift
4. Spacing Closes with eruption of permanent successors

Table 7.5.
Mixed dentition

S.
Transient malocclusion Reason for correction
No.
1. Deep bite Physiologic bite raisers at 6 and 12 years with the eruption of first and second permanent molars. The
overlying gingival pad of tissue will act as a bite raiser
2. Ugly duckling stage Eruption of maxillary canine
3. Lower anterior crowding Increase in intercanine width
4. End on molar relationship Late mesial shift
5. Edge to edge at about 6 years of age flush Both late mesial shift and differential jaw growth
terminal plane relationship
Keys of occlusion
There are two keys of occlusion: (i) Andrew’s keys of static occlusion and (ii) Roth’s
keys of functional occlusion.

Andrew’s keys of static occlusion

Andrew’s six keys (1972) are based on 120 nonorthodontic normals.

Key 1: Molar relation (Fig. 7.15):

• Mesiobuccal cusp of upper first molar rests in the

mesiobuccal groove of lower first molar.

• Distal surface of the distobuccal cusp of upper first molar

should occlude with mesial surface of the mesiobuccal cusp
of lower second molar.

• Mesiolingual cusp of the upper first molar should occlude in

the central fossa of lower first molar.
Key 2: Crown angulations (tip): The gingival portion of the long axis of each crown
should be distal to the incisal portion (Fig. 7.16).

It is measured by the inclination of long axis of the crown to a line perpendicular to the occlusal
plane.

Key 3: Crown inclination (torque):

• It refers to the buccolingual inclination of the long axis of the

crown, not to the long axis of the entire tooth (Fig. 7.17).

• Lingual crown inclination occurs in the maxillary and

mandibular posteriors (negative inclination).

• Positive or labial inclination in maxillary incisors.

It is determined by the resulting angle between a line perpendicular to the occlusal plane and one
 tangent to the middle of the labial or buccal clinical crown.

Key 4: Rotation (Fig. 7.18):

• Absence of rotation.

• Arch should be devoid of any rotated tooth.

• A rotated molar occupies more mesiodistal space, creating a

situation unreceptive to normal occlusion.

• A rotated incisor occupies less space.

Key 5: Interproximal contact:

• Proximal contacts should be tight.

• Absence of spacing.
Key 6: Curve of Spee (Fig. 7.19):

• Deep curve of Spee results in a more confined area

(crowding).

• Flat curve of Spee is most receptive for normal occlusion.

• Reverse curve of Spee results in excessive room (spacing).

 FIG. 7.15. Molar relation.

FIG. 7.16. Crown angulation.

FIG. 7.17. Crown inclination.

FIG. 7.18. Rotation.

 FIG. 7.19. Curve of Spee: (A) deep curve, (B) flat curve and (C) reverse curve.

Roth’s keys of functional occlusion

Key 1: Coincidence of intercuspal position (ICP) and retruded contact position (RCP).

Key 2 (Fig. 7.20): Maximum and stable cusp to fossa contacts throughout the buccal
segments.

Key 3: Disclusion of the posterior teeth in mandibular protrusion by even contacts on

the incisors.

Key 4: Lateral movements of the mandible are guided by the working side canines, with
disclusion of all the other teeth on both working and nonworking sides.
 FIG. 7.20. Diagram showing cusp to fossa contact.

ACCESSORY POINTS
➤ Primary spacing: Normal developmental space present in deciduous dentition, also
called physiological or developmental spacing

➤ Secondary spacing: Occurs in closed dentition wherein erupting lower incisors push
primary canine laterally and create space

➤ Tertiary spacing: Space caused due to extraction, proximal slicing

➤ Sequence of tooth formation: Initiation, proliferation, histodifferentiation,

morphodifferentiation and mineralization

➤ Jaw radiograph of a newborn will show 24 teeth

➤ Teeth that are initiated after birth are premolars, second and third molars

➤ Early mesial shift occurs at 6–7 years of age due to closure of primate space by
pressure of erupting permanent molars

➤ Late mesial shift occurs at 10–11 years of age due to closure of leeway space after
shedding of primary second molars

➤ Space age is the other name for mixed dentition period

➤ Primary teeth in boys are generally larger than girls

➤ Ankylosis of primary teeth is more common than permanent teeth

➤ Lower primary teeth are twice more prone for ankylosis. Reason is not clear, but
thought to be occurring during normal physiological resorption of teeth
➤ Step child of dentition – third molars

➤ Cornerstone of the dentition – first molars

➤ Corner tooth of the dentition – canines

➤ Servant of the tooth – alveolar bone

➤ Slave of the orthodontist – alveolar bone

➤ Bread of the orthodontist – periodontal ligament

➤ Maxillary laterals are generally displaced – lingually

➤ Maxillary canines are generally displaced – labially

➤ Mandibular laterals are generally displaced – lingually

➤ Arch length decreases in permanent dentition (2–3 mm)

➤ Arch length is greatest before eruption of permanent first molar

➤ Open dentition – spaces present in deciduous dentition

➤ Closed dentition – absence of space in deciduous dentition

➤ Bolton’s tooth ratio is considered to be the seventh key of occlusion

➤ Total eruption path of first permanent molar is about 2.5 cm

➤ With the exception of mandibular central incisors and maxillary third molars, each
permanent tooth occludes with two teeth

➤ Leeway space of Nance is more in the mandibular arch than the maxillary arch

➤ Space for eruption of permanent molars in mandible is created by resorption at the

anterior border of the ramus and apposition at the posterior border of the ramus

Advanced Learning
Forces of occlusion
The forces of occlusion are divided into three types: (i) forward or anterior component
force, (ii) distal and lingual forces and (iii) anterior resultant force.

Forward force: This force is also called anterior component of force.

• This force is the result of the effect of buccinator and
masseter muscles on the teeth.

• The force is produced because of the relationship of long

axis of teeth to the occlusal surfaces and action of muscles.

• Anterior component force comes into effect after the

eruption of first permanent molar into occlusion.
Distal and lingual forces:

• These are produced by circumoral muscles and buccinator.

• Act on incisors and help to keep the canines in place.

Anterior resultant force: An anterior resultant of the two forces which act in the
opposite way.

• Apart from these three forces of occlusions, teeth have the

‘mesial drifting tendency’.

• This is because of inherent disposition of teeth to drift

mesially.
Key of occlusion and angle’s concept of normal occlusion
Angle’s concept of normal occlusion is based on: (i) key of occlusion and (ii) line of
occlusion.
Key of occlusion:

➤ Angle considered maxillary first permanent molar as the key of occlusion (see Fig.
7.15).

➤ He said maxillary first molar is the most constant in its position.

➤ Angle related maxillary first molar to key ridge position.

➤ The mesiobuccal cusp of upper first molar rests in the mesiobuccal groove of the
mandibular first molar in normal occlusion. This is called class I molar relation.
 Line of occlusion:
There are two lines of occlusion: (i) maxillary and (ii) mandibular.

Maxillary: Smooth curve passing through the central fossa of upper molars and along
the cingulum of upper canines and incisors (Fig. 7.21).

FIG. 7.21. Maxillary line of occlusion.

Mandibular: Runs along the buccal cusps of posteriors and incisal edges of the
anteriors (Fig. 7.22).

FIG. 7.22. Mandibular line of occlusion.

Angle’s concept of normal occlusion
Class I normal occlusion:

➤ Molars are in class I relation.

➤ Lines of occlusion are intact in both maxillary and mandibular arches.

➤ There should be full complement of teeth present.

CHAPTER 8
Stomatognathics in orthodontics

CHAPTER OUTLINE
❖ Stomatognathics: definition and its various components
❖ Trajectorial theory of bone formation/Wolff’s law
❖ Trajectories of force/Benninghoff’s lines
❖ Buccinator mechanism
❖ Movements and positions of mandible
❖ Various functions of stomatognathic system
❖ Mastication
❖ Infant feeding
❖ Adult mastication
❖ Retained infantile swallow
❖ Deglutition/adult or mature swallow
❖ Speech and malocclusion
❖ Accessory points
❖ Advanced learning
❖ Muscles of mastication and their role in malocclusion
❖ Various movements and positions of mandible
Stomatognathics: Definition and its various
components
Salzmann’s definition
Stomatognathics is the approach to the practice of orthodontics which takes into
consideration the interdependence of form and function of the teeth, jaw relationship,
temporomandibular articulation, craniofacial conformation and dental occlusion.
Stomatognathics deals with the functional anatomy. Stability of the orthodontically
moved teeth depends on the integration of the stomatognathic components.
The components of stomatognathics:

1. Teeth and their supporting structures

2. Jaw bones and their functional osteology

3. Myology of the head

4. Temporomandibular joints

5. Tongue

6. Nerves

7. Vascular supply

8. Related structures

The different functions of stomatognathic system:

1. Mastication

2. Deglutition

3. Speech

4. Respiration
Trajectorial theory of bone formation/julius
wolff’s law
➤ Bone is one of the hardest materials in the body.

➤ It is also one with higher plastic characteristics and responds extensively to

functional forces.

➤ Whenever there is a tussle between bone and soft tissue, bone yields.

Histology of bone
➤ Mature bone is composed of two kinds of tissue: (i) compact (dense in texture like
ivory) and (ii) spongy or cancellous core.

➤ Compact bone is always on the exterior aspect of the surrounding bone.

➤ Spongy or cancellous core consists of meshwork of trabecular pattern within which

intercommunicating spaces or trabeculae are present.

Trajectorial theory
In the year 1867, Georg Hermann von Meyer, an anatomist, proposed the trajectorial
theory of bone formation.
The trajectorial theory states that the lines of orientation of the bony trabeculae follow
the pathways of maximal pressure and tension.

➤ The trabeculae are thicker in areas of maximum stress.

➤ He stressed that the alignment of the trabeculae in the spongy bone followed
trabecular lines like in a mechanical structure.

➤ The trabeculae are actually lines of maximum stress within the bone.

➤ Most of the trajectories crossed at right angles, an excellent arrangement to resist

manifold stresses on the bone (Fig. 8.1).
 FIG. 8.1. Alignment of bony trabeculae in stress trajectories.

Wolff’s law of transformation of bone

➤ In the year 1870, Julius Wolff gave reason for the arrangement of trabecular pattern.

➤ He attributed that the trabecular arrangement is due to the functional forces.

➤ A change in the direction and magnitude of force could produce a marked change in the
internal architecture and external form of the bone. This is called ‘Wolff’s law of
transformation of bone’.

➤ Increase in function leads to increase in the density of bone.

➤ Lack of function leads to decrease in trabecular pattern.

➤ Simply stated, stresses of tension or pressure on bones stimulate changes within the
bone.
Trajectories of force/benninghoff’s lines
The trajectorial theory states that the lines of orientation of the bony trabeculae follow
the pathways of maximal pressure and tension.

➤ Benninghoff A did extensive study on dried craniofacial bones.

➤ He said that stress trajectories or lines of orientation of the bony trabeculae involve
not only the cancellous bone but also the compact bone.

➤ These trajectories are formed not only in direct response to functional influences but
also to epigenetic influences.

➤ The intrinsic genetic potential has no role in the formation of trajectories.

➤ The stress trajectories respond to the demands of functional forces collectively as a

unit and not as a single bone.

Accordingly, the head is made up of only two functional units:

(i) craniofacial unit and (ii) mandible.
➤ These trajectories or functional lines are otherwise called Benninghoff’s lines.

Craniofacial unit
➤ The trajectories extend in a fan-like fashion from the midpalatal suture across the
alveolar bone through the maxilla and end at the base of the skull.

➤ The bones of the face are united with the cranial bones by these fan-like trajectories.

➤ The trajectories continue across the facial bones and do not stop at the suture.

Trajectories of maxilla (fig. 8.2)

Maxilla provides maximum strength with minimum material because of the trajectories.
 FIG. 8.2. Trajectories of maxilla showing the three vertical pillars.

Frontonasal vertical pillar/buttress

➤ Purpose of this pillar or buttress is to transmit pressures from the incisors, canines
and first premolar.

➤ Runs vertically along piriform aperture and crest of the nasal bones and ends in the
frontal bone.

Zygomatic vertical pillar/buttress

➤ Transmits stress from the posterior teeth.
➤ It also receives force of the masseter muscles.

➤ In the zygomatic area, it splits into three parts and finally ends in the base of the
skull (Fig. 8.3).

FIG. 8.3. Zygomatic vertical pillar.

Pterygoid vertical pillar/buttress

➤ Runs vertically from the conchae of nasal cavity and posterior teeth.

➤ Ends in the middle portion of the base of the skull.

Horizontal reinforcing members

➤ Supraorbital rim acts as a receptor of forces from canine and zygomatic pillar.

➤ Other reinforcing members are infraorbital, zygomatic buttress, hard palate, walls of
orbit and lesser wings of sphenoid.

Trajectories of mandible
Mandible is made of major and minor trajectories (Fig. 8.4).
 FIG. 8.4. Trajectories of mandible.

Major trajectories
➤ Trabecular columns originate from beneath the teeth in the alveolar process and join
together into a common stress pillar or trajectory system.

➤ Mandibular canal and nerve are protected by this concentration of trabeculae.

➤ The thick cortical layer of trabeculae present along the lower border of the mandible
offers high resistance to bending forces.

Minor trajectories
➤ Trajectories are also seen at the symphysis, gonial angle.

➤ One trabecular pattern is seen running downwards from the coronoid process into
the ramus and body of the mandible.

➤ The accessory stress trajectories are due to the effect of muscle attachment.
Buccinator mechanism
Muscles are a potential force whether they are at rest or in active function.
Teeth and supporting structures of the jaw are under the control of the adjacent
muscles.
The balance between the muscles is responsible for the integrity of the dental arches
and the relation of teeth to the arches.

➤ Buccinator mechanism is a continuous band of muscles that encircle the dentition and
is firmly anchored at the pharyngeal tubercle of the occipital bone (Fig. 8.5).

➤ Buccinator mechanism starts with the decussating fibres of the orbicularis oris
joining the right and left fibres of the lip which constitute the anterior component of
the buccinator mechanism.

➤ It then runs laterally and posteriorly around the corner of the mouth, joining other
fibres of the buccinator muscle which gets inserted into the pterygomandibular raphe.

➤ Here it mingles with the fibres of superior constrictor muscle and runs posteriorly
and medially to get fixed to the pharyngeal tubercle.

➤ All these muscles numbering 13, with elasticity and contractility, act like a rubber
band tightly encircling the bone system, the mandible.

➤ Tongue acts opposite to the buccinator mechanism exerting an outward force.

 FIG. 8.5. Buccinator mechanism.

Clinical significance
➤ Any imbalance in buccinator mechanism leads to malocclusion.

➤ In pernicious oral habits like thumb sucking, tongue thrusting, the equilibrium
between buccinator mechanism and tongue is lost. This causes various changes in
dentition like:

• Constricted maxillary arch

• Increased proclination

• Open bite
Various functions of stomatognathic system
The various functions of stomatognathic system:

➤ Mastication

➤ Deglutition

➤ Respiration

➤ Speech
Mastication
Mastication can be grouped as infant feeding (before teeth eruption – Fig. 8.6) and
mature or adult mastication (after teeth eruption).

Infant feeding

FIG. 8.6. Infant feeding: Mechanism.

Adult mastication
Mastication is defined as reducing food in size, changing its consistency, mixing it with
saliva and forming into a bolus suitable for swallowing.
There are six stages of mastication as outlined by Murphy RJ (Fig. 8.7).

FIG. 8.7. Adult mastication: Different stages.

Infantile swallow/retained infantile swallow
➤ Infants consume food by suckling. This is an automatic reflex in human beings.

➤ Infants’ suckling and swallowing proceed together.

➤ In suckle-swallow, there is:

• Caving in of the cheeks

• Bobbing of the hyoid bone

• Elongated tongue

• Head extended

• Anterior mandibular thrust

• Lips pursed around the nipple

Moyers lists the features of the infantile swallow as:

➤ Jaws are apart with the tongue placed between the gum pads.

➤ Mandible is positioned by muscles of the facial expression.

➤ Swallow is guided by the lips and tongue.

• With the change in food from liquid to semisolid and the

eruption of teeth, there is a change in swallowing pattern
also.
Deglutition/adult or mature swallow
Mature swallowing patterns are observed usually by 18 months of age.
The features of adult swallow:

➤ Teeth are together.

➤ Mandible is stabilized by muscles of mastication.

➤ Tongue tip is placed against the palate above and behind incisors.

➤ Minimum contractions of the lips during swallow.

➤ Mature swallow is usually seen by 18 months of age.

Stages of deglutition
Fletcher had divided the deglutition pattern into four stages:

1. Preparatory phase

2. Oral phase

3. Pharyngeal phase

4. Oesophageal phase (Fig. 8.8)

FIG. 8.8. Deglutition stages.
Speech and malocclusion
➤ Speech is a learned behaviour.

➤ Development of speech pattern follows a front-to-back maturation.

➤ Bilabial sounds are the first sound to be developed.

➤ Lips, tongue and velopharyngeal structures modify the outgoing breath stream to
produce different variations in speech.

➤ The different types of speech and the malocclusion conditions where they are
affected are given in Table 8.1.

Table 8.1.
Variations of speech

ACCESSORY POINTS
➤ Functional movements of the mandible occur during speech, mastication and
swallowing

➤ Functional movements take place within the three-dimensional limits and are called
border positions

➤ Parafunctional movements of the mandible are usually habitual and include tooth-to-
tooth contacts (bruxism and clenching ), tooth-to-soft tissue contacts (lip biting,
thumb sucking), soft tissue-to-soft tissue contacts (abnormal swallowing, jaw
 posturing) and foreign objects-to-tooth contacts (pencil biting)

➤ Dysfunctional movements of the mandible are abnormal or impaired movements

caused either by a derangement of the articular disc of the TMJs or by hyperactivity
in the muscles of mastication

➤ Stimulation of lips and tongue movements are seen by 14 weeks in utero

➤ Gag reflex starts at → 18.5 weeks IUL

➤ Respiration starts at → 25 weeks in utero

➤ Suckling starts at → 29 weeks in utero

➤ Deglutition starts at → 32 weeks in utero

➤ An average individual swallows about once a minute at rest; during eating, 9 times

➤ Normally, the number of swallows per day in a normal adult when he/she is awake
is 800 times

➤ In the year 1867, Meyer, an anatomist, proposed the trajectorial theory of bone
formation

➤ Trajectories or functional lines are otherwise called Benninghoff’s lines

➤ Number of muscles attached to mandible is 13

➤ The ability of a muscle to shorten its length under innervational impulse is called
contractility

➤ Instrument used to measure occlusal force is gnathodynamometer

➤ Newborn infants are obligatory nasal breathers

➤ When incisors are used to bite food substance, the occlusal forces are transmitted
through canine pillar

Advanced Learning
Muscles of mastication and their role in malocclusion
Mandibular movements are a complex phenomenon. All the muscles that are attached
to the mandible influence the position and movements of the mandible and maintain
the head posture (Fig. 8.9).
 FIG. 8.9. Diagrammatic representation to show muscle groups involved in maintaining head
posture.

These muscles are classified into two groups:

1. Supramandibular muscles or elevators of the mandible

2. Inframandibular muscles or depressors of the mandible

Supramandibular muscles
The following are the supramandibular muscles:

1. Masseter

2. Temporalis

3. Medial pterygoid

4. Lateral pterygoid

The origin, insertion, nerve supply and functions of the supramandibular muscles
are provided in Table 8.2.

Table 8.2.
Supramandibular muscles
Inframandibular muscles
Inframandibular muscles consist of the following muscles:

➤ Digastric

➤ Geniohyoid

➤ Mylohyoid

➤ Stylohyoid

• Inframandibular muscles are arranged between cranium and

mandible and the hyoid bone.

• Their action is to elevate the hyoid bone and/or to depress

the mandible ( Table 8.3).

Table 8.3.
Inframandibular muscles
Muscle changes during growth
➤ There is correlation between the growth of muscles and development of the
dentition.

➤ Development of the muscle is rapid after puberty when the deciduous teeth are
replaced by permanent successors.

➤ Correlation exists between the growth of muscles of mastication, development of

dentition and the strength of mandible.

➤ Abnormal force to the bone during growth by muscles can produce abnormal form.

Based on their attachments, muscles can be divided into two groups: (i) periosteal
and (ii) tendinous. The features of periosteal and tendinous muscles are given in Table
8.4.

Table 8.4.
Periosteal and tendinous muscles: features

Periosteal Tendinous
• Fibrous layer of the periosteum • Tendon which cannot be removed from the bones without some destruction to the
bone
• This group can shift its attachment by changes in the growth of • Change occurs due to deposition and resorption, which carries the whole tendinous
periosteum attachment with it
• The muscle moves along with periosteum to maintain constant • Example: Lateral pterygoid and suprahyoid group of muscles
spatial relationship

Muscles function and bone development

➤ Muscle function begins in prenatal life itself.

➤ Muscle function influences the internal arrangement of bones and also induces the
changes on the surface of the bones.

➤ Osteogenesis proceeds in the opposite direction to muscular stresses.

➤ Between 6 and 10 years of age, there is a steady rate of muscle development.

➤ Development of muscles is rapid during the replacement of deciduous teeth by

permanent teeth.

➤ Child acquires coordinated activity of the voluntary muscles gradually.

➤ The balance of voluntary muscles is easily upset by habits. Muscles of facial

expression, mimetic and vocal muscles are easily influenced by habits.

➤ There are two types of muscle contraction: (i) isotonic – contraction seen with
shortening of muscle and (ii) isometric contraction – no change in size of muscles.

➤ The degree of muscle function determines the quantity, quality, structure and form
of the face.

➤ Masseter and temporalis muscles show strong developmental increase in size.

➤ Because of the muscle functions, maxillary tuberosities become well developed,

mandible shows everted border, and bigonial width increases.

Muscle function and malocclusion

➤ Muscle function is an important factor in shaping the dental arches and stability of
the teeth subsequent to orthodontic treatment.

➤ Abnormal muscle posture or function can cause malocclusion.

➤ Muscle tone is a continuous state of contraction of the muscle. It is this property of

muscle which permits the teeth and jaw relationship to maintain changes brought
about by orthodontic treatment.

➤ Muscles can adapt to new functional patterns and growth changes.

➤ During retention period, muscles adapt to the new functional pattern brought by
orthodontic treatment.

➤ Insufficient retention causes inability to achieve muscle balance and then relapse.

Various movements and positions of mandible

Movements of the mandible are studied in sagittal, coronal and horizontal planes.
Sagittal plane movements
1. Physiologic rest position
Physiologic rest position or postural rest position is defined as
the position of the mandible when the muscles of
mastication are in a minimum tonus of contraction.

It is the position where the antagonist and agonist concerned

with the mandibular opening are in a state of equilibrium.

Factors influencing the rest position:

• Body and head position

• Sleep

• Psychic factor

• Age

• Pain

• Proprioception from the dentition and muscles

• Occlusal changes

• TMJ disease

• Muscle disease and spasm

Freeway space is the measured distance between the occlusal

surfaces of the maxillary and mandibular dental arches.

The distance between the rest intermaxillary dimension and

full occlusion indicates the amount of clearance between the
teeth in the dental arches. This constitutes the interocclusal
space or freeway space.
Clinical significance:

• Normal freeway space is 2–4 mm.

• A large freeway space is related to excessive deep bite, e.g.

class II division 2.

• Class I usually has smaller freeway space than class II and

class III.

• Bite opening by extrusion of molars which interferes with

normal freeway space will not be stable.

• Care should be taken to preserve normal freeway space for

stability of orthodontic treatment.
2. Centric relation

Centric relation is the unstrained neutral position of mandible

in which the anteroposterior surfaces of the mandibular
condyles are in contact with the concavities of articular disc.
From this position, lateral movements are possible.
3. Initial contact

When the patient takes the mandible from rest position to

occlusion, the position at which first tooth contact occurs is
called initial contact position; the movement that occurs in the
temporomandibular joint is entirely rotation in the lower
joint space. Initial contact and centric occlusion should
coincide.

In situations like premature contact, anterior crossbite and

pseudo-class III malocclusion, from initial contact mandible
 slides to new occlusal contact position.
4. Centric occlusion (ICP-Intercuspal position)

Centric occlusion is defined as the mandibular position in

which there is maximum intercuspation of the teeth (Fig.
8.10).

FIG. 8.10. Centric occlusion.

5. Most retruded position (RCP-Retruded contact position)

• Mandible can hinge about a horizontal axis called the

retruded axis or terminal hinge axis (RP). This is the most
retruded position of mandible (Fig. 8.11).
 FIG. 8.11. Most retruded position.

6. Maximum opening of mouth

• As the mandible continues to open beyond the retruded axis,

the condyle translates forwards and downwards to a
position of maximum opening (Fig. 8.12).

FIG. 8.12. Maximum opening of mouth.

Coronal plane movements

Working side:
➤ Working side is the side to which mandible moves.

➤ During right lateral movement of mandible, the right condyle (condyle on the side
towards which movement occurs) is referred to as the working side condyle.

Balancing side: Balancing side or nonworking side is the opposite side to mandibular
movement.
Bennett movement (Fig. 8.13):

➤ Bodily side shift of the mandible towards the working side during lateral excursion is
called Bennett movement.

FIG. 8.13. Bennett angle and movement.

➤ The working side condyle may either rotate or rotate and move laterally, and also
upwards or downwards.

➤ Bennett movement is necessary to permit rotation of the working condyle, because of

the restraining influence of the temporomandibular ligament on the working side, the
walls of the glenoid fossa.

➤ Stages of Bennett movement: Immediate shift and progressive side shift.

• If the lateral component occurs early in the movement, it is

termed as immediate or early side shift.

• A gradual lateral component is termed as progressive side

 shift.
Canine guidance:

➤ Lateral movements of the mandible guided by the working side canines, with
disclusion of all the other teeth on both working and non-working sides.

➤ There is contact in lateral movement only between canines on the working side.

Group function:

➤ If there is contact on the working side between two or more teeth, the working side
guidance is referred to as group function.

Horizontal plane movements

Bennett angle:

➤ When the working side condyle shifts laterally, the non-working side condyle moves
downwards, forwards and inwards.

➤ Angle formed between the forward and inward movements of the non-working
condyle and a straightforward movement is known as Bennett angle (Fig. 8.13).

Gothic arch: The border movements of the mandible in the horizontal plane are often
described as a gothic arch when observed in the incisal area.
SECTION III
Development of Problems
OUTLINE

9. Classification of malocclusion

10. Aetiology of malocclusion

CHAPTER 9
Classification of malocclusion

CHAPTER OUTLINE
❖ Malocclusion definition
❖ Definition of classification in orthodontics
❖ Need/purpose/uses of classification
❖ Methods of recording and measuring malocclusion/various methods of
classification of malocclusion
❖ Angle’s classification of malocclusion
❖ Merits and demerits of Angle’s classification/validity of Angle’s classification
❖ Modifications of Angle’s classification
❖ Lischer’s modification
❖ Dewey’s modification
❖ Simon’s classification
❖ Incisor classification/British standard classification of incisor relationship
❖ Ackerman–Proffit classification
❖ Quantitative methods of classification of malocclusion
❖ Accessory points
❖ Advanced learning
❖ Skeletal classification
❖ WHO/FDI classification
❖ Aetiologic classification of malocclusion
Malocclusion definition
Malocclusion is a condition in which there is a departure from the normal relation of
teeth to the other teeth in the same arch and/or to the teeth in the opposing arch (White
TC, Gardiner JH and Leighton B).
Definition of classification in orthodontics
➤ Classification in orthodontics is concerned with the recognition of deviation from a
quantitative and qualitative biological norm.

➤ Classification is also defined as the orderly reduction of the database to a list of the
patient’s problem (William R Proffit).

Classification employs various diagnostic criteria like clinical examination, facial

photographs, radiographs and diagnostic casts.

Need/purpose/uses of classification
There are various purposes/uses of classification:

➤ Classification is used for grouping of orthodontic problems into a category.

➤ Such grouping helps in ease of reference.

➤ Useful in locating the problems which have to be treated.

➤ Classification helps in diagnosis and treatment plan.

➤ Classification is done for the purpose of comparison of different types of

malocclusions.

➤ Classification is used for self-communication.

➤ Useful for documentation of the problem.

➤ Used for studying in the prevalence and severity of malocclusion in population

groups. Used for epidemiological studies.

➤ Training of orthodontist.

➤ To assess treatment effects of orthodontic appliances.

Methods of recording and measuring
malocclusion/various methods of classification
of malocclusion
Methods of classification can be broadly divided into two types: (i) quantitative and
qualitative types of classification and (ii) intraarch and interarch problems.

I. Classification of malocclusion: quantitative and qualitative methods

Quantitative and qualitative methods of classification are

depicted in Table 9.1.
II. Classification based on intraarch and interarch problems

Malocclusion can also be classified depending upon the

problems present in the same arch (intraarch) and the
problems present between maxillary and mandibular arches
(interarch).

a. Malpositions of an individual tooth or groups of teeth in the

same arch/intraarch problems. This has five types:

i. Sagittal problems

Labioversion

Linguoversion

Mesioversion

Distoversion

ii. Transverse problems

 Crowding

Spacing

Buccoversion

Linguoversion

iii. Vertical problems

Supraversion

Infraversion

iv. Rotated teeth

v. Transposition of teeth

b. Malrelationship between upper and lower arches or interarch

problems

i. Sagittal

Class II malocclusion

Class III malocclusion

ii. Transverse

Crossbites, scissor bite

Midline shift

iii. Vertical
 Deep bite
Open bite
Table 9.1.
Malocclusion: qualitative and quantitative methods
Qualitative methods
Angle’s classification (1899)
Modification of Angle’s classification
Simon’s classification
Bjork’s classification (1964)
Bennett’s classification
Skeletal classification
Ackerman–Proffit classification
WHO/FDI classification
Aetiologic classification
Incisor classification
Quantitative methods or indices used for epidemiological purpose
Massler and Frankel
Malalignment index by van Kurt and Pennel
Handicapping labiolingual deviation index by Draker
Occlusal feature index by Poulton
Malocclusion severity estimate by Grainger
Occlusal index by Summers
Treatment priority index by Grainger
Handicapping malocclusion assessment record by Salzmann
Index for orthodontic treatment need (IOTN) by Shaw
Angle’s classification of malocclusion
Introduction
➤ Angle’s system of classification is based on the anteroposterior relationship of the
teeth with each other.

➤ Edward Hartley Angle introduced this classification with the concept of key of
occlusion and line of occlusion.

➤ Maxillary first permanent molar is considered to be the key of occlusion and Angle
stated that the position of the maxillary first permanent molar is relatively constant.

Angle’s classification
Angle described three classes of malocclusion (Fig. 9.1).

FIG. 9.1. Angle’s classification of malocclusion.

The three classes of malocclusion are based on the permanent first molar relationship.
Class II malocclusion has got two types, namely division 1 and 2.

Angle’s class I malocclusion (neutroclusion) (fig. 9.2)

Molar relation: The mesiobuccal cusp of the upper first molar occludes with the
mesiobuccal groove of the lower first molar.

Canine relation: The mesial incline of the upper canine occludes with the distal incline
of the lower canine whereas the distal incline of the upper canine occludes with
mesial incline of lower first premolar.

Line of occlusion: Line of occlusion will be altered in the maxillary and mandibular
arches:

• Individual tooth irregularities, like crowding, spacing,

rotations, absence of tooth, will be seen.
• Interarch problems, like deep bite, open bite, proclination or
increased overjet, crossbite will be present.

FIG. 9.2. Angle’s class I malocclusion.

Class I bimaxillary protrusion

Class I bimaxillary malocclusion is a condition where both the key of occlusion and
line of occlusion are not altered, but the upper and lower anteriors are proclined and
exist usually in an edge–edge relationship.

Angle’s class II division 1 malocclusion (distoclusion) (fig. 9.3)

Molar relation: Lower dental arch is distally positioned in relation to upper arch. The
distobuccal cusp of the upper first permanent molar occludes with the mesiobuccal
groove of the lower first permanent molar.
 FIG. 9.3. Angle’s class II division 1 malocclusion.

Class II canine relation: The distal incline of upper canine occludes with mesial
incline of lower canine.
Line of occlusion: Altered; other features of class II division 1 are:

1. V-shaped or constricted maxilla

2. Proclined maxillary incisors

3. Lip trap

4. Exaggerated curve of Spee

5. Deep bite

Class II division 1 subdivision: Condition where the class II molar relationship is

unilateral or present only on one side with normal class I molar occlusion on the other
side.

Angle’s class II division 2 malocclusion (fig. 9.4)

Class II molar relation: Lower dental arch is distally positioned in relation to upper
arch. The distobuccal cusp of the upper first molar occludes with the mesiobuccal
groove of the lower first molar.
 FIG. 9.4. Angle’s class II division 2 malocclusion.

Class II canine relation: The distal incline of the upper canine occludes with the
mesial incline of the lower canine.
Line of occlusion: Altered.
Other features:

➤ Characteristic lingual inclination of upper central incisor alone or central and lateral
incisors together.

➤ Canine overlaps the retroclined incisors (Fig. 9.5).

➤ Closed bite will be present.

➤ Square-shaped arch.

➤ Exaggerated curve of Spee.

FIG. 9.5. Typical class II division 2 maxillary incisor position.

 Class II division 2 subdivision: Condition when the class II molar relation exists on
only one side with normal molar relation on the other side.

Angle’s class III malocclusion (mesiocclusion)

Class III molar relation: The lower dental arch is in anterior relation to the maxillary
arch. Mesiobuccal cusp of the upper first permanent molar occludes with the
interdental space between the lower first and second permanent molars (Fig. 9.6).

FIG. 9.6. Angle’s class III malocclusion.

Class III canine relation: Upper canine occludes with the interdental space between
the lower first and second premolars.
Line of occlusion: May or may not be altered.
Other features are:

➤ Reverse overjet or anterior crossbite

➤ Maxillary anterior crowding

➤ Posterior crossbite

Class III subdivision: Condition in which class III molar relation is present only on
one side with normal molar relation on the other side.
True class III: This is a skeletal malocclusion. The reasons for skeletal class III
malocclusion are
➤ Retrognathic maxilla

➤ Prognathic mandible

➤ Combination of both

In this class III, molar relation exists both in centric occlusion and rest position.
Pseudo-class III/habitual class III:

1. This is not a true class III malocclusion. Due to occlusal prematurities, when the
mandible moves from rest position to occlusion, it slides forwards into a pseudo-class
III position.

2. These patients show normal molar relationship in rest position.

3. In centric occlusion, they show class III relation.

4. Cephalogram in both rest position and occlusion helps to differentiate between true
class III and pseudo-class III malocclusion.
Merits and demerits of angle’s
classification/validity of angle’s classification
Merits
1. Angle’s system of classification is the most traditional and oldest system still in use.

2. Most practical and easy to comprehend method of classification.

3. Most popular.

4. Easy to communicate.

5. Widely used for teaching purpose.

Demerits
1. Disregarded the relationship of the teeth to the face.

2. Malocclusion is a three-dimensional problem, but Angle considered only sagittal

dimension.

3. The position of the maxillary first permanent molar is not stable as stated by Angle.

4. Muscle malfunction and growth of bones were overlooked. These factors influence
the molar position.

5. Classification is not applicable when first permanent molars are missing.

6. Not applicable in deciduous dentition.

7. When there is migration of first molar, classification is not feasible.

8. Aetiology of the malocclusion is not known.

9. Skeletal problems are not given consideration.

10. Differentiation between dentoalveolar and skeletal malocclusion is not possible.

11. The classification considers only static occlusion.

Modifications of angle’s classification
There are two modifications of Angle’s classification: (1) Lischer’s modification and (2)
Dewey’s modification.

Lischer’s modifications
1. Lischer introduced the following names to Angle’s classification.

Neutroclusion – class I

Distoclusion – class II

Mesiocclusion – class III

2. Lischer also introduced nomenclature to describe malpositions of individual tooth.

It consists of adding the suffix ‘version’ to the word. These

indicate the direction of deviation from the normal position.

• Mesioversion – mesial to the normal position.

• Distoversion – distal to the normal position.

• Linguoversion – lingual to the normal position.

• Labioversion/buccoversion – towards the lip or cheek.

• Infraversion – away from the line of occlusion.

• Supraversion – crossing the line of occlusion.

• Axiversion – wrong axial inclination.

• Torsiversion – rotated on its long axis.

• Transversion – transposition – wrong position in the arch.

Dewey’s modification
Martin Dewey divided Angle’s classes I and III into further types:

➤ Class I is divided into five types.

➤ Class III is divided into three types.

➤ Class II has no types.

Class I
➤ Type 1: Crowded maxillary anterior teeth; canines may be abnormally positioned;
other individual tooth irregularities present.

➤ Type 2: Proclined or labioversion of maxillary incisors.

➤ Type 3: Linguoversion of maxillary incisors; anterior crossbite present.

➤ Type 4: Incisors and canines are normally positioned. Molars and premolars are in
buccoversion. Posterior crossbites are seen.

➤ Type 5: Mesioversion of molars; molars have moved mesially due to premature loss
of teeth anterior to molar.

Class III
➤ Type1: Well-aligned teeth and dental arches; edge–edge relationship exists.

➤ Type 2: Crowded mandibular incisors; normally placed lower incisors behind the
upper incisors.

➤ Type 3: Crowded maxillary incisors; underdeveloped maxilla; anterior crossbite

present.
Simon’s classification
➤ In Simon’s classification, the dental arches are related to three anthropologic planes
(Fig. 9.7).

➤ Since malocclusion is a three-dimensional problem, Simon devised this method of

classification orienting dental arch to three different planes.

➤ It is a craniometric form of classification.

FIG. 9.7. Simon’s classification.

Planes used
1. Frankfort horizontal plane or eye–ear plane (E–E–P)

• This plane is obtained by drawing a line through the margin

of inferior orbit below the eyeball and upper margin of
auditory meatus.

• This plane helps to detect deviations in the vertical plane.

• Height of the dental arches and teeth is related to the

cranium.
• Dental arch closer to the plane is called attraction and farther
away from the plane is called abstraction (Fig. 9.8).
2. Orbital plane (O–P)

• This plane is obtained by drawing a line perpendicular to

the Frankfort horizontal plane at the margin of the bony
orbit below the pupil.

• This plane helps to detect deviations in the sagittal plane.

• Anteroposterior relationship of the dental arches and axial

inclinations of the teeth are related to cranium.

• Dental arch more anteriorly placed is called protraction and

posteriorly placed dental arch is called retraction.
3. Raphe median plane (R–M–P) or midsagittal plane

• This plane is obtained by drawing lines through midpalatal

raphe at right angle to Frankfort plane (Fig. 9.9).

• This plane helps to detect deviations in the transverse plane.

• Mediolateral relationship of the dental arches and axial

inclination of teeth are related to midline of the head.

• Dental arch closer to midsagittal plane is called contraction

and farther away from midsagittal plane is called distraction.
 FIG. 9.8. Deviations from the Frankfort plane.

FIG. 9.9. Deviations from the midsagittal plane.

Law of canines
According to Simon, in a normal arch relationship, the orbital plane passes through the
distal aspect of canine. This is called ‘law of canines’.
Interpretations of Simon’s classification of malocclusion are depicted in Table 9.2.

Table 9.2.
Interpretations: Simon’s classification

Plane Condition Inference

Frankfort horizontal plane (vertical plane) Attraction Dental arch closer to the Frankfort plane

Orbital plane (sagittal plane)
Midsagittal plane (transverse plane)
Abstraction Dental arch farther away from the Frankfort plane
Protraction Dental arch more anteriorly placed
Retraction Dental arch more posteriorly placed
Contraction Dental arch nearer to the mid-sagittal plane
Distraction Dental arch farther away from the mid-sagittal plane
Incisor classification/British standard
classification of incisor relationship
➤ British Standards Institute’s incisor relationship classification (1983) is used
commonly nowadays.

➤ This classification is used without considering the molar relationship in some cases
(Fig. 9.10).

➤ Incisor classification is prone for interexaminer errors.

Class I. The lower incisor edges occlude with or lie immediately below the cingulum of
the upper central incisors.

Class II. The lower incisor edges lie posterior to the cingulum prominence of the upper
incisors.

Division 1: The upper central incisors are proclined or of

average inclination. There is an increase in overjet.

Division 2: The upper central incisors are retroclined. The

overjet is usually minimal but may be increased.
Class III. The lower incisor edges lie anterior to the cingulum prominence of the upper
incisor. The overjet is reduced or reversed.

FIG. 9.10. (A) Class I incisor relationship, (B) class II division 1 incisor relationship, (C) class II
division 2 incisor relationship and (D) class III incisor relationship.
Ackerman–proffit classification
➤ Ackerman and Proffit introduced a new method of classification to overcome the
drawbacks of traditional Angle’s classification.

➤ This is an all inclusive method of categorizing malocclusion.

➤ This system included Angle’s classification and five characteristics of malocclusion

within a Venn diagram.

➤ Alignment and symmetry of teeth within the arch is represented as universe or outer
envelope (Group 1) since it is common to all dentitions.

➤ Then profile becomes a major set (Group 2) within the universe.

➤ Transverse, sagittal (anteroposterior) and vertical are shown as deviations from the
normal with their interrelationships as interlocking subsets (Group 3 through 9)
within the profile set.

➤ In this classification, any malocclusion can be described by five or fewer

characteristics.

Procedure (fig. 9.11)

Group 1 (intraarch alignment and symmetry)
➤ Analysis of alignment and symmetry is done. Individual tooth irregularities are
described.

➤ Possible malocclusions in this step are crowding, rotations, spacing and mutilated
conditions.

➤ If no abnormality is present, it is called ideal.

➤ Since the degree of alignment and symmetry is common to all dentition, it is

represented as group 1.
 FIG. 9.11. Ackerman–Proffit classification system.

Group 2 (profile)
➤ Proceeding inside the Venn diagram, the profile of the patient is studied.

➤ Possibilities are straight, convex and concave profile and anterior or posterior
divergence.

Group 3 (type)
➤ Lateral or transverse arch characteristics are analysed.

➤ The term type is used to describe the kinds of crossbites.

Types of crossbite

➤ Buccal – unilateral, bilateral

➤ Palatal – unilateral, bilateral

➤ Dental

➤ Skeletal

Group 4 (class)
➤ Consists of analysis of sagittal/anteroposterior relationship.
➤ Angle’s classification is used.

➤ Skeletal and dental malocclusions differentiation is made.

Group 5 (bite depth)

Patient’s skeletal relationship and dentition are analysed for problems in the vertical
dimension.

Vertical deviations
Open bite – anterior open bite, posterior open bite, skeletal, dental

Deep bite – dental, skeletal

Collapsed bite – posterior

• The overlapping groups are seen in the centre of Venn

diagram.

• Group 9 will have the most severe form of malocclusion

comprising problems in all the three dimensions.

Advantages of ackerman–proffit classification

➤ The complexities of malocclusion are explained.

➤ All three planes or dimensional problems are included.

➤ Profile of the patient is given due consideration.

➤ Differentiation between skeletal and dental problems is made.

➤ Arch length problems are evaluated.

➤ This classification helps in complete diagnosis and differential treatment planning.

➤ Readily adaptable to the computer processing.

Disadvantages
➤ Aetiological considerations are not included in the classification.

➤ The classification is based only on static occlusion. Functional occlusion is not

included.
Quantitative methods of classification of
malocclusion
Refer to Chapter 2 and write about the indices
ACCESSORY POINTS
Imbrications denote teeth, especially lower incisors which are arranged irregularly
within the arch due to lack of space.
Primary classification
➤ Deformities of the osseous components of the head in general which affect dental
occlusion – cephalic anomaly

➤ Deformities of teeth, dental arches, alveolar processes, jaws – dysgnathic anomaly

➤ Anomalies of teeth alone – eugnathic anomalies

Classifications by body build (kretschmer)

➤ Tall, thin person with narrow shoulders, slim arms and hands, face is high and
narrow, mandible is underdeveloped – asthenic

➤ Person who is comparatively short, with short neck, broad face – pyknic

➤ Person with strong muscles, broad shoulders, square and fully developed mandible –
athletic

Class IV malocclusion means

➤ Class II on one side and class III on other side

Incidence of malocclusion
➤ Class I – 60%

➤ Class II – 25%

➤ Class III – 5%

➤ Crowding is the single most type of prevalent malocclusion.

➤ Key of occlusion: Maxillary first permanent molar is considered to be the key of

occlusion.

➤ Key ridge: It is the inferior most point of the anterior border of zygoma as seen in
 lateral cephalogram.

Normally, the mesiobuccal root of maxillary permanent first molar is in line with the
key ridge.
Bennett’s classification
➤ Class I – malocclusion due to local causes

➤ Class II – malocclusion due to developmental defects in either arches

➤ Class III – malocclusion due to abnormal relation of both arches

Crowding in mixed dentition

➤ First-degree crowding: Slight malalignment of the anterior teeth; no abnormality in
supporting zone

➤ Second-degree crowding: Pronounced malalignment of anterior teeth; no abnormality

in supporting zone

➤ Third-degree crowding: Severe malalignment of all four incisors; supporting zones

restricted

➤ Law of canine was proposed by Paul Simon

➤ Transposition means two teeth interchanging position

➤ Class II molar relation on one side and class I on another side is called class II
subdivision

➤ Class III molar relation on one side and class I on another side is called class III
subdivision

➤ Venn diagram is used in the classification proposed by Ackerman–Proffit

➤ Transverse occlusal deviations (Fig. 9.12)

 FIG. 9.12. Transverse occlusal deviations.

Advanced Learning
Skeletal classification
Skeletal classification considers both the facial skeletal pattern and also the relationship
of the teeth.
Skeletal class I
➤ The bones of the face, maxilla and mandible are in normal relation to each other.

➤ Maxilla and mandible are in normal relation to the cranium also.

➤ Profile is orthognathic.

Division 1: Malpositions of incisors, canines or premolars.

Division 2: Proclined maxillary incisors.

Division 3: Linguoversion of maxillary incisors.

Division 4: Bimaxillary protrusion.
Skeletal class II
➤ Mandibular development retarded when compared to maxilla.

➤ Distal relationship of mandible to maxilla.

Division 1: Protrusion of maxillary anterior teeth.

Narrow maxillary arch.

Crowding in canine region.

Posterior crossbite.

Retrognathic profile.

Division 2: Retroclined maxillary central incisors.

Lateral incisors normal or labially placed.

Skeletal class III

➤ Increased growth of mandible

➤ Prognathic profile

➤ Increased mandibular angle.

WHO/FDI classification
This classification comprises recording five major groups of items.

Group 1: Gross anomalies like dentofacial abnormalities are recorded.

Group 2: Individual tooth malpositions like anodontia, supernumerary tooth,

malformed incisors and ectopic eruption of teeth are noted.

Group 3: Arch length problems, like spacing, crowding and diastema, are evaluated.

Group 4: Evaluation of occlusion.

a. Incisal segment:

• Overjet

• Crossbite

• Deep bite

• Open bite

• Midline shift

b. Lateral segment:

• Anterior-posterior relation

• Open bite

• Posterior crossbite
Group 5: Subjective judgement of orthodontic treatment

• Not necessary

• Doubtful

• Necessary

• Urgent

Aetiologic classification of malocclusion

This classification is according to the tissues primarily involved.

1. Osseous (problems in bone growth)

a. Skeletal malocclusion
b. Dentofacial deformities
2. Muscular (problems in function of dentofacial musculature)

a. Sucking habits

b. Functional aberrations

c. Tongue thrust

d. Mouth breathing

e. Abnormal path of closure

3. Dental (problems in teeth and supporting structures)

a. Malpositions of teeth

b. Anomalies in size, shape of teeth

CHAPTER 10
Aetiology of malocclusion

CHAPTER OUTLINE
❖ Classification of aetiologic factors
❖ Prenatal causes of malocclusion
❖ Role of genetics in malocclusion
❖ Butler’s field theory
❖ Postnatal causes of malocclusion
❖ Developmental causes
❖ Endocrine disturbances
❖ Nutritional deficiencies
❖ Allergy
❖ Muscular activity
❖ TMJ problems
❖ Functional causes
❖ Head posture
❖ Mouth breathing
❖ Tongue posture
❖ Tongue thrusting
❖ Abnormal swallowing
❖ Functional shifts
❖ Sucking and other habits
❖ Environmental or local factors of malocclusion
❖ Disturbances of dental development
❖ Trauma as aetiologic factor
 ❖ High-frenal attachment/persistent labial frenum
❖ Dental caries and improper restorations
❖ General causes of malocclusion
❖ Accessory points
❖ Advanced learning
❖ Equilibrium theory
Classification of aetiologic factors
I. Graber’s classification (Table 10.1)

Table 10.1.
Graber’s classification of aetiologic factors

II. Proffit’s method of classification (Table 10.2)

Table 10.2.
Proffit’s method of classification of malocclusion
Prenatal causes of malocclusion
Prenatal causes of malocclusion can be broadly studied under the following headings.

1. Disturbances in embryologic development – (a) neural crest cell problems, (b) defects
in formation of organs

2. Teratogens

3. Fetal moulding

4. Birth injuries

5. Maternal infection, diet and metabolism

6. Genetic or hereditary

1. Disturbances in embryologic development

Johnston MC and Bronsky PT have identified five stages in the

craniofacial development. The stages and the related
problems are given in the Table 10.3.
2. Teratogens

Chemical or other agents which cross the placental barrier and

produce embryologic defects are called teratogens. The
various teratogens and their effects are enumerated in Table
10.4.
3. Fetal moulding: intrauterine moulding

• During intrauterine life, any pressure effect on rapidly

growing areas leads to distortion of growth.

• On rare occasions, arm is pressed against the face, in utero,

resulting in ‘maxillary deficiency’.
• Sometimes, fetal head is flexed tightly against the chest in
utero. This retards the mandibular growth due to decreased
volume of amniotic fluid. The restriction of the mandible
forces the tongue upwards and, therefore, closure of the
palate is stopped leading to cleft palate. This happens in
‘Pierre Robin syndrome’ in which combination of
micrognathia with cleft palate occurs.
4. Birth trauma

• During delivery, usage of forceps will damage the temporo

mandibular joint. This will cause retarded growth of
mandible (micrognathia).
5. Maternal diet and infection

• The frequency of defects is more in children born to

nutritionally deficient mothers.

• The important nutritional factors are calcium, phosphorus,

iron, vitamins B, C and D.

• Congenital syphilis: Syphilis is derived from the infection of

the mother and varieties of manifestations are present in the
child.

Features of congenital syphilis:

1. Frontal bossing

2. Hypoplastic maxilla

3. High-arched palate
 4. Mulberry molars

5. Hutchinson incisors

6. Prominent zygoma

7. Rhagades

8. Relative mandibular prognathism

• Rubella: Dental effects of rubella:

1. Delayed eruption

2. Hypoplasia

3. Microcephaly

4. Caries

• Measles and chickenpox: Maternal measles and chickenpox are

followed by defective offspring.
6. Heredity

Genetic disorders can be seen sometimes at the time of birth.

They are called congenital defects. Heredity plays part in the
following conditions:

1. Congenital deformities

2. Facial asymmetry

3. Macrognathia and micrognathia

 4. Macrodontia and microdontia

5. Anodontia, oligodontia, hypodontia

6. Tooth shape variations

7. Cleft palate or lip

8. Frenum diastema

9. Deep bite

10. Crowding and rotation

11. Mandibular retrusion

12. Mandibular prognathism

Table 10.3.
Stages of craniofacial development

Table 10.4.
Teratogens and their effect

Teratogens Effect
Aminopterin Anencephaly
Aspirin Cleft lip and palate
Cigarette smoke Cleft lip and palate
Cytomegalovirus Microcephaly, hydrocephaly
Dilantin Cleft lip and palate
Ethyl alcohol Central midface deficiency
6-mercaptopurine Cleft palate
13-cis retinoic acid Retinoic acid syndrome
Rubella virus Microphthalmia, deafness
Thalidomide Hemifacial microsomia like features
Toxoplasma Microcephaly, hydrocephaly
X-radiation Microcephaly
Valium Cleft lip and palate
Vitamin D excess Premature suture closure
Role of genetics in malocclusion
I. Introduction

Genetic disorders are conditions that are caused due to

disturbances in germ plasm or chromosomes or genes.
Genetic disorders can be classified into (1) hereditary and (2)
mutational.

1. Hereditary disorders

• Hereditary disorders are conditions which are transmitted

from one generation to another.

• Neel’s criteria for considering a problem as hereditary

disorder are as follows:

– Occurrence of disease in definite numerical proportions

among individuals related by descent.

– Failure of disease to spread to nonrelated individuals.

– Onset of disease without a known precipitation acts at a

characteristic age.

– Greater concordance of disorder in identical twins.

2. Mutational disorders

• Mutational disorders arise de novo in a previously

unaffected individual as a result of damage to the germ
plasm.
• If it gets transmitted to the future generation, it becomes
hereditary.
II. Types of transmission of malocclusion

Malocclusions are transmitted by three ways: (i) repetitive, (ii)

discontinuous and (ii) variable.

• Repetitive: Recurrence of a single dentofacial deviation within

the immediate family.

• Discontinuous: Recurrence of tendency for a malocclusal trait

to reappear after few generations. Some generations will be
skipped.

• Variable: Expression of different but related types of

malocclusion within the several generations of the same
family.
III. Modes of inheritance

Following are the modes of inheritance:

• Autosomal dominance

• Autosomal recessive

• X-linked

• Polygenic

• Chromosomal
IV. Genetic influence
Malocclusions could be produced by heredity in two major
possible ways:

1. Inherited disproportion between size of teeth and size of

jaws.

2. Inherited disproportion between size and shape of upper

and lower jaws, which leads to occlusal malrelationships.

Different malocclusions due to genetic reasons are given in

previous question.
V. Genetic studies

There are basically two methods of genetic study: (i) twin

study and (ii) family study.

Twin study:

• In this study, twins are compared.

• Comparing monozygotic twins with dizygotic twins is the

best way to determine the extent of genetic effect on
malocclusion.

Monozygotic twins

• These happen due to early division of fertilized egg

• Both the individuals will have the same DNA

• They are genetically similar

• Also called identical twins

Dizygotic twins

• These happen when two eggs fuse with two different

spermatozoa

• The twins will have different DNA

• They are genetically dissimilar

• Also called fraternal twins

Procedure

• The heritability of the malocclusion can be determined by

comparing the monozygotic twins, dizygotic twins and
ordinary siblings.

• In monozygotic twins, any change in occlusion or feature

could be attributed to environment factor since both have
same DNA.

• In dizygotic twins, interplay of genetic and environmental

factors is studied.

Disadvantages of twin studies

• Difficulty in identifying identical twins.

• Difficult to establish the same environment for the twins.

Family study/pedigree study:

• In this method of study, occlusal features and differences

between mother–child, father–child and siblings are
 analysed.

• Helps to differentiate between dominant and recessive traits.

• Dominant traits will be expressed in all the subsequent

generations.

• Recessive traits will be expressed in children born of

consanguineous marriage.
VI. Contemporary view

Contemporary views on aetiology of malocclusion attribute

some of the malocclusions to hereditary or genetic causes.

1. Dental problem

a. Crowding – hereditary and environment reasons

b. Individual tooth malalignments and crossbites – pressure

environment

2. Skeletal problem

Mostly attributed to inherited or genetic cause, e.g.

a. Retrognathic mandible

b. Retrognathic maxilla (achondroplasia)

c. Prognathic mandible (Hapsburgs jaw)

d. Skeletal deep bite

VII. Advances in genetics
• Gene mapping: Mapping of genes to specific locations on
chromosomes.

• Cloning: Clone is a series of identical DNA.

• Gene therapy: Insertion of normal genes in the bodies of

individuals affected with genetic disorder.
Butler’s field theory
The human dentition is divided into four fields: (i) incisor (ii) canine, (iii) premolar and
(iv) molar.

➤ The most distal tooth in each field is the most susceptible to changes or variations.

➤ The changes include absence of tooth, variation in size, shape and structure.

➤ Accordingly, lateral incisors, second premolars and third molars are the most
variable in their group.

➤ This is called ‘Butler’s field theory’.

➤ Canine is the least variable tooth in the arch.

➤ Butler’s field theory does not apply in lower anterior region, where mandibular
central incisor is more commonly missing than lateral incisor.
Postnatal causes of malocclusion
Postnatal dentofacial anomalies occur due to developmental deficiencies, functional
disturbances and environmental interferences (Table 10.5).

Table 10.5.
Postnatal causes

Developmental causes
1. Endocrine disturbances (Table 10.6)

2. Nutritional deficiencies

• Nutritional deficiencies can lead to arrested development

and faulty bone formations.

• Conditions like scurvy, rickets and beri-beri can produce

malocclusion.

• Features include open bite and deficient maxilla, disturbed

eruption of teeth and irregular dental arches.
3. Allergy

• Chilldren with allergy will be mouth breathers. Features of

mouth breathing will be seen.
4. Muscular activity

• Muscles influence jaw growth in two ways:

• Formation of bone at the muscle attachment depends on the

activity of muscle.

• Muscle forms part of the soft tissue functional matrix.

• Loss of muscle due to injury or nerve damage results in

underdevelopment of that part. Excessive contraction of
muscles also restricts bone growth, e.g. torticollis. There is
facial asymmetry in torticollis.

• Muscular weakness which occurs in cerebral palsy causes

vertical displacement and severe open bite.
5. TMJ problems

• Ankylosis early in life interferes with jaw growth and

alignment of teeth.

• Trauma to TMJ, arthritis, fracture of condyles influence the

growth of mandible.

• Rarely, unilateral excessive growth of mandible occurs in

metabolically normal individuals. Mandible shifts to normal
side. This condition is called hemimandibular hypertrophy.

Table 10.6.
Endocrine problems and manifestations

Condition Features
Achondroplastic dwarf Prominent forehead, depressed nose, Class III profile, open bite
Hypothyroidism (cretinism) Stunted height, tongue is large and thick, spaced dentition, delayed dental age
Hypopituitary dwarfism Delayed eruption, delayed onset of puberty
Gigantism/acromegaly Enlarged supraorbital ridges, prognathic mandible, tongue enlargement, spacing and enlargement of the whole face
Hyperthyroidism Rare in children; premature eruption, fragile bone, orthodontic treatment contraindicated
Hypoparathyroidism Delay in eruption, morphology of teeth is affected
Hyperparathyroidism Loss of lamina dura, brown tumour, loose teeth

Functional causes
➤ Normal functional activity is required for inherent growth pattern to be expressed.

➤ Any interference with function interferes with form.

➤ Majority of the malocclusions are attributed to local functional causes.

1. Head posture

• Faulty head posture can effect changes in bones.

• Curvature of the neck and cervical spine causes forward and

upward positioning of head. This situation exists in some
class II problems.

• Orthostatic head posture is advised for normal development

of face.
2. Mouth breathing

Mouth breathing results in typical adenoid facies, long face

with open bite.

The effect of mouth breathing in producing malocclusion is

explained as follows:
Features of adenoid facies or long face syndrome

1. Increased overjet

2. Increased facial height

3. Narrow maxillary arch

4. Supraeruption of posterior teeth

5. Mandible rotates downward and backward

6. Open bite.
3. Tongue posture

Position of tongue is very important in creation of

malocclusion.

• Position or posture is analysed by the following methods:

• Direct intraoral method

• Cephalometric method
• Palatographic method

• Cinefluororadiographic method.

• Normal resting position of the tongue is retracted tip lies just

behind the lower incisors and lateral border resting on the
linguo-occlusal surfaces of lower posterior teeth.

• In class II tongue, tip is more retruded in rest position.

• In class III tongue, tip lies far forward.

4. Tongue thrusting

There are two types of tongue thrust swallows that might

cause malocclusion: (i) simple and (ii) complex tongue
thrust.

• Usually the tongue thrust is preceded by digital sucking.

• Bimaxillary spacing, anterior open bites are results of tongue

thrust (Fig. 10.1).

• Tongue thrust causes malocclusion more because of altered

posture (Fig. 10.2).

• Posterior open bite may also be present.

 FIG. 10.1. Tongue thrusting.

FIG. 10.2. Lowered tongue posture in habits does not counteract buccal soft tissue pressures.

5. Retained infantile swallow

There is alteration of buccinator mechanism which leads to

malocclusion similar to tongue thrust.
6. Functional shifts

• Functional shifts during eruption of permanent teeth

produce malocclusion in both anteroposterior and
transverse direction.
• Displacements or shifts can contribute to the development of
anterior and posterior crossbite.

• Posterior crossbite due to functional shift is seen in children

with prolonged thumb sucking. Anterior crossbite is seen
due to deflected eruption of maxillary incisors towards the
palatal aspect.
7. Sucking and other habits (Fig. 10.3)

FIG. 10.3. Thumb sucking and its effects.

Deleterious effects of thumb sucking is explained in Fig. 10.3.

Children who sleep in the night with thumb or finger between the teeth can get
significant malocclusion. These children produce 6 h of pressure or more. The three
important factors of habit which contribute to the occurrence of malocclusion are
duration, frequency and intensity. These three factors are called trident of habit factors
(Fig. 10.4).

FIG. 10.4. Trident of habit factors.

Environmental or local factors of malocclusion

Local factors/environmental factors of malocclusion are classified as follows:

I. Disturbance of dental development

Missing teeth

Supernumerary tooth

Supplemental tooth

Malformed tooth

Delayed eruption

Ectopic eruption

Early loss of tooth

Prolonged retention
II. Trauma to teeth and jaws
III. Mucosal barrier

Frenal attachment

Soft tissue impaction

IV. Dental caries and improper restoration

Disturbances of dental development

1. Missing teeth (Fig. 10.5)

• The prevalence of missing teeth is about 3%.

• This condition may appear in succeeding generations.

• It is a hereditary problem and results from disturbances

during the initiation and proliferation stages of tooth
formation.

When a tooth is absent, the space which it should occupy gets

closed. As a general rule, if only few teeth are absent, it will
be the most distal tooth of that type, e.g. third molars, lateral
incisors.

Order of missing tooth

Third molar > lower second premolar > upper lateral incisor >
upper second premolar > lower central incisor

When a premolar is missing, the predecessor deciduous molar

is usually retained and this can lead to crowding as the
mesiodistal width of deciduous molar is more. Hypodontia
is seen in some syndromes like ectodermal dysplasia, Down
syndrome and cleft palate.
 FIG. 10.5. Missing teeth. Different terminologies and explanation.

2. Extra tooth/hyperodontia/supernumerary tooth/supplemental tooth

• The reason for supernumerary tooth is any disturbance

during initiation and proliferation stages of tooth
development. Incidence of supernumerary tooth is about 1%
and m:f ratio is 2:1 (Di Bias, 1969).

• Presence of supernumerary tooth leads to crowding in the

arch. There are two types of hyperodontia (Fig. 10.6).

• The process of gemination and twinning is explained in Fig.

10.7.

• The most common supernumerary tooth occurs in the

midline of maxilla and is known as mesiodens.

• Other sites are premolar, distal to third molars, lateral

incisors.

• Extra tooth interferes with normal occlusal development.

• Extractions of entire tooth should be carried out at the

earliest to obtain normal occlusion.

• Extra teeth are seen in cleidocranial dysplasia, cleft lip and

palate.
3. Malformed teeth/shape and size of teeth

FIG. 10.6. Hyperodontia.

FIG. 10.7. (A) Gemination and (B) twinning.

• Anomalies in tooth size and shape arise due to disturbances

in the morphodifferentiation stage of tooth development.

• Variation in size is the most common in maxillary lateral

incisor followed by second premolars. Gemination and
 fusion could contribute to increase in size or shape
difference.

• Fusion is the process by which two teeth buds unite to form

a single tooth.

• In gemination and twinning, a single tooth bud divides into

two.

• Gemination and fusion can be differentiated clinically by

counting the number of teeth.

• About 5% of the population show tooth size discrepancy

between upper and lower teeth.

• In any condition when there is a malformed tooth, normal

occlusion is not possible.
4. Delayed eruption/dentitiotarda

• There are two mechanisms involved in tooth eruption:

a. Resorption of the deciduous roots and overlying bone.

b. Guidance of the erupting tooth into the path created.

• Interference with any one mechanism can lead to delayed

eruption of tooth.

• In cleidocranial dysostosis, delayed eruption occurs due to

defective bone resorption.

• Presence of supernumerary tooth will act as a mechanical

interference to eruption. Removal of supernumerary tooth
 should be done at the earliest.

• Early loss of deciduous tooth will result in the formation of

dense sclerotic bone over the permanent tooth. This delays
the eruption of permanent tooth.

• Mucosal barrier is a common cause for delayed eruption.

Excision of mucosal barrier will prevent this problem.

• Endocrine disorders, like hypothyroidism, hypopituitarism,

cause delay in eruption.

• Ankylosis of the primary tooth delays eruption of

permanent successor.

Reasons for delayed eruption

1. Presence of supernumerary tooth

2. Early loss of primary tooth and dense sclerotic bone

3. Mucosal barrier

4. Endocrine disorders

5. Ankylosis of primary tooth

5. Ectopic eruption/abnormal eruptive path (Fig. 10.8)

• Malposition of a tooth bud will lead to eruption of tooth in a

wrong place. This is called ectopic eruption.

• Maxillary first permanent molar and mandibular incisors are

the frequently affected teeth.
• Maxillary first molar erupts too far mesially causing
resorption of roots of second primary molars.

• Ectopic eruption could be due to arch length deficiency.

• Ectopic eruption of mandibular lateral incisors may cause

transposition of the lateral incisor and canine.

• Retained root fragment of primary tooth may also cause

ectopic eruption.
6. Early loss of primary teeth (Fig. 10.9)

• Two important functions of the primary teeth are:

a. To act as space maintainers for the successor.

b. To maintain the opposite tooth in the occlusal level.

• Premature loss of the primary tooth will result in loss of

space and also derangement of occlusion.

• Loss of primary tooth in the anterior region does not cause

significant change in arch relationship.

• Mesial drift of the permanent first molar after early loss of

primary second molar contributes to development of
crowding in the posterior region.

• Premature loss of primary canines and first molar also

results in tendency for the space to close.

• Space closure is more by distal drift of incisors. The distal

drift is primarily by pull of trans-septal fibres with pressure
 from lips and cheeks adding to it.
7. Retained deciduous teeth

• This is a condition where there is delay in eruption of

permanent successor due to the presence of deciduous tooth
beyond its chronological age.

• There are two types of retained deciduous teeth: (i) those

with permanent successor and (ii) those with missing
permanent successor.

• Most frequently retained primary teeth are the primary

canines and primary second molars.
Reasons for retention of primary teeth

• Absence of permanent successor

• Ectopic eruption of permanent successor

• Impacted permanent tooth

• Presence of odontome

• Ankylosis of primary tooth.

• Hypothyroidism
 FIG. 10.8. Ectopic eruption.

FIG. 10.9. Early loss of deciduous tooth results in premature closure of space and the
resultant crowding.

Trauma as aetiologic factor

Trauma can affect either the jaws or teeth or both.
Trauma to jaws:

➤ Any fracture to the condylar neck can retard the mandibular growth.

➤ Trauma to TMJ also affects mandibular growth (e.g. forceps delivery).

➤ Mechanism by which trauma causes retarded growth is that it interferes with

function.
➤ Loss of function either due to scar or immobilization retards the growth of mandible.

➤ In children, conservative management of fracture with early mobilization is advised.

Trauma to teeth:

➤ Trauma to teeth causes malocclusion in three ways:

a. Damage to permanent tooth buds (Fig. 10.10)

b. Drift of permanent teeth after premature loss of primary

teeth

c. By direct injury to permanent teeth

➤ The effects of trauma to the tooth are as follows:

1. Trauma to primary teeth

2. Displacement of the crowns of permanent tooth

Defective enamel formation

Short stunted roots (or) dilacerated roots

➤ Trauma to permanent teeth can lead to possibility for ankylosis, nonvitality and
displacement of the tooth.
 FIG. 10.10. Relationship of permanent tooth bud to primary tooth.

High-frenal attachment/persistent labial frenum

➤ In the newborn, the frenum is seen as a large, fleshy attachment which joins low
down over the crest of the alveolus into the incisor papilla.

➤ With time, it recedes up the labial surface of the alveolar process.

➤ Recession is because of the vertical growth of this portion of maxilla.

➤ Persistence of the labial frenum breaks the continuity of trans-septal fibres between
the central incisors.

➤ In the presence of invaginated labial frenum, the direction of trans-septal fibres is

horizontal for a very short distance away from midpalatal suture.

➤ The presence of persistent labial frenum can be confirmed by blanch test.

➤ Blanch test: This test is done to assess the role of deep frenal attachment in midline
diastema. If the upper lip is retracted and a pull is exerted on the frenum, the
interdental tissue and the area around the papilla becomes blanched or anaemic; then
true diastema due to frenal attachment exists.

➤ Occlusal radiograph shows notching in the intermaxillary suture.

Management of high-frenal attachment:

➤ The presence of high-frenal attachment warrants excision of the tissue.

➤ Timing of excision of the attachment is crucial.

➤ Normally, excision is done when there is only 2 mm of space during the treatment
and before final closure of the median diastema.

Dental caries and improper restorations

The mechanism by which dental caries causes malocclusion is shown in Figs 10.11 and
10.12.

FIG. 10.11. Dental caries and improper restorations.

FIG. 10.12. Effect of proximal caries on arch length. Arch length reduces.
General causes of malocclusion
Combine the answers given under genetic, developmental, functional and
environmental causes.
ACCESSORY POINTS
➤ Causes act at times on tissues producing results. This orthodontic equation was given
by Dockrell R.

➤ ‘Vogelgesicht’ is retarded mandibular growth.

➤ Hapsburg jaw denotes prognathic mandible.

➤ Intrauterine moulding often occurs due to decreased volume of amniotic fluid.

➤ The consequences of intrauterine moulding are Pierre Robin syndrome, respiratory

difficulty at birth and maxillary deficiency.

➤ The reason for more asymmetric development of mandible when compared to

maxilla after trauma is that soft tissue scarring affects mandibular growth.

➤ Soft tissue pressures of lip, cheek and tongue influence the dentition most during
rest.

➤ The duration threshold for the pressure from soft tissue to act and produce any effect
on the dentition in humans is 6 hours according to equilibrium theory.

➤ Of all the forces that oppose the eruption of teeth, the most important is tongue and
other soft tissues.

➤ In muscle weakness syndrome like muscular dystrophy, which of the malocclusions

is most commonly seen? open bite.

➤ Oblique facial cleft is due to improper fusion of premaxilla and maxilla.

➤ Cheek pressure during thumb sucking is greatest at canine area.

➤ Aetiology of minor class I problem is usually alteration in function.

Table 10.7.
Syndromes causing malocclusion

Class II Class III

Pierre Robin Achondroplasia
Ankylosis of condyle Cleidocranial dysostosis
Milwaukee brace Down’s syndrome
Mandibulofacial dysostosis Craniofacial dysostosis
Mobius syndrome Marfan’s syndrome
Goldenhar syndrome Bilateral condylar hyperplasia
Still’s disease Gorlin syndrome

➤ An 8-year-old child comes to your office. On examination, she is found to have

anterior open bite (moderate). The facial proportions are satisfactory. The most likely
cause is thumb sucking.

➤ Microtrauma is usually caused by habits.

➤ Oral drive theory was proposed by Sears RR and Wise GW.

➤ Rooting and placing reflex as a hypothesis to thumb sucking was proposed by

Benjamin LS.

➤ Endocrine disorders being aetiology of malocclusion most often interfere with rate of
eruption of teeth.

➤ Early loss of primary teeth with subsequent delay in eruption of permanent teeth is
due to bone reform on top of permanent teeth.

➤ Decrease in arch length during mixed dentition is mostly due to interproximal caries in
primary molars.

➤ In mandibular arch, the tooth most often found to be locked out of arch due to space
discrepancy is second premolar.

➤ Presence of supernumerary tooth leads to crowding in the arch.

➤ Genetic make-up is identical in monozygotic twins.

Advanced Learning
Equilibrium theory
Definition: When an object is subjected to unequal forces, it will be accelerated and
move to a different position in space.
For an object to be in the same position, the forces acting on it should be in
equilibrium.
Equilibrium theory and dentition
There are four force contributors to dentition:

1. Masticatory force

2. Soft tissue pressure

3. External pressure
Habits

Orthodontics
4. Internal pressure

Periodontal fibres

Gingival fibres

Masticatory force
➤ Masticatory forces rarely move the teeth to new position.

➤ Reason is that it is the duration of force which is responsible for moving the teeth.
The duration threshold for tooth movement to occur is about 6 h.

➤ Masticatory forces, even though heavy, are transient. Hence, they do not cause any
change in dentition in normal condition.

Soft tissue pressures

➤ Pressures from lips, cheek and tongue are of lesser magnitude, but their duration is
more.

➤ Since the light pressures from lips, cheek and tongue are maintained for a longer
duration, tooth position is affected by these pressures.

➤ Another important aspect is the resting posture. This has the longest duration. Hence
posture of the tongue is an important contributor of malocclusion.

External pressures
➤ Prolonged habits and continuous orthodontic force are the source for external
pressure.

➤ Both can alter the position of teeth.

Internal pressures
The contribution to internal pressures are (i) periodontal fibres and (ii) gingival fibres.

➤ Gingival trans-septal fibres cause the lost space to be closed.

➤ The same trans-septal fibres cause opening of the space after active orthodontic
 treatment because the fibres pull the tooth to its original posture.

➤ Trans-septal fibres have no role in dental equilibrium. Their role is only with
orthodontic treatment. Periodontal fibres – take part in active stabilization of tooth.

➤ Forces act in three dimension–anteroposterior, vertical and transverse.

Equilibrium effects on jaw size and shape

The effect of force equilibrium on the jaw size is not clear.
But the same principles apply. It is the duration which plays a vital role rather than
the magnitude.
Conclusion
Intermittent forces have minimal effect on the dentition and jaw.
Light continuous or long-lasting force has an impact on the position of dentition and
size of jaws.
SECTION IV
Diagnosis
OUTLINE

11. Case history and clinical examination in orthodontics

12. Radiographs and related diagnostic aids

13. Model analysis

14. Cephalometrics
C H A P T E R 11
Case history and clinical examination in
orthodontics

CHAPTER OUTLINE
❖ Classification of diagnostic aids and various diagnostic methods employed in
orthodontics
❖ Importance of case history in orthodontic diagnosis
❖ Clinical evaluation of orthodontic patient
❖ Accessory points
❖ Advanced learning
❖ Macro-, micro- and mini-aesthetics
❖ Pitch, roll and yaw
❖ Smile analysis
Classification of diagnostic aids and various
diagnostic methods employed in orthodontics
➤ Diagnosis is a systematic procedure that permits identification of clinical problem, its
nature and extent.

➤ It is a statement of a patient’s problems expressed in terms of deviation from normal.

➤ Comprehensive orthodontic diagnosis is established after collecting maximum useful

clinical information using diagnostic aids.

Orthodontic diagnostic aids can be broadly classified into two types:

I. Essential diagnostic aids

II. Supplemental diagnostic aids

Essential diagnostic aids

➤ Essential diagnostic aids are the set of diagnostic records that are considered
important for all the cases.

➤ The dental practitioners should have the facility to obtain essential diagnostic aids.

Following are the essential diagnostic aids:

➤ Case history

➤ Clinical examination

➤ Plaster study casts

➤ Radiographs (IOPA, bitewing and panoramic radiographs)

➤ Facial photographs

Supplemental diagnostic aids

Supplemental diagnostic aids require special equipment which may not be available
with a dental practitioner. They provide valuable information in some cases.
Supplemental diagnostic aids:

1. Special radiographic views:

 a. Cephalometric radiographs

• Lateral cephalometric radiographs

• Frontal cephalometric radiographs

• Oblique cephalometric radiographs

b. Occlusal radiographs

c. Selected lateral jaw views

d. Tube shift technique

2. Electromyographic examination

3. Hand–wrist radiographs

4. Estimation of BMR and endocrine tests

5. Occlusograms

6. Diagnostic set-up
Importance of case history in orthodontic
diagnosis
Introduction
➤ Case history involves eliciting all relevant information by the direct questioning of
the patient or parent.

➤ The process of recording case history starts with recording the personal details of the
patient like name, age and sex.

➤ Knowing the patient’s name helps in communication.

➤ Knowing the patient’s age helps in identifying and anticipating certain transient
problems in the mixed dentition. It also helps in treatment planning.

➤ The timing of growth spurts differ in males and females. So knowing the patient’s
sex is essential for treatment planning.

➤ Case history also helps to explore the motivation of the patient. Motivation is
external, if the pressure is from another individual. Individual’s perception of his/her
problem leads to internal motivation.

I. Major complaints

• The chief complaint of the patient is recorded with emphasis

on whether the patient is seeking orthodontic care for
functional or aesthetic improvement or both.

• Impaired dentofacial aesthetics can lead to psychosocial

problems.

• The chief complaint is recorded in the patient’s own words.

• The main objective of chief complaint is to find out what is

important to the patient.
II. Medical history
• The important areas of concern in the medical history are
depicted in Box 11.1.
III. Dental history

• Dental history is elicited with focus on history of toothache,

sensitivity, bleeding from gums, pain in the TMJ region,
trauma, previous dental visit, etc.

• Orthodontic treatment in the presence of periodontal disease

is contraindicated.

• Trauma to teeth interferes with tooth movement due to the

possibility of root resorption.

• Previous history of orthodontic treatment should be elicited.

IV. Prenatal history

• Health of mother during pregnancy, history of premature

delivery, type of delivery and drugs used at the time of
pregnancy are noted.

• Forceps delivery causes trauma to the condylar region and

results in micrognathia.

• Some drugs, like tetracycline, cause pigmentation of the

teeth.
V. Postnatal history

• Duration and frequency of feeding, milestones reached

during growth, presence of habits and history of childhood
diseases are the important areas in postnatal history.
• Milestones correlate with development of an individual.

• Chronic medical problems can result in alterations of growth

status of patients.

• Habits can explain some aspects of malocclusion seen in the

patient.
VI. Family history

• Recording the family history is important in inherited

conditions like skeletal class III, skeletal class II
malocclusions, skeletal open bite and cleft lip and palate.

• Family history throws light on the possible hereditary aspect

of the patient’s problem.

• It provides information on parents’ knowledge about

orthodontic treatment.

Box 11.1.
Essential Medical History for orthodontic treatment
plan
• History of allergy

• Allergy to any drugs

• Allergy to latex

• Allergy to nickel-containing alloys

• Allergy to acrylic, impression materials

• History of blood dyscrasias
• Require special management, if extractions are required.

• Doctor and nurse should be protected against HIV and

hepatitis B since these patients undergo frequent blood
transfusions.

• Patients under corticosteroid therapy, tooth movement will

be impeded. Steroids interfere with prostaglandin synthesis.
• History of rheumatic fever or cardiac anomalies

• These patients require antibiotic prophylaxis.

• They should be treated using bonded attachments as bands

produce bacteraemia.

• Chronic medical problems can result in alterations of growth

status of patients.
• History of exanthematous fever. They cause hypoplasia and retarded growth.

• History of chronic painful conditions

• Nonsteroidal anti-inflammatory analgesics impede tooth

movement.
• History of epilepsy

• Epilepsy should be controlled before orthodontic treatment.

• The patient should be treated with fixed appliances. The

patient may swallow removable appliances at the time of
seizures.
• History of diabetes
• Controlled diabetes patients can undergo orthodontic
treatment
• History of trauma
Clinical evaluation of orthodontic patient
➤ Clinical examination is a prerequisite for the correct assessment and interpretation of
quantitative analysis obtained through various investigations.

➤ The goals of clinical examination are to evaluate and document:

• Facial problems

• Occlusal problems

• Functional problems

Clinical examination
It consists of:

➤ Examination of body

➤ Functional examination

➤ Extraoral (EO) examination

➤ Intraoral (IO) examination

I. Examination of general state of the patient

• Examination of general state of the patient involves

recording height, weight, posture, gait and body build.

• Recording of height and weight is to assess the patient’s

growth status.

• Gait is the way a person walks while posture is the way a

person stands.

• Sheldon has classified body build into three types (Box 11.2).
• Ectomorphic individuals are late maturers whereas
endomorphic individuals are early maturers.

Box 11.2.
Body build: Sheldon’s classification
1. Ectomorphic: Tall and thin – body tissue is made of primarily skin and neural
elements.

2. Mesomorphic: Average – body tissue is made of primarily mesodermal tissues:

muscular and robust individuals.

3. Endomorphic: Short and obese – body tissue is made of primarily fat tissues.

II. Extraoral examination

During extraoral examination, the position of patient is very

important. Patient should be placed upright with the
Frankfort plane parallel to the floor.

1. Head type: It is determined based on the anthropometric

determination of maximum skull width and maximum
skull length (Box 11.3).

2. Facial form: Facial form is estimated by dividing

morphological facial height by bizygomatic width (Box
11.4).

• Usually dolichocephalic head will have leptoprosopic face

and brachycephalic head will have euryprosopic face.

• Long and narrow faces are associated with high-angle

cases, open bites, class II division 1.

• Broad and short faces are seen in low-angle cases like class
II division 2.
• Sometimes head form and facial form will vary. They are
called dinaric individuals (Fig. 11.2).

3. Facial symmetry and proportions: The face is examined

in the frontal and lateral views for symmetry.

• In the frontal plane, intercanthal distance equals width of

the nose (Fig. 11.3).

• Interpupillary distance equals width of the mouth. An

ideally proportioned face can be divided into central, medial
and lateral equal fifths. The intercanthal distance constitutes
the central fifth and the width of the eyes form the medial
fifths. The nose and chin should be centred within the
central fifth.

• The nasal length in the vertical plane is one-third of total

facial height. The aesthetic appearance of the face is partly
determined by size, shape and position of nose.

• The nasal contour can be straight, convex or crooked.

Vertical facial proportions (Fig. 11.4)

• Vertical height of the midface should equal the height of

lower face.

• In the lower face, mouth equals one-third between nose and

chin.

• Forehead: The height of the forehead is measured from

hairline to glabella. It measures one-third of the total facial
height. Forehead is flat, protruding or steep (Fig. 11.4).
 • In normally balanced face, upper facial height, middle face
and lower facial height should be equal.

Box 11.3.
Head type: Classification
1. Mesocephalic: Average-shaped head

2. Brachycephalic: Broad and round head

3. Dolichocephalic: Long and narrow head (Fig. 11.1)

FIG. 11.1. Head type: classification.

Box 11.4.
Facial form: Classification
1. Mesoprosopic: Average facial form

2. Euryprosopic: Broad and short facial form

3. Leptoprosopic: Long and narrow facial form

FIG. 11.2. Dinaric individual.

FIG. 11.3. Facial symmetry.

 FIG. 11.4. Vertical facial proportions.

4. Facial profile: The facial profile is examined by viewing

the patient from the side (Fig. 11.5).

• Three landmarks and two lines are used to assess the facial
profile.

• The landmarks are soft tissue nasion, subnasale and soft

 tissue pogonion.

• The first line is dropped from soft tissue nasion to

subnasale and the second line is dropped from subnasale to
soft tissue pogonion.

• Helps in analysing the anteroposterior positioning of the

jaws (Box 11.5).

5. Facial divergence: Facial divergence determines the

position of lower part of the face relative to the forehead
(Fig. 11.6; Box 11.6).

• Divergence was described by Milo Hellmann.

• Divergence can be defined as the inclination of lower face

relative to forehead.

• It uses two soft tissue landmarks, namely soft tissue nasion

and soft tissue pogonion.

• A line is drawn between the forehead and the chin in the

natural head position.

6. Lip posture and prominence: Upper lip is protruded

slightly in relation to lower lip in a balanced face.

• Two millimetres of incisal edges of upper incisors showing

at rest is considered normal.

• Lip competency can be defined as the ability to approximate

the lips without any strain (Box 11.7).

Lips should be examined for habits like:

• Lip sucking.

• Lip thrust.

• Lip insufficiency.

• Abnormal lip habits can be observed when the patient

speaks or swallows.

• Any lip activity during swallowing is abnormal.

7. Nasolabial angle (NLA) and incisor protrusion: It is the

angle formed by tangent to base of the nose and a tangent
to upper lip (Fig. 11.7).

• Normal angulation is 110°.

• NLA is acute or decreases with proclination of upper

incisors.

• NLA is obtuse or increased in retroclination of incisors.

8. Clinical FMA:

• The inclination of mandibular plane angle to the Frankfort

horizontal plane should be noted.

• In patient’s face, one scale is placed over the Frankfort

plane.

• Another scale is placed along the lower border of mandible.

• Position where the posterior ends of the two scales meet is

noted.
• In a high-angle case, the posterior ends of the angle meet
behind the auricle or within the occiput.

• Steep mandibular plane angle is seen in patients with long

face and open bites.

• Flat mandibular plane angle is seen in short faces and

skeletal deep bite cases.

• In a low-angle case, the two lines are parallel and meet very
far away.

• In average FMA cases, it meets behind the occiput.

The examination of profile, divergence, vertical facial

proportions, lip posture, incisor protrusion and clinical
FMA constitute the facial profile analysis. It is also called
‘poor man’s cephalometric analysis’.

9. Chin:

• Chin is examined for height, width and contour.

• Mentolabial sulcus is shallow in bimaxillary protrusion.

• Deep mentolabial sulcus is seen in class II division 1

malocclusion.

• Hyperactive mentalis activity is also seen along with lip

habits like lip sucking and thrusting.

• Puckering of mentalis muscle can be visualized.

10. Assessment of submental soft tissues: Throat form is

 evaluated in terms of the contour of the submental tissues.
Straight throat form is better. Chin–throat angle and
throat length are assessed. The ideal chin–throat angle is
90° and a longer throat is aesthetically pleasing up to a
specific point.

FIG. 11.5. Facial profile: (A) straight, (B) convex and (C) concave.

Box 11.5.
Facial profile
1. Straight profile: The lines form a straight line.

2. Convex profile: The lines form an angle which is pointed away from the face;
associated with class II skeletal pattern.

3. Concave profile: The lines form an angle which is pointed towards the face; associated
with class III skeletal pattern (Fig. 11.5).
 FIG. 11.6. Facial divergence: (A) posterior divergent, (B) straight (orthognathic) and (C)
anterior divergent.

Box 11.6.
Facial divergence
1. Posterior divergent face: The line is inclined posteriorly in the chin region; seen in class
II cases.

2. Straight or orthognathic face: The line is perpendicular to the floor; seen in class I cases.

3. Anterior divergent face: The line is inclined anteriorly in the chin region; seen in class III
cases.

Box 11.7.
Lip competency based on configuration
• Competent lips: Lips which are in slight contact when the musculature is relaxed.

• Incompetent lips: Anatomically, short lips which do not contact each other when the
musculature is relaxed.

• Potentially incompetent lips: The lips are normally developed but the patient is unable
to approximate the lips at rest due to upper incisor proclination.

• Everted lips: These are hypertrophied lips with redundant tissue. They show weak
muscular tonicity.
 FIG. 11.7. Nasolabial angle (NLA).

III. Functional examination

• Functional examination studies the dynamic nature of the

stomatognathic system for optimal function.

• Functional examination is important in identifying the

aetiology of malocclusion and, therefore, helps in planning
the type of orthodontic treatment initiated.

• Detailed functional examination involves:

1. Examination of postural rest position and maximum

intercuspation

2. Examination of path of closure

3. Examination of temporomandibular joint (TMJ)

4. Examination of orofacial dysfunctions

1. Postural rest position

• Postural rest position is that position of mandible where the
synergistic and antagonistic muscular components are in
dynamic equilibrium with their balance being maintained
by basic muscle tonus.

• When the mandible is in the rest position, it is 2–3 mm below

the centric occlusion recorded in canine area.

• Determination of postural rest position is accomplished

when the patient’s musculature is relaxed. The methods
employed for attaining relaxation are depicted in Table 11.1.

The postural rest position, once determined, is registered by

various methods.

1. Direct intraoral method – plaster core

2. Direct extraoral method – caliper measurements using the

difference between vertical relation at rest and at
occlusion

3. Indirect extraoral method – best reliable methods;

examples are cephalometry, electromyography and
kinesiography

Clinical significance:

• Increased freeway space is seen in true deep bite cases where

there is infraocclusion of posteriors. In such conditions, bite
opening by molar extrusion can be attempted.

• Pseudo deep bite with normal freeway space has normal

eruption of posteriors. Bite opening by intrusion of incisors
 is recommended.

2. Path of closure

The path of closure of mandible from the postural rest position

to maximum intercuspation is evaluated in sagittal, vertical
and transverse planes (Table 11.2).

A patient is examined for presence of functional shifts in the

anterior, posterior or lateral direction.

3. Examination of TMJ

Table 11.1.
Muscle relaxation methods

Methods for muscle relaxing Procedure

Phonetic exercises Patient is made to repeat certain consonants repeatedly (e.g. ‘M’)
Command methods Patient is commanded to perform functions like swallowing
Non-command methods Patient is distracted so that muscles are relaxed
Combined methods Best suited method; observed during functions and manually guided by tapping the chin area

Table 11.2.
Path of closure

Type of path of closure Inference

Upward and forward Normal
Upward and backward Class II division 2
Upward and laterally with midline shift in occlusion only Posterior crossbite conditions and constricted maxillary arches
Upward and laterally with midline shift in rest position and occlusion Laterognathia
Upward forward and forward Pseudo class III and anterior crossbites

Palpation: This involves palpation of TMJ and palpation of

musculature.

• The TMJ is palpated for tenderness and synchrony of action.

• Muscles are palpated for tenderness.

Auscultation: A stethoscope is used for checking the joint for

 clicking or crepitus. Clicking can be:

• Initial click

• Intermediate click

• Terminal click

• Reciprocal click

Functional analysis of TMJ: The opening and closing

movements of the mandible as well as its protrusive,
retrusive and the lateral excursions are examined.

4. Examination of orofacial dysfunctions

Examination of orofacial dysfunction consists of analysis of the

following functions:

a. Swallowing

b. Tongue

c. Lips

d. Respiration

e. Speech

a. Examination of swallowing pattern: The normal

swallowing pattern has the following features:

• Contraction of mandibular elevators.

• The tongue is enclosed in the oral cavity.

• Teeth occlude momentarily.

• Dorsum of the tongue approaches the palate.

Infants swallow in a different manner. Retained infantile

swallow could lead to malocclusion. Signs of infantile
swallow are:

• Jaws are apart while swallowing.

• Tongue is placed between the teeth.

• Mandible stabilized by contraction of lips and tongue.

• Muscles of facial expression involved.

• Nodding of head.

• Anterior mandibular thrust.

• Caving-in of cheeks.

b. Examination of tongue:

• The posture, size, shape and function of the tongue are

assessed.

• The most common functional aberration of tongue is tongue

thrust.

• Tongue posture is very important.

Tongue size:

• Microglossia

• Small tongue and collapsed arch.

• Macroglossia

• Spaced dentition and crenations in lateral border of tongue

will be seen.

Tongue thrust: Types of tongue thrust:

• Anterior tongue thrust

• Lateral tongue thrust

• Complex tongue thrust

• Endogenous tongue thrust

• Habitual tongue thrust

• Adaptive tongue thrust

Anterior tongue thrust is associated with anterior open bite.

Lateral open bite is seen in lateral tongue thrust. Complex
tongue thrust patient occludes teeth only in the molar
region.

Tongue posture:

• Position of tongue is very important in creation of

malocclusion.
• Position or posture is analysed by the following methods:

1. Direct intraoral method

2. Cephalometric method

3. Palatographic method

4. Cinefluororadiographic method

• Normal resting position of the tongue is retracted tip lying

just behind the lower incisors and lateral border resting on
the linguo-occlusal surfaces of lower posterior teeth.

• In class II, tongue tip is more retruded in rest position.

• In class III, tongue tip lies far forward.

c. Examination of lips:

• Lips are assessed for configuration, functioning and

presence of dysfunctions.

• The common lip dysfunctions are:

• Lip sucking

• Lip thrust

• Lip insufficiency

The lip dysfunctions can be observed when the patient is

speaking or swallowing. Pronounced lip activity during
swallowing is unphysiologic.
 d. Examination of respiration:

• The mode of respiration is examined to establish whether

nasal breathing is impeded or not.

• Prolonged difficulty in nasal breathing leads to mouth

breathing.

• Mouth breathing results in disturbed orofacial musculature

which leads to long face syndrome (adenoid facies)

• Tests for mouth breathing are depicted in Table 11.3.

e. Examination of speech: Speech is affected in a variety of

dysfunctions or structural defects involving the palate,
tongue, lips, dentition, etc. The pronunciations of different
consonants are a guide to locate the area of abnormality
(Box 11.8).
IV. Intraoral examination

Mouth opening:

• Intraoral examination begins with mouth opening.

• Maximum mouth opening is recorded with the help of

dividers between the incisor edges.

• Normal mouth opening is 45–55 mm for adults.

• For children, it is less than 45 mm.

Tongue:
• The size, colour and configuration of tongue should be
assessed.

• The tongue can be small, long or broad.

Palate:

• Palate is assessed for contour which depends upon the

patient’s head form.

• Palatal vault will be high in mouth breathers and congenital

syphilis.

• Palatal mucosal surface is examined for ulcerations,

indentations, clefts or pathologic swellings.

Gingiva:

• The gingiva is examined for signs of inflammation,

hypertrophy or recession.

• Orthodontic treatment is not indicated in patients with

periodontal problems.

Frenal attachments:

• Midline diastemas may arise due to thick maxillary labial

frenum.

• Blanch test: This test is done to assess the role of deep frenal
attachment in midline diastema. If the upper lip is retracted
and a pull is exerted on the frenum, the interdental tissue
and the area around the papilla becomes blanched or
anaemic; then true diastemas due to frenal attachment
 exists.

• High attachment of mandibular labial frenum could lead to

gingival recession.

Adenoid and tonsils: Examined for enlargement and

inflammation.

Dentition: The following factors are recorded:

• Number of deciduous teeth

• Number of permanent teeth

• Presence of caries, attrition, erosion, fractures, etc.

• Presence of supernumerary tooth or missing tooth

• Size, shape and form of teeth

Table 11.3.
Tests to assess mouth breathing

Tests Procedure
Visual Size, shape and activity of external nares are observed; alar muscles are inactive in oral respiration
examination
Mirror test Two-surfaced mirrors are used: in nasal breathers, upper surface will cloud; in mouth breathers lower surface of mirror will cloud
Butterfly test Use of cotton butterfly to assess nasal breathing
Water holding test Patient is asked to sit with mouthful of water for 2 min; mouth breathers will find it difficult to retain water as it interferes with oral
respiration

Box 11.8.
Speech: Types
Labiodental (f,v)
Bilabial (p,b)
Linguodental (‘th’)
Linguoalveolar (t, d)
Linguopalatal (‘sh’, ‘ch’)
Linguopharyngeal (‘k’)
Glottis (‘h’)
Intra-arch examination
➤ Assessment of arch shape (Fig. 11.8), symmetry and alignment. Symmetry can be
assessed with dividers.

➤ Midlines are verified.

➤ Crowding, spacing and contact areas are checked.

➤ Rotations of teeth are noted.

➤ Dental age of the patient is assessed.

FIG. 11.8. Types of dental arches.

Interarch examination
➤ Midline shift between the maxilla and mandible is recorded.

➤ Sagittal relations: Molar relationship on both sides, canine relationship on both sides,
overjet and anterior crossbite are recorded (Fig. 11.9).

➤ Vertical relation: Deep bite, open bite to be assessed and recorded.

➤ Transverse relation: Posterior crossbites to be checked for and recorded, if any, on

both sides.
 FIG. 11.9. Measurement of overbite and overjet.

Summary of clinical examination

Examination of body
1. Height
2. Weight
3. Gait
4. Posture
5. Body build
• Ectomorphic
• Mesomorphic
• Endomorphic
Extraoral examination
1. Head type
• Mesocephaly
• Brachycephaly
• Dolichocephaly
2. Facial form
• Mesoprosopy
• Leptoprosopy
3. Facial symmetry
4. Facial profile
• Straight
• Convex
• Concave
5. Facial divergence
• Anterior
• Posterior
6. Lip posture and prominence
• Competent
• Incompetent
• Potentially incompetent
• Everted
7. Nasolabial angle
• Acute
• Obtuse
• Straight
 8. Clinical FMA
• Average
• High
• Low
9. Chin
• Height
• Mentolabial sulcus
• Hyperactive mentalis
• Chin prominence
10. Chin soft tissues
• Throat form
• Chin–throat angle
• Throat length
Functional examination Intraoral examination
1. Postural rest position 1. Mouth opening
2. Path of closure 2. Soft tissues
3. TMJ examination 3. Hard tissues
4. Orofacial dysfunction • Intra-arch analysis
• Swallowing • Inter-arch analysis
• Tongue
• Lips
• Respiration
• Speech

ACCESSORY POINTS
➤ Beginning of ossification of ulna sesamoid usually marks the beginning of the pubertal
growth spurt.

➤ Condylar guidance is less prominent in adolescent and children because contours of

the TMJ are not well developed.

➤ Posterior crossbite is usually described in terms of the position of upper molars.

➤ In class II division 2 malocclusion, the positions of the lower incisors are retroclined or
upright.

➤ In the examination of posterior crossbite in a patient, it is found that palatal vault is

wide and the dentoalveolar process lean inward and the molars are in crossbite. This
is dental crossbite.

➤ The most common reason for anterior open bite in a child in late mixed dentition or
early permanent dentition is prolonged thumb sucking.

➤ V-shaped arch/arches tolerate expansion treatment better.

➤ Distortion of fricatives is seen in skeletal class III.

➤ Lisping is usually evident in a condition where there is spacing between incisors.

➤ Sleep disorders are often related to mandibular deficiency.

➤ An effort on the part of the patient with skeletal class II malocclusion of bringing the
mandible forward to look better is called Sunday bite.

➤ Facial profile analysis is also called poor man’s cephalometric analysis.

➤ What amount of lip separation is normally considered lip incompetence? Greater than
3–4 mm.

➤ A unilateral crossbite is usually due to symmetric maxillary constriction and functional

shift.

➤ The most common permanent tooth to suffer root resorption due to ectopic eruption
of adjacent tooth is maxillary lateral incisor.

➤ Which functional shift is seen in class II division 2 after initial contact? Backward shift.

➤ What is the equivalent of the dolichocephalic head type? Leptoprosopic face.

➤ Flattening of profile occurs with maturation during transition from childhood to

adulthood.

➤ Diagnostic factor in differentiating pseudo class III malocclusion is abnormal path of

closure from rest position to occlusion.

➤ Stable area to evaluate craniofacial growth is anterior cranial fossa.

Advanced Learning
Macro-, mini- and micro-aesthetics
Macro-aesthetics
Assessment of macro-aesthetics consists of evaluation of extraoral proportions or facial
proportions. Analysing facial proportions consists of the following steps:

➤ Frontal view assessment, profile analysis, divergence, evaluation of lip posture,

nasolabial angle, clinical FMA, throat form (all these are already explained in
extraoral clinical examination section).

Mini-aesthetics
Mini-aesthetics involves assessing the following:

(i) Tooth–lip relationships; this is done in the following way:

• Note the relationship of the dental midline of each arch to

the skeletal midline of that jaw.

• Assess the vertical relationship of the teeth to the lips, at rest

and on smile. Note down the amount of incisor display.
Excessive incisor or gingival display could be due to short
 upper lip or long face.

• Record the transverse cant of the occlusal plane.

(ii) Smile analysis – refer to section on smile analysis.

Micro-aesthetics (dental appearance)

For optimum aesthetics, there should be ideal proportions in the shape of teeth.

➤ Width relationships and golden proportion: In frontal view, the apparent width of
lateral incisor should be 62% of the width of central incisor, the apparent width of
canine should be 62% of the width of lateral incisor, and the apparent width of
premolar should be 62% of the width of canine. This recurring ratio of 62% is referred
to as the ‘golden proportions’.

➤ Height–width relationships: The width of the tooth should be 80% of the height
(Fig. 11.10)

FIG. 11.10. Height width ratio: Tooth width should be 80% of the height.

➤ Gingival heights, shape and contour: Proportional gingival heights contribute to

normal and attractive dental appearance. The central incisor has the highest gingival
level; the lateral incisor is about 1.5 mm lower and canine at the level of central
incisor (Fig. 11.11). Gingival shape refers to curvature of the gingiva at the margin of
tooth. Ideal gingival shape for central incisor and canine is elliptical and oriented
distal to long axis. Lateral incisor should have symmetrical half-oval or half-circle.
The gingival zenith (most apical point of the gingival tissue) should be located distal
to long axis of maxillary centrals and canines, while in maxillary laterals it should
coincide with long axis.
 FIG. 11.11. Gingival height. Note the difference in height between central and lateral incisors.
Canine corresponds to central incisor height.

➤ Connectors: The connector, also termed as interdental contact area, is where adjacent
teeth appear to touch. The contact points of maxillary teeth move progressively
gingival from the central incisors to the premolar.

➤ Embrasures: The triangular spaces incisal and gingival to the contact area are called
embrasures. Short interdental papillae result in an open gingival embrasure above the
connectors which are called ‘black triangles’. Black triangles affect the appearance of
teeth on smile. All actual and potential triangles should be noted during clinical
examination.

➤ Shade and colour of tooth: A normal progression of shade change from midline
towards posteriorly is essential for an attractive and natural smile.

Pitch, roll and yaw

Pitch, roll and yaw of the aesthetic line of the dentition are useful ways to evaluate the
relationship of the teeth to the soft tissues that frame their display (Proffit WR).
Pitch: Excessive upwards or downwards rotation of the dentition relative to the lips
and cheeks is noted as pitch. It can be up or down, in front or back.
Roll: It is described as rotation up or down on one side or the other. Roll consists of
transverse orientation of the dentition to both the soft tissues and facial skeleton.
Yaw: Rotation of the jaw or dentition to one side or the other, around a vertical axis
produces a skeletal or dental midline discrepancy. This is described as yaw. Extreme
yaw is seen in facial asymmetries.
Smile analysis
Creation of pleasing smile is an important aspect of orthodontic treatment.
Assessment of smile is a prerequisite for proper treatment planning and diagnosing
the problem.
Types of smile
Unposed smile (Fig. 11.12)

➤ It is natural and expresses authentic human emotion.

 FIG. 11.12. Unposed smile.

➤ It is dynamic.

➤ It is spontaneous and characterized by more lip elevation.

Posed smile (Fig. 11.13)

➤ Posed smile is voluntary and need not be accompanied by emotion.

FIG. 11.13. Posed smile.

➤ It is static, which means it can be sustained.

➤ It is a learned greeting and characterized by less lip elevation.

Features of smile
1. Vertical characteristics

• There are two main features of vertical characteristics:

• Pertaining to incisor display

• Pertaining to gingival display

• Inadequate incisor display can be due to vertical maxillary

deficiency, restricted lip mobility and short clinical crown.

• In normal smile, the gingival margins of the canine should

be coincident with the upper lip. Lateral incisors should be
positioned slightly inferior (Fig. 11.14).

FIG. 11.14. Ideal relationship of gingival margin and upper lip in smile.

• Gummy smile will be associated with vertical maxillary

excess.

• Amount of incisor proclination can affect how much they are

displayed on smile. Flared incisors tend to reduce incisor
display and upright maxillary incisors tend to increase
incisor display (Fig. 11.15).
 FIG. 11.15. Incisor proclination and vertical incisor display.

2. Transverse characteristics

There are three important features:

Buccal corridor width

• Buccal corridor is calculated from the mesial line angle of the

maxillary first premolars to the inner portion of the
commissures of lip.

• Corridor is represented by a ratio of intercommissure width

divided by the distance from one maxillary first premolar to
opposite side first premolar.

• Excessively wide buccal corridor is referred to as ‘negative

space’.

Arch form

• Arch form plays an important role in the form of smile.

• In patients with collapsed arch or narrow maxilla, smile also

is narrow and the buccal corridor is wide.
• Orthodontic expansion of the arch improves the smile by
reducing the buccal corridor.

• Transverse smile dimension is also improved.

• Transverse smile dimension is related to buccal projection of

premolars into the buccal corridors.

Transverse cant

• Appearance of transverse cant or tilt of the smile line could

be due to asymmetric vertical growth of the arches or due to
differential eruption of teeth.

• Ideally, there should not be any transverse cant.

3. Oblique characteristics

• Maxillary occlusal plane from premolar to premolar should

be in consonant with the curvature of the lower lip on smile.

• Deviation includes downwards tilt of the posterior maxilla

or upwards tilt of anterior maxilla.
CHAPTER 12
Radiographs and related diagnostic aids

CHAPTER OUTLINE
❖ Radiographs used in orthodontics
❖ Role of intraoral radiographs in orthodontics
❖ Intraoral periapical radiographs
❖ Bitewing radiographs
❖ Occlusal radiographs
❖ Panoramic radiography
❖ Facial photograph as a diagnostic tool
❖ Hand–wrist radiographs
❖ Electromyography (EMG)
❖ Digital radiography
❖ Accessory points
❖ Advanced learning
❖ Occlusogram
❖ Advanced diagnostic aids
❖ Xeroradiography
❖ Magnetic resonance imaging (MRI)
❖ Computed tomography (CT)
❖ Photocephalometry
❖ Cinefluororadiography
❖ Laser holography
Radiographs used in orthodontics
➤ X-rays were discovered in 1895 by WC Roentgen.

➤ The use of X-rays in orthodontics has made it possible to visualize the bony skeleton
of the patient as shadows formed in the acetate film.

Classification of radiographs used in orthodontics

I. Based on the location of the radiographic film

Intraoral radiographs (film is placed inside the mouth)

1. Intraoral periapical (IOPA) radiographs

2. Bitewing radiographs

3. Occlusal radiographs

Extraoral radiographs (film is placed outside the mouth)

1. Panoramic radiographs

2. TMJ radiographs

3. Cephalograms
II. Based on the area of interest

Radiographs to assess condition of teeth

1. IOPA radiographs

2. Bitewing radiographs

3. Occlusal radiographs
 4. Panoramic radiographs

Radiographs to assess the facial skeleton

1. Lateral cephalometric radiographs

2. Frontal cephalometric radiographs

3. Oblique cephalometric radiographs

III. Based on importance in diagnosis

Essential diagnostic radiographs

1. IOPA radiographs

2. Bitewing radiographs

3. Panoramic radiographs

Supplementary diagnostic radiographs

1. Occlusal radiographs

2. Cephalometric radiographs

3. Hand–wrist radiographs

4. Temporomandibular joint radiographs

Role of intraoral radiographs in orthodontics
➤ Intraoral radiographs are taken with the film placed in the patient’s mouth.

➤ They provide vital information about the teeth and their supporting structures.

➤ There are three types of intraoral radiographs used in orthodontics:

1. IOPA radiographs

2. Bitewing radiographs

3. Occlusal radiographs.

IOPA radiographs
➤ Most commonly used radiographs in dentistry.

➤ Used to visualize the teeth and the supporting alveolar bone.

➤ Adult size IOPA film measures 32 × 41 mm.

➤ The X-ray film is placed in the mouth lingual to the teeth to be examined.

➤ There are two methods of obtaining IOPA radiographs:

1. Paralleling technique

2. Bisecting angle technique

Paralleling technique
➤ X-ray film is placed parallel to the long axis of the teeth.

➤ Central ray of the collimated X-ray beam is perpendicular to the long axis of the
tooth and the film.

➤ Advantage: Reduced geometric distortion.

➤ Disadvantage: Morphological limitations imposed by oral cavity in the correct

placement of the film.
Bisecting angle technique
➤ Bisecting angle technique uses Cieszynski’s rule of isometry, which is a geometric
theorem.

➤ According to the rule of isometry, two triangles are equal when they share a
complete side and two equal angles.

➤ The central X-ray beam is perpendicular to the angle bisecting the long axis of the
teeth and the long axis of the film.

➤ Advantage: Convenient to the operator; the film is placed close to lingual surfaces of
the tooth.

➤ Disadvantage: Faulty X-ray beam angulation results in foreshortening or elongation

of the image.

Uses of IOPA radiographs

1. To examine the tooth for demineralization due to caries.

2. To study the extent of root formation in the permanent teeth and root resorption in
the primary teeth.

3. To examine the root for fractures or external root resorption.

4. To examine the dental pulp for internal root resorption and calcific changes.

5. To assess the height of alveolar bone crest, mesial and distal to the tooth.

6. To examine the alveolar bone for root fragments.

7. To visualize the apical area of teeth to rule out pathology.

8. To view impacted teeth, their size, location and angulation.

9. To study quality of alveolar bone and periodontal ligament space.

10. To examine the alveolar bone for potential areas of implant placement.

11. To confirm the congenital absence of teeth or presence of supernumerary tooth.

Advantages
➤ Ability to visualize the area of interest in high detail.

➤ Minimal radiation exposure to patient.

➤ Easy to store and transport.

Disadvantages
➤ Pain and gagging may occur while placing the film.

➤ Full mouth survey requires many radiographs.

➤ Exposure to radiation when used for full mouth examination.

Bitewing radiographs
➤ Bitewing radiographs are used to examine the tooth and the supporting alveolar
bone up to half the length of the root.

➤ A standard adult size periapical film is fitted with bitewing tab. The patient bites on
the bitewing tab and stabilizes the film on exposure.

➤ The central beam of the X-ray is perpendicular to the film.

Uses of bitewing radiographs

1. Detecting interproximal caries at an early stage

2. Detecting secondary caries under restorations

3. Detecting bone loss at the alveolar crest due to inflammation

4. Detecting calculus deposits at the interproximal areas

5. Detecting proximal overhangs in the restoration

6. Assessment of occlusal pattern

Advantages
➤ No geometric distortions

➤ No magnification

➤ Convenient to the patient and operator

➤ Can be taken for children with ease when compared to periapical film

Occlusal radiographs
➤ Occlusal radiograph is indicated when there is a need to visualize a large segment of
the dental arch with reasonable extent of adjacent structures.

➤ The occlusal radiograph uses a film 3× 2¼ inches in size. The film is placed between
the occlusal surfaces of the teeth in the plane of occlusion.

➤ The tube side of the film is turned to the jaw being examined.

Based on the projection of the X-ray, occlusal radiographs can be classified into:

1. Maxillary occlusal radiographs

• Topographical maxillary occlusal projection

• Cross-sectional maxillary occlusal projection

• Lateral topographical maxillary occlusal projection

2. Mandibular occlusal radiographs

• Topographical mandibular occlusal projection

• Cross-sectional mandibular occlusal projection

• Lateral cross-sectional mandibular occlusal projection

• Mental spine view

Uses of occlusal radiographs
1. Enable to check for supernumerary and missing teeth

2. Used to observe abnormal eruption pattern of the canines

3. Minimal error

4. Used to analyse treatment effects after rapid expansion of maxillary arch

5. Used to differentiate buccal or lingual positioning of tooth

6. Buccal expansion of bony lesion can be studied clearly

7. Used in patients with limited mouth opening
Panoramic radiography
➤ Panoramic radiography is a radiographic procedure used to record a single image of
maxillary and mandibular arches and their supporting structures (Fig. 12.1).

➤ Panoramic radiography was introduced by Dickson E and Copola F.

FIG. 12.1. Panoramic radiograph: Visualization of maxilla, mandible and supporting

structures.

Procedure
➤ Patient is made to stand or sit biting the bite fork with the incisors. This positions the
patient’s head in the panorex machine.

➤ An X-ray source rotates around the patient’s head. The photons will fall on the film
which rotates in the opposite direction through a narrow collimator.

➤ The rate at which the X-ray source moves is kept the same as the rate at which the
film rotates.

➤ The image seen on the film is composed of anatomic structures lying along
predetermined curved image zone called focal trough.

➤ Objects away from the focal trough are blurred, distorted, magnified or reduced.

Uses
➤ Evaluation of dental development in the mixed dentition by assessing the extent of
 root resorption in the deciduous teeth and amount of root development in the
permanent teeth.

➤ To locate supernumerary tooth or congenitally missing tooth.

➤ It is used to locate impacted tooth.

➤ It is used to assess the development of third molars.

➤ Evaluation of mesiodistal angulation of permanent tooth and their relation to the

resorbing deciduous root.

➤ To detect presence of pathologic lesions in the jaw bones and to ascertain its extent;
also useful in diagnosis of jaw bone fractures.

➤ It is used to locate caries, bone loss secondary to periodontal disease, retained

deciduous tooth, etc.

Advantages
➤ The radiation dose to the patient is low when compared with full mouth IOPA
radiographs.

➤ Highly valuable as an initial survey radiograph of the dentofacial region.

➤ It is useful in patients with extreme gag reflex.

➤ It is useful in patients with trismus.

Disadvantages
➤ It is not suitable for diagnosis of lesions requiring high resolution, e.g. early alveolar
bone loss. Full mouth IOPA films are superior to panoramic radiographs in this
regard.

➤ Magnification, minimization or blurring of incisor teeth may take place.

➤ Shadows are formed by radio-opaque structures like earrings, ramus of mandible

and spinal cord.

➤ Overlapping of the structures occurs.

➤ It requires expensive equipment.

Facial photograph as a diagnostic tool
➤ Facial photographs assume greater importance as a diagnostic tool because both
frontal and profile facial analyses can be carried out.

➤ It is preferable to take profile and frontal view photographs simultaneously with the
help of two cameras.

➤ This helps in reproducing the same position of the patient for both profile and frontal
views.

Photographs
➤ Extraoral view ➤ Intraoral view
• Profile • Right and left lateral
• Frontal • Anterior
• Oblique • Upper and lower occlusal

➤ Intraoral photographic series consists of five views namely: Right and left lateral,
anterior, upper and lower occlusal views.

Uses of photographs
1. Photographs form a permanent record of the patient’s pretreatment appearance and
profile.

2. Facial profile and frontal analyses can be done on photographs.

3. For assessment of facial type.

4. Facial asymmetry can be studied.

5. Intraoral photographs can be used for correlating the clinical and study model
findings.

6. Used to assess treatment changes.

7. Can be used for motivation of patients.

8. Hereditary patterns in the family can be diagnosed by comparing photographs of the

parents and siblings.

9. Monitoring of treatment progress.

Hand–wrist radiographs
Hand–wrist radiographs are used to assess the skeletal maturity status of an individual.

Skeletal maturity
➤ Assessing the skeletal maturity status of an individual helps in knowing whether he
or she will grow appreciably in the treatment period. This has important implications
in the treatment planning and response to treatment.

➤ The position of the patient in the facial growth curve is important while planning
orthopaedic therapy, functional appliance therapy and orthognathic surgery.

➤ The orthopaedic or functional appliance treatment during the periods of accelerated

growth can contribute significantly to correction of dentofacial deviations leading to
an improvement in the facial appearance.

➤ The physical maturity of an individual is not related to chronological age.

➤ Physical maturity can be assessed by the skeletal maturity or skeletal age. The other
parameters like peak height velocity (PHV), secondary sexual changes and dental age
are inferior to skeletal age in estimating physical maturity.

➤ The bones mature at different rate and follow a reasonable sequence in doing so.
Hence the developmental status of a child can be estimated by determination of
degree of completion of facial skeleton.

The skeletal maturity indicators commonly used are:

1. Hand–wrist radiographs

2. Cervical vertebrae cephalogram

3. Pelvis radiographs

4. Canine calcification intraoral radiographs

History of hand–wrist radiographs

➤ There are numerous small bones in the hand–wrist region. They follow a pattern in
ossification and union of epiphysis with diaphysis.

➤ Carpal bones were first named by Michael Lyser in 1653.

➤ The left hand and wrist are used by convention and a postero-anterior view is taken
to register the hand–wrist region.

Anatomy of hand–wrist region

➤ Each hand–wrist area has 8 carpals, 5 metacarpals and 14 phalanges, which make a
total of 27 bones. Distal ends of radius and ulna also appear in the hand–wrist
radiograph (see Fig. 3.11).

➤ Radius and ulna are the long bones of the forearm. Ulna lies in the medial aspect
and radius in the distal aspect when the palm is facing front.

➤ The carpal bones are arranged in two rows:

• Distal row: Trapezium, trapezoid, capitate, hamate.

• Proximal row: Scaphoid, lunate, triquetral, pisiform.

➤ These small irregular bones lie in between the long bones of forearm and the
metacarpals.

➤ Metacarpals are small long bones. Each of the five metacarpals has a base, shaft and
head. They lie between the carpals and phalanges forming the skeletal framework of
the palm. Each finger has a proximal phalanx, middle phalanx and distal phalanx.
Middle phalanx is absent in the thumb. The small round bone located in the thumb
embedded in the tendons is called the sesamoid bone. The phalanges have a pattern
of ossification which can be divided into three stages:

• Stage I: Epiphysis and diaphysis are equal (Fig. 12.2A).

• Stage II: The epiphysis caps the diaphysis (Fig. 12.2B).

• Stage III: Fusion occurs between epiphysis and diaphysis

(Fig. 12.2C)
 FIG. 12.2. (A) Width of epiphysis. (B) Capping of epiphysis. (C) Fusion.

Bjork A divided the skeletal development in the hand–wrist area into eight stages.
Each of the stages represents a particular level of skeletal maturity (Table 12.1).

Table 12.1.
Skeletal development in hand–wrist area

Hagg U and Taranger J noted that stages of ossification of middle phalanx of third
finger (MP3) follow pubertal growth spurt. The stages of ossification are outlined from
stage F to stage I.

➤ Stage F: The epiphysis is as wide as the metaphysis. About 40% of the individuals are
before PHV. Very few are at PHV.
➤ Stage FG: The epiphysis is as wide as the metaphysis, and there is a distinct medial
or lateral (or both) border of the epiphysis forming a line of demarcation at right
angles to the border. About 90% of the individuals are 1 year before or at PHV.

➤ Stage G: The sides of the epiphysis are thickened, and there is capping of the
metaphysis, forming a sharp edge distally at one or both sides. About 90% of the
individuals are at or 1 year after PHV.

➤ Stage H: Fusion of the epiphysis and metaphysis has begun. About 90% of the girls
and all the boys are after PHV but before the end of the pubertal growth spurt.

➤ Stage I: Fusion of the epiphysis and metaphysis is completed. All individuals except
a few girls have ended the pubertal growth spurt.

Other methods of assessing the hand–wrist radiographs are:

1. Greulich and Pyle method

2. Tanner and Whitehouse method

3. Singer’s method

4. Fishman skeletal maturity indicator method

Indications of hand–wrist radiographs

1. To assess the potential for growth before treating the patient with skeletal class II or
class III malocclusion.

2. It is indicated when there is a major discrepancy between the dental age and the
chronological age.

3. To predict the pubertal growth spurt.

4. To assess the skeletal age in a patient whose growth is retarded by infections or

neoplasm.

5. To evaluate whether any growth is left prior to orthognathic surgery such that the
chances of relapse linked to postsurgical growth can be minimized.

6. Serial assessment of skeletal age is used in studying growth of an individual.

7. It is used in research to elucidate the effect of heredity and environment on

dentofacial growth.
Electromyography
➤ Electromyography (EMG) is a procedure that is used to record the action potentials
formed in the voluntary muscles when they are excited. The instrument used is called
electromyograph and the output is called electromyogram.

➤ The surface membrane of the muscle cells is positively charged on the external
surface and negatively charged on the internal surface. The action potential reverses
the charge on the muscle membrane. A series of changes then occur which bring
about muscle contraction.

➤ The electromyograph measures frequency, amplitude and duration of action

potential.

➤ It receives, amplifies and records the action potential.

➤ Recording of the electrical charges from the muscle is accomplished by means of

surface electrodes or needle electrodes.

➤ The surface electrode is placed in the skin overlying the muscle. Its use is limited to
superficial muscles.

➤ Needle electrode is placed into the belly of muscle. It is an invasive procedure when
used in deep muscles.

➤ Permanent paper record is obtained with a writing device. Electromyogram can be

displayed on an oscilloscope.

Uses
➤ EMG has been used to study the role of musculature in craniofacial growth.

➤ EMG is used to study the activity of mandibular elevators and depressors in mouth
breathers.

➤ EMG is used to study the pronounced buccinator activity in class II division 1

malocclusion.

➤ EMG is used to assess the aberrant muscular activity associated with various habits.

Disadvantages
➤ EMG readings may be compromised by unknown levels of muscular fatigue or pain.
➤ Muscle activity differs at different periods even in the day time.

➤ Measures of EMG activity during clenching, swallowing, etc. may differ considerably
between subjects.
Digital radiography
Digital or electronic imaging has been available for more than a decade. The first direct
digital imaging system RadioVisioGraphy (RVG) was invented by Dr Frances Mouyens
and manufactured by Trophy Radiologie (Vincennes, France) in 1984.
Digital imaging is the result of X-ray interaction with electrons in electronic sensor
pixels (picture elements), conversion of analogue data to digital data, computer
processing and display of the visible image on a computer screen.
Data acquired by the sensor are communicated to the computer in analogue form.
Computers operate on the binary number system in which two digits (0 and 1) are used
to represent data. These two characters are called bits (binary digit), and they form
words eight or more bits in length called bytes. The total number of possible bytes for 8-
bit language is 28 = 256.
The analogue-to-digital converter transforms analogue data into numerical data
based on the binary number system.

Advantages of digital radiography

Direct digital imaging systems produce a dynamic image that permits immediate
display, image enhancement, storage, retrieval and transmission.
Digital sensors are more sensitive than film, and require significantly lower radiation
exposure.
ACCESSORY POINTS
➤ The important indication for frontal cephalometry is to assess facial asymmetry.

➤ Beginning of ossification of ulna sesamoid usually marks the beginning of the

pubertal growth spurt.

➤ Holography is the only visual recording and playback process that can record our
three-dimensional image on a two-dimensional recording medium.

➤ Swallowing patterns can be studied using cinefluororadiography.

Advanced Learning
Occlusogram
An occlusogram is a 1:1 reproduction of occlusal surfaces of plaster models on an
acetate tracing paper. The upper tracing is oriented to lower tracing using grooves cut
in the back of plaster models (Fig. 12.3).
 FIG. 12.3. Occlusogram: Typical ideal class I relation.

Technique
➤ For the occlusogram, photostatic or photographic copies of the maxillary and
mandibular study models are made.

➤ Copies are taken parallel to the occlusal plane.

➤ Tracings of the teeth of both the arches can be superimposed to match the occlusion.

Occlusogram norms ( fig. 12.3)

1. Biting edge of upper anterior lies in front of biting edge of lower anterior by 0.7 mm.

2. Upper bicuspids are wider than the lower bicuspids by 1.9 mm each side.

3. Upper posterior teeth extend beyond lower posterior teeth by 2.3 mm.

4. Upper molars are wider than lower molars by 1.4 mm each side.

5. Each upper tooth touches two teeth below it, except last molar.

6. Key to firm static occlusion is the width and position of lateral incisors.

Uses of occlusograms
1. Occlusograms can be used to develop ideal natural individualized arch form.

2. It permits the clinician to make accurate and reliable arch length discrepancy
measurements.
3. It is possible to do occlusal simulation.

4. It is possible to identify problems in the transverse plane.

5. Anticipated movements can be simulated to determine the future position of teeth.

6. Occlusograms are useful for predicting occlusal relationship.

Disadvantages
1. Occlusograms are two-dimensional records.

2. They are inferior to study casts which permit a three-dimensional evaluation of

patient’s occlusion.

Advanced diagnostic aids

Newer techniques used in orthodontic diagnosis:

1. Xeroradiography

2. Magnetic resonance imaging (MRI)

3. Computed tomography (CT) scan

4. Computerized cephalometric systems

5. Photocephalometry

6. Cinefluororadiography

7. Laser holography

Xeroradiography in orthodontics
➤ Xeroradiography is a radiographic method that involves recording images in a
manner similar to photocopy machines.

➤ Invented by Chester Carlson for copying purposes.

➤ The conventional radiographic film is not employed. Rather a printout is taken on

paper.

Method
➤ Selenium photoreceptors are given a uniform electrostatic charge in a device called
conditioner before placing into the cassette.
➤ The light-tight cassette with the photoreceptor is placed intraorally and X-ray
exposed like film.

➤ Selective discharge occurs from the areas of photoreceptors when exposed to the X-
rays proportional to the density of the rays.

➤ The areas with discharge and without discharge together form the latent image.

➤ The latent image is converted to visible image by exposing it to charged powder

particles in toner.

➤ The toner image is then transferred from the photoreceptor and fixed to a white
plastic substrate for viewing. After cleaning, the photoreceptor is available for reuse.

➤ In contrast to film images, xeroradiographic images are exposed and processed

sequentially. Processing time is approximately 20 s.

Uses
➤ Xeroradiography is a valuable alternative to conventional radiography for detecting
carious lesions, calculus deposits and periodontal diseases.

➤ It is also of value in interpreting periapical structures.

Advantages
1. High-edge enhancement

2. Choice of positive and negative displays

3. Wide exposure latitude

4. Good detail

5. Requires only about one-third of the radiation dose required for conventional
radiographs.

Magnetic resonance imaging in orthodontics

Introduction
➤ MRI is a new nonradiographic method used to visualize the craniofacial tissues.

➤ The major constituent of the body is water. Water molecule has two hydrogen atoms.
Hydrogen has only one proton.

➤ The hydrogen protons behave like small magnets when they are placed in magnetic
 field.

➤ The protons will move around the magnetic field inducing a minute current which is
amplified and displayed on an oscilloscope.

Uses
1. Evaluation of the position, mobility and morphology of the articular disc of TMJ.

2. Used to study internal derangements of the disc.

3. Used to evaluate the position of the articular disc after treatment with functional and
orthopaedic appliances.

4. Examination of tongue movements during deglutition.

Advantages
1. No radiation exposure.

2. Greater tissue characterization compared to CT scanning.

3. With MRI, it is possible to get a better spatial resolution.

4. A sectional view can be created in any desired direction in the human body.

Disadvantages
1. Inability to visualize bony lesions.

2. Cannot be used in patients with cardiac pacemakers.

3. More time consuming.

4. More expensive than CT scanning.

Computed tomography in orthodontics

Introduction
➤ CT is the radiographic examination of body structures in the cross-sectional form.

➤ All the objects between the X-ray source and the film are superimposed in the
conventional radiograph. Superimpositions reduce the diagnostic value of the image.

➤ Tomography is a radiographic method used to visualize a section or slice of the

object of interest.
➤ CT uses scanners that measure the extent of X-ray transmission through the object
and produce digital data.

Parts of CT scan system

1. Scanner (movable X-ray table + gantry)

2. Computer system

3. A display console

Uses
1. Used in radiographic examination of TMJ

2. Analyse effects of rapid maxillary expansion

3. Evaluation of cortical bone thickness for orthodontic implants

4. Diagnosis and treatment planning for maxillary canine impaction

5. Study the effect of distraction osteogenesis devices

Advantages
1. High geometric precision.

2. Ability to discriminate between objects with minor difference in density.

3. Images can be manipulated by changing the contrast to highlight or accentuate areas

of interest.

4. Large amount of information secured in short period.

Disadvantages
1. Radiation exposure

2. High cost

Photocephalometry
Introduction
➤ The photocephalometry apparatus was described by Thomas Hohl et al. in 1978.

➤ Photocephalometry involves taking the photograph and lateral cephalogram from

the same distance and position. The photograph is enlarged in accordance with the
 cephalogram and it is superimposed.

Method
➤ Patient is made to assume natural head position with relaxed lips.

➤ Four 4 × 4 mm sized radio-opaque metallic markers are placed on the patient’s face
and the lateral and anteroposterior cephalograms are taken.

➤ Lateral and frontal photographs are taken maintaining same distance and position.

➤ The photographic negatives are enlarged allowing the photographic images of the
metal markers to be superimposed on the radiographic image on the cephalogram.

➤ The projection of enlarged negative is put in transparent photographic film which is

superimposed on the cephalogram.

Advantages
1. Valuable quantitative information about soft tissue can be easily obtained.

2. Permits direct measurement between skeletal and soft tissue landmarks.

3. Changes in the soft tissues of the face can be compared pre- and postorthognathic
surgery.

4. Useful in serial growth studies.

Disadvantages
1. Accurate comparisons between soft-tissue and hard-tissue anatomies by simply
superimposing the images are not feasible because of the difference in the
enlargement factors between the photographs and X-ray films.

2. It is a complex procedure.

3. Expensive when compared to conventional cephalometry.

Cinefluororadiography
Introduction
➤ It is a study of moving body structures – similar to an X-ray ‘movie’.

➤ A continuous X-ray beam is passed through the body part being examined, and is
transmitted to a TV-like monitor so that the body part and its motion can be seen in
detail.
➤ Cinefluororadiography is used in many types of examinations and procedures, such
as barium X-rays, cardiac catheterization and placement of intravenous (IV) catheters
(hollow tubes inserted into veins or arteries).

➤ Cinefluororadiography may be part of an examination or procedure that is done

either on an outpatient or inpatient basis.

Method
➤ The radiologist uses a switch to control an X-ray beam that is transmitted through
the patient.

➤ The X-rays then strike a fluorescent plate that is coupled to an ‘image intensifier’ that
is (in turn) coupled to a television camera.

➤ The radiologist can then watch the images ‘live’ on a TV monitor.

Uses
➤ To evaluate swallowing patterns.

➤ To examine the upper airway in obstructive sleep apnoea.

➤ Useful to evaluate the morphology of TMJ and its function.

Laser holography
➤ Holography is the only visual recording and playback process that can record our
three-dimensional image on a two-dimensional recording medium. The recorded
image is called a hologram.

➤ Holography uses two coherent beams which converge to produce a constructive and
destructive interference pattern which is recorded in a film.

➤ Pulse laser or gas laser beams are used for holographic set-up.

Principle of holography
➤ Our eyes need a minimum of two viewpoints in order to see depth. Conventional
photographs have only one viewpoint.

➤ Vision using two viewpoints of an object is called stereoscopic vision.

➤ Each eye receives a slightly different viewpoint of an object, our brain combines the
two and we perceive depth.

➤ Our eyes can see images in three dimensions by taking two slightly different views of
 an object and allowing each eye to see only one image, the right image for the right
eye and the left image for the left eye.

➤ This principle is being used in holography.

Uses
1. Holographic images of study casts are more convenient in terms of storage and
retrieval.

2. Locating the centre of resistance of the upper dentition and the nasomaxillary
complex.

3. Studying the effect of rapid maxillary expansion on the maxilla.

4. Studying the effect of facemask protraction on the maxilla.

5. To study bone deformations resulting from headgear forces in human skull.

6. To locate the centre of resistance of anterior teeth during intrusion.

7. To measure incisor extrusion during orthodontic therapy.

8. It is used to locate centre of rotation of tooth undergoing orthodontic tooth

movement.

Disadvantages
1. The three dimensionality is not quite there, if we move our head from side to side or
up and down.

2. Volumetric content of the hologram is lost when the sizes of imaged objects are
identical and shadows are not there.
CHAPTER 13
Model analysis

CHAPTER OUTLINE
❖ Study models/casts
❖ Classification of model analyses/various methods of model analyses used in
orthodontics
❖ Bolton’s ratio
❖ Ashley Howe’s analysis
❖ Pont’s index
❖ Linderhearth’s analysis
❖ Kesling’s diagnostic set-up
❖ Moyer’s mixed dentition analysis
❖ Tanaka–Johnston analysis
❖ Radiographic method of mixed dentition model analysis
❖ Carey’s analysis
❖ Accessory points
❖ Advanced learning
❖ Peck and Peck ratio
❖ Korkhau’s analysis
❖ Occlusogram
Study models/study casts
Introduction
➤ Study models are plaster reproduction of teeth and their surrounding soft tissues
that provide a reasonable ‘facsimile’ of the occlusion of the patient (T. Graber’s
definition).

➤ Study casts have a prominent role in diagnosis and treatment planning as an

essential diagnostic aid.

➤ Plaster study casts have a long and proven history in orthodontics. They were in
widespread use even before skull radiography became popular.

➤ Study casts reproduce the teeth and the investing structures with a fair degree of
accuracy. The clinician can study the occlusion from the study casts in the absence of
the patient.

Parts of study model (fig. 13.1)

1. Anatomic portion: It is the replica of the patient’s teeth and supporting structures
obtained by impression. It is further divided into tooth portion and soft tissue portion.

2. Artistic portion: Artistic portion is made while basing around the anatomic portion.
The artistic portion supports the anatomic portion and orients it in a manner that is
pleasing to eye.

FIG. 13.1. Study cast.

 The ratio between anatomic portion and artistic portion should be 2:1 in a well-
trimmed study cast. The tooth portion, soft tissue portion and the artistic portion are
related in 1:1:1 fashion. The completed model should be 13 mm in height in the anterior
and posterior region.
Fabrication of study casts involves the following steps:

➤ Impression making

➤ Disinfection of the impression

➤ Pouring the impression

➤ Basing and trimming

➤ Finishing and polishing

Impression technique
Care must be taken to obtain as nearly a perfect reproduction of teeth and investing
tissues as possible. A preimpression mouthwash removes debris and reduces surface
tension on tooth surface cutting down bubble formation during impression making.
Alginate impressions are ideally suited for this. A quick setting type with a time span
from mixing to completion of the mix should not exceed 90 s. Strips of soft utility wax
are adapted to the tray periphery to hold the alginate impression and assist in
reproduction of the details of the vestibular fornix.
Greatest concentration of material should be in the anterior region of the tray. The
upper tray should be inserted so that the anterior periphery of the tray first fits under
the lip. The tray is then pushed upwards to force the alginate out into the mucobuccal
fold to record muscle attachments, then the upper lip is pulled down to trim the muscle
at the periphery.
A good maxillary and mandible impression will show a peripheral roll and record the
muscle attachments. The retromolar pads in the lower jaw and the tuberosity in the
upper jaw should be included.

Wax bite records

A wax bite record is valuable, permitting the dentist to relate the upper and lower casts
correctly in full occlusion. Two layers of soft base plate wax, roughly shaped to arch
form and warmed in water, may be used to make satisfactory record.

Pouring the impression

The impression is rinsed and the excess water shaken out. This removes mucin and
debris that might reduce the quality of surface reproduction.
A good grade of white stone model plaster is usually satisfactory to pour the
impression. It is best to use a mechanical spatulator or vacuum mixer, if this is not
available, the plaster, or plaster and stone may be mixed according to predetermined
proportions on a mechanical vibrator. The mechanical vibrator not only eliminates the
bubbles but also permits the use of heavier mix. A heavier mix is much easier to handle
in pouring up and producing a strong cast.

Forming the base of the model

The art portion or base is poured with rubber base moulds that are readily available.
They serve to confine the plaster and are fabricated to shape the base in artistically
pleasing contours.
Orientation of the tray is done in such a way that the anatomic portion is in the centre
of the rubber mould with the occlusal plane parallel with the cast base of the base
former.
The Broussard cast former may be used to establish symmetrical cast shape. Another
type of base former is the Columbia anterior segment single unit study cast former.

Finishing of the cast

Bubble removal
Bubbles that appear at the gingival margin should be removed nicely with a small
universal sealer. Bubbles reproduced from the impression in the mucobuccal fold area
can be removed with a Kingsley-type scraper.
After the bubbles have been removed the anatomic portion can be made symmetrical
by carving an even periphery where it joins the art portion of the base.
Final finishing can be done with fine waterproof sand paper where the knife or
scraper has been used with an Arkansas stone and water on the base, or art portion.

Individualization of casts
Although preformed case casts appear uniform and neat, some orthodontist prefer
individualizing casts because of additional information that can be gained and more
accurate orientation with the occlusal plane parallel with cast base.
Even the most careful positioning of the inverted tray during pouring-up procedure
permits only an approximation of the occlusal plane relationship. These modifications
require a cast trimmer or a set of a plaster files. The procedure is as follows:

➤ The upper model is cut with the back edge at right angles to the middle line of the
palate.

➤ The front surfaces are cut so that the point of intersection of the front surfaces is in
line with the middle line of the palate which is ascertained from the position of the
midpalatine raphe.
➤ The sides of the model are cut symmetrically about the middle line.

➤ The upper model is used as a guide in trimming the back edge and sides of the lower
model.

➤ By using the set square, the back corners of the upper and lower models are trimmed
simultaneously.

➤ The distal corners are cut symmetrically to the middle line. This stage is conveniently
done with the models in occlusion.

➤ The front of the lower model is trimmed to a smooth curve.

Guidelines for trimming

➤ The occlusal plane should be parallel to the top and bottom of the study casts.

➤ Back surfaces of the study casts should be perpendicular to the top and bottom of the
study casts.

➤ Study casts should reproduce the occlusion when they are placed on their backs.

➤ The study casts after trimming should be symmetrical.

➤ Upper study cast should have seven sides and lower study cast should have six sides
when viewed from occlusal plane (Fig. 13.2).

FIG. 13.2. Sides of lower and upper study casts.

Uses of study casts

➤ Study casts provide a three-dimensional precise record of the teeth and their
supporting structures. Thus, it enables the study of malocclusion from all sides.

➤ Study casts are considered an essential diagnostic aid in diagnosis and treatment
 planning.

➤ They are valuable aids in patient education and communication.

➤ Serial study models from the same patient can be used to evaluate the treatment
progress.

➤ Intraarch irregularities in shape, symmetry, width and alignment of the dental arches
can be analysed on the study casts.

➤ Interarch relationships in all three planes can be evaluated from study casts.

➤ Arch length deficiencies and excesses can be evaluated on a study cast using study
cast analyses. Some analyses measure the tooth size ratio between maxillary and
mandibular arches.

➤ To assess and record the curves of occlusion.

➤ Evaluation of occlusion with the help of articulators.

➤ They are used in mixed dentition analyses along with charts and radiographs.

➤ Surgical repositioning of jaws can be mimicked on the study casts.

➤ To detect abnormalities like localized enlargements.

➤ Study casts help in communication between orthodontists regarding nature of

malocclusion.

Advantages
➤ Study casts permit a more objective assessment of malocclusion than clinical
examination or photographs.

➤ They make it possible to view the patient’s occlusion from the lingual aspect;
something which is impossible in patient’s mouth.

➤ Study casts are a permanent record of the patient’s malocclusion.

➤ They are less expensive.

➤ Can be duplicated easily when needed.

Disadvantages
➤ Occupy considerable storage space.
➤ Retrieval takes time with mass storage.

➤ Possibility of breakage of study models.

➤ No detailed information obtained about soft tissues in the oral cavity.

➤ Relationship of teeth to the facial profile cannot be elicited.

Classification of model analyses/various
methods of model analyses used in orthodontics
Model analyses can be classified in the following way:

I. Analyses to study the size relationships of groups of teeth

a. Bolton’s tooth ratio analysis

b. Sanin–Savara analysis

c. Peck and Peck ratio

II. Analyses to study the relationships of tooth size to the size of supporting
structures

a. Ashley Howe’s analysis

b. Pont’s analysis

c. Linderhearth’s analysis

d. Diagnostic set-up

e. Korkhau’s analysis
III. Analyses to study the relationships of tooth size and available space during the
mixed dentition (mixed dentition analyses)

a. Moyer’s mixed dentition analysis

b. Tanaka–Johnston analysis

c. Staley and Kerber analysis

d. Radiographic method
IV. Analyses to study the relationships of tooth size and available space in the
permanent dentition

a. Carey’s analysis

b. Arch perimeter analysis

c. Total space analysis

Bolton’s analysis/Bolton’s ratio
Bolton’s analysis evaluates the maxillary and mandibular teeth for tooth size
discrepancies. According to Bolton, there is a relation between the combined width of
mandibular and maxillary teeth.
In a patient with tooth size discrepancy, the teeth in one arch may occupy greater
amount of space than the teeth in opposing arch resulting in occlusal misfit. Hence, it is
important to identify such cases before treatment.

Method
Estimating overall ratio
➤ The width of all the teeth from first molars on one side to the first molars on the
opposite side is measured and added for both arches.

➤ Bolton’s overall ratio is calculated by the following formula:

➤ The ideal overall ratio is 91.3. Good overbite and overjet relationships and posterior
occlusion are seen in cases where the tooth size ratio approximates this value.

➤ If the value is greater than 91.3, the inference is overall mandibular tooth material
excess. Values less than 91.3 show overall maxillary tooth material excess.

➤ It is possible to quantify the overall tooth material excess by using the following
formulas:

Estimating anterior ratio

➤ The width of all the teeth from canines on one side to the canines on the opposite
side is measured and added for both arches.
➤ Bolton’s anterior ratio is calculated by the following formula:

The ideal anterior ratio is 77.2.

➤ An increase from 77.2 corresponds to mandibular anterior tooth material excess.
Decrease is associated with maxillary anterior tooth material excess.

➤ It is possible to quantify the anterior tooth material excess by using the following
formulas:

Disadvantages
➤ Good occlusal relationships have been demonstrated in cases with major Bolton
discrepancies. It is perceived to be inaccurate by some authors.

➤ Bolton had used perfect class I occlusions as the sample for estimating the tooth fit
ratio. Hence, he underestimated the variation.

➤ Population and gender composition of Bolton’s sample is not specified.

➤ Different races in the world have dentitions which differ in tooth size even among
various types of teeth. Hence, they will have different ideal ratio.
Ashley howe’s analysis
➤ Howe’s proposed that a relationship exists between the sum of mesiodistal widths of
teeth anterior to second molars and width of the dental arch in the first premolar
region (Fig. 13.3).

➤ Crowding is the result of reduced dental arch width at the first premolar region
according to him.

FIG. 13.3. Ashley Howe’s analysis.

Method
➤ Tooth material (TM): Sum of mesiodistal width of all the teeth in the arch from first
molar on one side to the first molar on the other side is measured and added up to
obtain tooth material.

➤ Premolar width (PMD): The width of the arch measured between the buccal cusp
tips of first premolars.

➤ Percentage of premolar width to tooth material: It is obtained by dividing the

premolar width by sum of tooth material and multiplying by hundred.

➤ First premolar basal arch width (PMBAW): The width of maxillary apical base
measured from the canine fossa on one side to the other from a point close to the
apices of first premolars. If the canine fossa is not deep enough to be distinguishable
 then the measurement can be taken from a point 8 mm below at the crest of
interdental papilla distal to canine.

➤ Expansion can be carried out to relieve crowding, if the first premolar basal arch
width is greater than premolar width. Arch expansion is not possible, if the first
premolar basal arch width is less than premolar width.

➤ Percentage of canine fossa width to tooth material: It is obtained by dividing first

premolar basal arch width by tooth material and multiplying with hundred.

➤ The arches can be considered sufficient to accommodate all the teeth, if the value
obtained is greater than 44%.

➤ The value less than 37% is suggestive of basal arch deficiency and extraction of first
premolars is indicated.

➤ The values between 37 and 44% are borderline and subjective decision should be
taken regarding extraction of first premolars (Table 13.1).

Table 13.1.
Ashley Howe’s analysis: Inference

Result Inference Treatment plan

Above 44% Sufficient arch width to accommodate all the teeth Non-extraction
Less than 37% Basal arch deficiency Extraction of first premolar
37–44% Borderline Subjective decision regarding extraction of first premolar

Basal arch length: Arch length is measured at the midline from distal marginal ridge
of first molars to the most anterior point of the basal arch represented by point A in the
maxillary arch and point B in mandibular arch.

➤ The percentage of basal arch length to tooth material is obtained by dividing basal
arch length by tooth material and multiplying by hundred.
Pont’s index/pont’s analysis
➤ Pont A in 1909 devised Pont’s index which is a method of predetermining the ideal
arch width based on mesiodistal width of crowns of maxillary incisors (Fig. 13.4).

➤ Pont suggested that the ratio of combined width of incisors to transverse arch width,
as measured from centre of occlusal surface of the teeth are ideally 0.8 in the first
premolar area and 0.64 in the first molar area.

➤ Pont’s index is a maxillary expansion index. Maxillary expansion indices help the
clinician in estimating how much maxillary expansion will be required to eliminate
crowding.

FIG. 13.4. Pont’s index.

Method
➤ The mesiodistal widths of maxillary incisors are measured and added. It is denoted
as sum of incisors (SI).

➤ The width of the arch in the premolar region is measured from the deepest point in
the transverse fissure of first premolar to its counterpart on the other side.

➤ The width of the arch in the molar region is measured from the point of intersection
 of transverse fissure with the buccal fissure of first permanent molar to its
counterpart on the other side.

➤ Expected arch width in the premolar region is SI/80 × 100.

➤ If the measured value is less than the calculated value, it indicates need for
expansion.

➤ Expected arch width in the molar region is SI/64 × 100.

➤ If the measured value is less than the calculated value, it indicates need for
expansion.

Disadvantages
➤ Pont’s index does not take into account the morphological variations like peg-shaped
lateral incisors.

➤ Pont’s index does not take into account the alignment of teeth.

➤ Subsequent research has shown that Pont’s index overestimates interpremolar and
intermolar width by 2.5–4.7 mm.
Linderhearth’s analysis
➤ Linderhearth suggested a new formula for predetermining the ideal arch width
based on mesiodistal width of crowns of maxillary incisors. It is similar to Pont’s
index.

➤ The ratio of combined incisor to transverse arch width, as measured from centre of
occlusal surface of the teeth, is ideally 0.85 in the first premolar area and 0.65 in the
first molar area, according to Linderhearth.

➤ Linderhearth index is a maxillary expansion index. Maxillary expansion indices help

the clinician in estimating how much maxillary expansion will be required to
eliminate crowding.

Method
➤ The mesiodistal widths of maxillary incisors are measured and added. It is denoted
as sum of incisors (SI).

➤ The width of the arch in the premolar region is measured from the deepest point in
the transverse fissure of first premolar to its counterpart on the other side.

➤ The width of the arch in the molar region is measured from the point of intersection
of transverse fissure with the buccal fissure of first permanent molar to its
counterpart on the other side.

➤ Expected arch width in the premolar region is SI/85 × 100

➤ If the measured value is less than the calculated value, it indicates need for
expansion.

➤ Expected arch width in the molar region is SI/65 × 100.

➤ If the measured value is less than the calculated value, it indicates need for
expansion.

➤ Linderhearth values for expected arch width in the premolar and molar region are
less than Pont’s values. Hence, it is a better guide to arch width than Pont’s index
which tends to overestimate the arch width.
Kesling’s diagnostic set-up
➤ HD Kesling (1956) proposed the diagnostic set-up with the intention of deriving
maximum clinical information from a set of trimmed study casts.

➤ Diagnostic set-up helps the clinician to estimate arch length discrepancy (Fig. 13.5).

FIG. 13.5. Kesling’s diagnostic set-up.

Method
➤ A patient’s maxillary and mandibular study casts are prepared. The study casts
should reveal the supporting structures to the depth of the sulcus.

➤ The bases of the study casts are trimmed parallel to the occlusal plane.

➤ Horizontal cuts are made in the mandibular cast 3 mm below the gingival margin
using Fretsaw blade. Vertical cuts are made to separate individual teeth. All teeth
 except second and third molars are removed.

➤ Mesial and distal end of roots of teeth are trimmed to facilitate seating in the new
position.

➤ Wax blocks are placed in the slits formed while cutting the teeth away.

➤ The mandibular incisors are arranged on the study cast at an angle of 65° to
Frankfort horizontal plane.

➤ Canines and premolars are placed in the correct contact relationships.

➤ If the remaining space is inadequate to receive the first molars, the extractions are
indicated. So, eliminate first premolars from the set-up and place second premolars in
contact with canine.

➤ The maxillary teeth are cut and repositioned in the wax set-up articulating them with
the mandibular set-up.

Uses
➤ The tooth size–arch length discrepancies can be visualized directly on the diagnostic
set-up.

➤ Serves as a guide in including extractions in the treatment plan.

➤ Helps in estimating whether uprighting of second molars could solve the arch length
discrepancy.

➤ Helps in visualizing the complex orthodontic tooth movements required on the

study cast.

➤ The patients can be motivated by simulating tooth movements on the study cast.
Moyer’s mixed dentition analysis
➤ Moyer’s analysis is a mixed dentition analysis. Its purpose is to evaluate the amount
of space available in the arch for succeeding permanent teeth and for necessary
occlusal adjustments.

➤ It is used in the early permanent dentition when the permanent incisors are erupted,
and permanent canines and premolars are not erupted.

➤ Moyer’s analysis employs prediction tables. The lower incisor mesiodistal widths are
measured and added to predict the sizes of unerupted teeth from the table.

Method
➤ The mesiodistal widths of mandibular incisors are measured with Boley’s gauge.
Sum of the incisors on one side of the arch is transferred to the gauge.

➤ Place one tip of Boley’s gauge in the midline and the other at the location of distal
surface of mandibular lateral incisor when it has been aligned. Mark this point.
Repeat this on the other side. The second mark will be on deciduous canine when
there is incisor crowding.

➤ The distance from the mesial surface of mandibular first permanent molars to the
marked point is the space available for eruption of mandibular canine and premolars
(Fig. 13.6).

➤ Predict the size of canines and premolars from the probability chart based on the
sum of widths of lower incisors.

➤ If the space available is greater than the predicted space, the excess space can be used
for late mesial shift of molars.

➤ If the space available is lesser than the predicted space, it is an indication of future
crowding.

➤ A different probability chart is employed while predicting the widths of maxillary

canines and premolars based on lower incisor width. Allowance should be made for
overjet correction when estimating the space to be occupied by aligned incisors.

➤ Seventy-fifth level of probability is employed by most clinicians. Seventy-fifth level

of probability takes the clinician to the safer side by decreasing the chances of
underestimating the tooth size.
 FIG. 13.6. Moyer’s mixed dentition analysis. Diagram shows the space required for alignment
of mandibular central and lateral incisors. It also shows space left for permanent canine and
first and second premolars.

Advantages
➤ No radiographs needed.

➤ Can be used inside the patient’s mouth.

➤ Does not require sophisticated clinical judgment.

➤ It has minimal systematic error and range of such errors is known.

➤ Allows for sexual dimorphisms with equal accuracy.

➤ Used for both arches and the procedure is not time consuming.

Disadvantages
➤ Does not take into account the natural increase in arch perimeter that occurs in the
transitional period.

➤ Inability to reflect the position of incisors to skeletal profile.

➤ Does not take into account the vertical occlusal curve (curve of Spee) present in the
dental arch.
Tanaka–Johnston analysis
➤ Tanaka–Johnston analysis is a mixed dentition analysis. It predicts the widths of
unerupted canines and premolars based on sum of the widths of lower incisors.

➤ This method is very convenient to use in the orthodontic practice. No radiographs or

reference tables are involved.

Method
➤ Measure the total arch length.

➤ Measure the mesiodistal widths of lower four incisors and sum it up.

➤ Divide the value obtained by 2 and add 10.5 mm to obtain the sum of widths of
mandibular canines and premolars in one quadrant.

➤ Divide the value by 2 and add 11 mm to obtain the sum of widths of maxillary
canines and premolars in one quadrant.

➤ Space available in the arch after the eruption of canines and premolars is calculated
by the following formula:

Space available = Total arch length – [sum of lower incisors + 2

× (calculated width of canine and premolar)].
➤ Tanaka and Johnston combined the sexes in their study. This is in contrast to Moyer’s
analysis which predicted the size of permanent teeth for males and females
separately.

➤ Tanaka and Johnston originally advocated use of 75th percentile. It is now known
that even 50th percentile may overpredict the tooth size a little. It is recommended to
use 50th percentile as a hedge against underpredicting tooth size.

Advantages
➤ Reasonably good accuracy

➤ Require neither radiographs nor reference tables

➤ Simple and practical

Radiographic method of mixed dentition model
analysis
➤ Radiographic method relies on intraoral radiograph to predict the size of unerupted
tooth using a formula.

➤ This method uses both the models and radiograph to assess the size of the erupting
tooth.

Procedure
➤ True size of the erupted deciduous molar is measured in the model.

➤ Radiographic width of the erupted deciduous molar is measured with the help of
intraoral radiograph.

➤ Radiographic size of the unerupted premolar is measured using the intraoral

radiograph.

➤ True width of the unerupted premolar is calculated by using the following formula:

Disadvantages
➤ Radiographic measurements are prone to distortion.

➤ Difficult to measure a rotated tooth in the radiograph.

➤ Cumbersome procedure.
Carey’s analysis
➤ Carey’s analysis is used to assess the difference between the space available for the
teeth in the dental arch and the space required for accommodating the teeth (Fig.
13.7).

➤ If the space required is less than the space available, spacing results.

➤ If the space required is more than the space available, crowding results.

➤ Hence, it is important to determine the amount of crowding in the maxillary and

mandibular dental arches for patients with malaligned teeth.

FIG. 13.7. Carey’s analysis.

Method
➤ Record the mesiodistal width of all the teeth mesial to mandibular first permanent
molar. The space required for teeth in the arch is obtained by adding the various
values obtained.

➤ Space available is measured by using a soft brass wire. The wire is contoured to the
individual’s arch form.

➤ It is placed over the incisal edges of lower anterior teeth and passed over the first
molar mesial contact area on both sides. It is marked at the points overlying mesial
 contact area of first molar.

➤ The brass wire is straightened and the length is measured from the mark on one
point to the other. This value is the space available in the arch.

➤ Subtract the space required from space available to arrive at the discrepancy (mm).
The discrepancy is a positive value, if the space required is less than the space
available (spacing). The discrepancy is a negative value, if the space required is
greater than the space available (crowding).

➤ The arch perimeter analysis is performed on maxillary study cast and is similar to
Carey’s analysis.

Inference
➤ If the discrepancy is 0–2.5 mm, the patient can be treated without extractions. The
minimal excess in the tooth width can be reduced by proximal stripping.

➤ Discrepancy of 2.5–5 mm is an indicator of mild to moderate discrepancy. Second

premolar extraction is indicated in such cases.

➤ Discrepancy of 5 mm and above shows moderate to severe discrepancy. First

premolar extraction is indicated in such cases (Table 13.2).

Table 13.2.
Carey’s analysis: Inference

Result Inference Treatment plan

0–2.5 mm Minimal discrepancy Proximal stripping
2.5–5 mm Mild to moderate discrepancy Extraction of second premolars
5 mm and above Severe discrepancy Extraction of first premolars

ACCESSORY POINTS
➤ Gnathostatic casts reproduce the inclination of the occlusal plane with reference to
the Frankfort plane.

➤ Gnathostatics is a diagnostic medium relating teeth and their base to each other and
to craniofacial structures.

➤ Gnathostatics was developed by Paul Simon.

➤ Symmetry in cast can be analysed by placing transparent ruled grid or symmetrograph.

➤ The symmetry of the dental cast is measured using midpalatal raphe as the indicator.

➤ The prominence of the chin compared with the prominence of lower incisors is
 determined by Holdaway ratio.

➤ Maxillary incisors are not taken into account in mixed dentition analysis because the
lateral incisors are variable.

➤ The base of the model and the occlusal plane should be parallel.

➤ The back of the model and the midpalatal line should be perpendicular.

➤ The angle between the posterior cuts of the model and the base is 130–135 degrees.

➤ In Tanaka–Johnston analysis, the width of the mandibular canine and premolar in

one quadrant is measured by the formula: ½ the mesiodistal width of lower incisors + 10.5
mm.

➤ In Tanaka–Johnston analysis, the width of the maxillary canine and premolar in one
quadrant is measured by the formula: ½ the mesiodistal width of upper incisors + 11 mm.

➤ Tooth size discrepancy is seen in approximately 5% of the population.

Advanced Learning
Peck and peck ratio
➤ Sheldon Peck and Harvey Peck ratio is used to determine whether lower incisor teeth
are excessively wider mesiodistally.

➤ They suggest that the ratio between the faciolingual dimension of the mandibular
incisor and its mesiodistal dimension should be approximately 1:1.

➤ If the mesiodistal dimension is more, proximal slicing is recommended.

➤ This measurement should be made intraorally since the greatest faciolingual

dimension is usually subgingival.

➤ The chief rationale for Peck concept is stability of rotational corrections of lower
incisors rather than tooth size considerations.

➤ This ratio is calculated only for mandibular central and lateral incisors.

Procedure (fig. 13.8)

Normal ratio for central incisor is 88–92%

Normal ratio for lateral incisor is 90–95%.

 FIG. 13.8. Peck and Peck ratio.

Korkhaus’ analysis
➤ Korkhaus in 1938 proposed this analysis. It is a study model analysis which would
reveal anteroposterior malpositioning of incisors in maxillary and mandibular arches
(Fig. 13.9).
 FIG. 13.9. Korkhau’s analysis.

➤ He proposed that there is a relation between the anterior arch length and sum of
mesiodistal width of upper incisors (SIu).

➤ Anterior arch length (AAL) is defined as the length of the perpendicular from the
labial surface of the most anterior upper incisors to the connecting line of reference
points of anterior arch width.

Method
➤ The mesiodistal widths of maxillary incisors are measured and added. It is denoted
as sum of incisors (SIu).

➤ The width of the arch in the premolar region is measured from the deepest point in
the transverse fissure of first premolar to its counterpart on the other side. Position a
ruler from first premolar to first premolar.

➤ Measure the distance from the midpoint of the ruler to the labial surface of most
anteriorly positioned maxillary central incisor. This forms the available anterior arch
length (Fig. 13.10).
 FIG. 13.10. Anterior arch length: Korkhau’s formula.

➤ The available anterior arch length (AAAL) is compared with ideal anterior arch
length.

➤ The ideal anterior arch length (IAAL) is obtained by Korkhau’s formula:

➤ If the AAAL is greater than the IAAL, the maxillary central incisors are anteriorly
malpositioned.

➤ If the AAAL is less than the IAAL, the maxillary central incisors are posteriorly
malpositioned.

➤ The AAL is measured in the mandibular arch in the similar manner. However, the
arch width at the premolar region is taken from the contact areas of first premolar
and second premolar for the mandibular arch.

➤ The anterior arch length of the maxilla is 2 mm more than the anterior arch length in
the mandible.
Interpretations (table 13.3)

Table 13.3.
Anterior arch length: Interpretations

Increased AAL Decreased AAL

Labioversion of anteriors Linguoversion of anteriors
Bimaxillary protrusion Class II division 2 malocclusion
Distoversion of premolars Mesioversion of premolars

Disadvantages
➤ Mesial migration of first premolars affects the outcome of the analysis.

➤ The correlation between arch length and arch width varies for different facial types.

Occlusogram
Refer Chapter 12
CHAPTER 14
Cephalometrics

CHAPTER OUTLINE
❖ Definition of cephalometrics
❖ Cephalometric radiography
❖ Cephalometric landmarks
❖ Reference planes used in cephalometry
❖ Classification of cephalometric analyses
❖ Steiner’s analysis
❖ Y-axis/growth axis
❖ Tweed’s analysis/Tweed’s diagnostic triangle
❖ Wits appraisal/analysis
❖ Ricketts analysis
❖ McNamara analysis
❖ Role of cephalometry in diagnosis and treatment planning
❖ Visualized treatment objective (VTO)
❖ Accessory points
❖ Advanced learning
❖ Holdaway’s lip analysis
❖ Holdaway ratio
❖ Down’s analysis
❖ Utility of cephalometrics in growth
❖ Computerized cephalometric system
Definition of cephalometrics
The measurement of the head from the shadows of the bony and soft tissue landmark
on the radiographic image is known as roentgenographic cephalometry.

➤ According to Robert E Moyers, cephalometrics is a radiographic technique for

abstracting the human head into a geometric shape.

The precursor of cephalometry is craniometry. Craniometry is the measurement of the head

of a living subject from bony landmarks located by palpation or pressing through the
adjacent tissues. The drawback of craniometry is that it is a cross-sectional study.

• With the advent of cephalometry, disadvantages of

craniometry were overcome.

• ‘Cephalo’ means head and ‘metric’ means measurement.

➤ Cephalometry can be used for longitudinal studies.
Cephalometric radiography
➤ X-rays were discovered in 1895 by Wilhelm Conrad Röntgen and it enabled the
clinicians to visualize the facial skeleton on the two-dimensional image obtained on
the film.

➤ The roentgenographic cephalometric technique was introduced to orthodontics by

Holly Broadbent of the USA and Herbert Hofrath of Germany in 1931.

➤ Broadbent developed a head positioning device called cephalostat which he used for
obtaining lateral and anteroposterior views of a patient’s skull.

➤ Cephalometric radiographs have become an integral part of orthodontic practice

since then.

➤ Cephalometric radiographs enable the clinicians to quantify facial and dental

relationships.

➤ It gives information about the spatial relationship of superficial and deep structures.

Types of cephalograms
➤ Lateral cephalogram

➤ Frontal or anteroposterior cephalogram

➤ Oblique cephalogram

Uses of cephalogram
➤ Cephalogram is used in orthodontic diagnosis to elucidate the skeletal, dental and
soft tissue relationships of the craniofacial region (Isaacson KG and Jones ML, 1994).

➤ It is a valuable tool in the identification and classification of skeletal and dental

anomalies.

➤ It helps in treatment planning. Response to treatment can be appraised on

subsequent cephalogram.

➤ Cephalograms are useful in estimating the facial type.

➤ It can be used to quantify the changes brought about by the treatment.

➤ It helps to distinguish changes produced by natural growth and orthodontic

 treatment.

➤ Assessment of growth of facial skeleton is possible through serial cephalograms.

➤ It is also used in growth prediction.

➤ It is used to plan the skeletal repositioning in surgical orthodontics.

➤ Functional analysis can be carried out with the help of cephalograms.

➤ Cephalograms are tangible records that are relatively permanent unlike other
diagnostic measurements like caliper readings, palpation and probing.

➤ Cephalograms are relatively nondestructive and noninvasive producing a high yield

of information at relatively low physiologic cost.

➤ Cephalograms are easy to store, transport and reproduce.

Limitations and drawbacks of cephalogram

➤ Patient is exposed to ionizing radiation which is harmful. Hence, it is used only
when it is diagnostically and therapeutically desirable.

➤ The absence of anatomical references which remain constant with time is a serious
disadvantage when clinicians wish to compare cephalograms taken at different time
points.

➤ The processes of image acquisition as well as measurement procedures are not well
standardized.

➤ Errors of identification: The difficulty in locating landmarks and surfaces on the X-

ray image as the image lacks hard edges and well-defined outlines (Baumrind S and
Frantz R, 1971).

➤ The structures being imaged are three-dimensional whereas the radiographic image
is two-dimensional.

➤ Anatomical structures lying at different planes within the head undergo projective
displacement.

➤ Some reference landmarks and planes do not agree with the anatomical landmarks.

➤ Patient is positioned with the ear rods in the external acoustic meatus. The operator
assumes that the meatuses are symmetrical. It need not be so.

➤ Patient is made to bite in maximum intercuspation while taking the cephalogram.

 There could be a mandibular shift from centric relation.

➤ A cephalometric analysis makes use of means obtained from different population

samples. They have only limited relevance when applied to individual patient.

➤ The composite of lines and angles used in the cephalometric analysis yields limited
information about the patient’s dentoskeletal patterns.

➤ An orthodontic diagnosis cannot be made solely on the basis of cephalometric

analysis.

Technique of cephalometric radiography (fig. 14.1)

Following are the basic components for producing a lateral cephalogram:

1. X-ray apparatus

It comprises an X-ray tube, transformers, filters, collimators

and a coolant system, all encased in the machine’s housing.
2. Image receptor system

It requires a complex image receptor system that consists of an

extraoral film, intensifying screens, cassette, grid and a soft
tissue shield.
3. Cephalostat

Cephalostat is the head holder. It positions the patient’s head

in three dimensions to receive the X-ray beam.

• The X-ray source is placed 5 feet or 60 inches away from the

patient’s mid-sagittal plane. This is done to reduce the
magnification. The film is placed 18 cm away from the mid-
sagittal plane.

• Patient’s Frankfort horizontal plane is oriented parallel to

the floor by means of ear rods inserted to the external
acoustic meatuses and the orbitale pointer. Mid-sagittal
 plane is parallel to the cassette for lateral cephalogram. It is
perpendicular to the cassette for posteroanterior
cephalogram.

• The upper part of the face is supported by the forehead

clamp positioned at the nasion.

• X-ray generator is a step-down transformer which generates

electric current (10–15 mA, 70–80 kVp).

• With medium speed films and intensifying screens, the

exposure time is 0.6–1.2 s. It is shorter when high-speed
films are used.

• Current technical specifications are 80 kVp; 8 mA and 0.8 s

exposure time.

• Some amount of magnification invariably occurs with this

technique. Acceptable magnification of the cephalogram is
in the range of 5–7%.

• By convention, cephalograms are taken of the left side of the

skull.

• The film size is 8 × 10 inches and the film is placed in the

cassette alongside the intensifying screen.
FIG. 14.1. Cephalometric radiography: Technique.
Cephalometric landmarks
Cephalometric landmarks (Fig. 14.2) can be broadly classified into hard tissue and soft
tissue points.

FIG. 14.2. Cephalometric landmarks.

Hard tissue points

Unilateral points
➤ Nasion (N): Point where frontonasal and internasal sutures meet in the midline.

➤ Anterior nasal spine (ANS): Most anterior point of maxilla; used for vertical
measurement.
➤ Point A (subspinale): The deepest point in the curvature between ANS and inferior
most point in the maxillary alveolar process.

➤ Point B (supramentale): The deepest point in the curvature between pogonion and
superior most point in the mandibular alveolar process.

➤ Pogonion (Pog): Anterior most point in the contour of the lateral shadow of the chin.

➤ Gnathion (Gn): The most anterior and inferior point on the lateral shadow of chin. It is
approximately in the midpoint between pogonion and menton.

➤ Menton (Me): The inferior most point in the contour of the chin.

➤ Basion (Ba): The most posterior and inferior point in the sagittal plane on the anterior
rim of foramen magnum.

➤ Sella (S): Centre of the pituitary fossa or sella turcica.

Bilateral points
➤ Orbitale (O): The lowest point on the outline of the bony orbit. In the lateral
cephalogram, overlapping of the two sides is seen. In that situation, lowest point in
the averaged outline is used for constructing this point.

➤ Gonion (Go): The most posterior and inferior point at the angle of mandible.

➤ Articulare (Ar): Intersection of the inferior surface of the cranial base and the posterior
surfaces of the necks of the condyles of mandible.

➤ Porion (Po): Superior most point of the external auditory meatus; usually only
anatomic porion is taken into consideration. The machine porion which is the shadow
of the ear rods is not considered.

➤ Bolton point (Bo): The highest point in the upward curvature of the retrocondylar
fossa.

Soft tissue points

➤ Soft tissue glabella (G’): The most prominent point in the midline of the forehead.

➤ Soft tissue nasion (Na’): Root of the nose in the midline.

➤ Soft tissue pogonion (SPog): Most prominent point in the soft tissue contour of chin.
Reference planes used in cephalometry
Most commonly used reference planes and their explanation are given in Table 14.1.
The diagrammatic representations of the reference planes are given in Fig. 14.3.

Table 14.1.
Reference planes and their explanation

Planes
Sella–nasion plane (SN)
Frankfort horizontal plane
(FH)
Maxillary plane (Max)
Occlusal plane (Occ)
Mandibular plane (MP)
Bolton plane (BO)
Pterygoid vertical plane
(PTV)
‘APo’ line
‘E’ plane (aesthetic plane)
Definitions
Line joining sella point and nasion
Line connecting orbitale and porion
Line drawn through anterior and posterior nasal spine
Line from the midpoint between the tips of upper and lower incisors to the anterior contact between upper and lower first
molars in occlusion
Line joining menton and gonion
Line joining the Bolton point and the nasion
Line drawn perpendicular to the Frankfort plane, passing through the distal of pterygopalatine fossa
Line joining point A to the pogonion
Line drawn from the tip of the nose to the most anterior part of the soft tissue chin

FIG. 14.3. Reference planes.

Classification of cephalometric analyses
I. Methodological classification

1. Angular analyses – SNA, SNB, ANB, Tweed’s analysis.

2. Linear analyses – McNamara analysis, COGS.

II. According to area of analysis

1. Skeletal analysis – SNA, SNB, ANB

2. Dentoalveolar analysis – upper 1 to NA

3. Soft tissue analysis – E plane

Steiner’s analysis
➤ Steiner’s analysis is a cephalometric analysis introduced by Cecil C Steiner in 1953.

➤ Steiner’s analysis provides maximum clinical information with minimum number of

measurements.

Steiner’s analysis consists of:

• Skeletal analysis

• Dental analysis

• Soft tissue analysis

Landmarks
The following cephalometric landmarks are used:

➤ Sella (S)

➤ Nasion (N)

➤ Point A (A)

➤ Point B (B)

• Steiner used the sella–nasion (S–N) plane, the plane obtained

by joining sella and nasion.

• SN plane uses anterior cranial base as the reference plane.

Skeletal analysis
SNA angle (fig. 14.4)
➤ It is the angle formed at the intersection of line connecting nasion and point A to S–N
plane.

➤ Angle SNA shows the position of maxilla in relation to anterior cranial base. Mean
 value of SNA is 82°.

➤ SNA >84° = Prognathic maxilla.

➤ SNA <80° = Retrognathic maxilla.

FIG. 14.4. Skeletal analysis: SNA angle.

SNB angle (fig. 14.5)

➤ It is the angle formed at the intersection of line connecting nasion and point B to S–N
plane.

➤ Angle SNB shows the position of mandible in relation to anterior cranial base. Mean
value of SNB is 80°.

➤ SNB >82° is indicative of prognathic mandible.

➤ SNB <78° is indicative of retrognathic mandible.

 FIG. 14.5. Skeletal analysis: SNB angle.

ANB angle (fig. 14.6)

➤ It is the angle formed by lines connecting nasion and point A and nasion and point B.

➤ Angle ANB denotes the relative positions of mandible and maxilla to each other. The
mean value of ANB is 2° in an adult.

➤ SNA – SNB = ANB

➤ ANB greater than 2° suggests skeletal class II pattern.

➤ ANB reading less than 2° or negative angulations suggests skeletal class III pattern.
 FIG. 14.6. Skeletal analysis: ANB angle.

Occlusal plane angle

➤ It is the angle formed by the S–N plane and the occlusal plane. Occlusal plane is
drawn through the overlapping cusps of first premolars and first molars.

➤ Occlusal plane angle shows the relation of dentition to anterior cranial base. The
mean value is 14°.

Mandibular plane angle

➤ It is the angle formed by the S–N plane and the mandibular plane. Mandibular plane
is drawn by a line connecting gonion and gnathion.

➤ Mandibular plane angle denotes the growth pattern of an individual. The mean
value is 32°.

➤ High mandibular plane angle is indicative of vertical growth pattern and low
mandibular plane angle is indicative of horizontal growth pattern.

Dental analysis
Maxillary incisor position
➤ Upper incisor is related to N–A line for determining its position.

➤ Upper incisor to N–A (linear): The distance between incisal edge of upper incisor and
the N–A line; mean value is 4 mm.

➤ It increases with upper incisor proclination and decreases with retroclination.

➤ Upper incisor to N–A (angular): The angle between long axis of upper incisor and
the N–A line; mean value is 22°.

➤ It increases with incisor proclination and decreases with retroclination.

Mandibular incisor position

➤ Lower incisor is related to N–B line for determining its position.

➤ Lower incisor to N–B (linear): The distance between incisal edges of lower incisor
and the N–B line; mean value is 4 mm.

➤ It increases with lower incisor proclination and decreases with retroclination.

➤ Lower incisor to N–B (angular): The angle between long axis of lower incisor and the
N–B line; mean value is 25°.

➤ It increases with lower incisor proclination and decreases with retroclination.

Interincisal angle
➤ Interincisal angle is formed by long axis of the upper incisor and long axis of the
lower incisor (Fig. 14.7).

➤ The mean value is 132°.

➤ More acute angulations are found when upper and/or lower incisors are proclined.

➤ More obtuse angulations are found when upper and/or lower incisors are
retroclined.

➤ Noting the angulations of upper teeth to N–A line and lower incisor to N–B line is
helpful in detecting incisors with defective angulations.
 FIG. 14.7. Interincisal angle.

Soft tissue analysis

➤ Steiner’s ‘S’ line is drawn from the middle of S-shaped curve formed by lower border
of nose to the soft tissue contour of the chin.

➤ The lips in well-balanced faces should lie along this line.

➤ Lips located anterior to this line are labelled protrusive. Orthodontic treatment may
be undertaken to reduce protrusion.

Drawbacks of Steiner’s analysis

➤ Steiner’s ANB angle which is a commonly used measure of jaw relationship is 2° in
normal adult.

➤ ANB angle is affected by rotation of jaws and length of cranial base.

➤ Clockwise rotation of jaw bases could lead to increase in ANB angulations.

Counterclockwise rotation leads to decrease in ANB angulations.

➤ Short cranial base results in backward position of nasion in relation to jaws. This
increases ANB angulations. Long cranial base leads to decrease in ANB angle.

Summary of Steiner’s analysis (table 14.2)

Table 14.2.
Steiner’s analysis: Summary
Y-axis/growth axis
➤ Y-axis or growth axis is an integral part of assessment of skeletal pattern in Down’s
analysis (Fig. 14.8).

➤ Cephalometric landmarks used in Y-axis are sella, gnathion, porion and orbitale.

➤ The cephalometric plane used is Frankfort horizontal plane.

➤ Y-axis is formed by the acute angle at the intersection of Frankfort horizontal plane
and the line connecting sella and gnathion.

➤ The mean value for Y-axis is 59.4°.

➤ Y-axis showed a range of minimal of 53° to maximal of 66°.

FIG. 14.8. Growth axis or Down’s Y-axis.

Interpretations
➤ Increase in Y-axis is suggestive of vertical growth pattern.

➤ Decrease in Y-axis is suggestive of horizontal growth pattern.

➤ Y-axis indicates the position of chin in anteroposterior and vertical planes.

➤ In other words, Y-axis indicates the downward, rearward or forward position of the
chin.

Rakosi’s Y-axis
➤ Rakosi’s Y-axis is the measured angle between N–S–Gn (Fig. 14.9).

➤ This angle determines the position of the mandible in relation to the cranial base.

➤ Mean value = 66°

➤ If the angle >66°, it implies retrognathic mandible with vertical growth pattern.

➤ If the angle <66°, it implies prognathic mandible with horizontal growth pattern.

FIG. 14.9. Rakosi’s Y-axis.

Tweed’s analysis/tweed’s diagnostic triangle
Charles Tweed stated that there is a relation between the inclination of mandibular
incisors and mandibular plane angle. The mandibular incisors should be placed upright
over basal bone for stability and aesthetics.

Cephalometric points used

➤ Porion: The superior most point of the external acoustic meatus.

➤ Orbitale: The inferior most point along the lower border of orbit.

Planes used
1. Frankfort horizontal plane: Obtained by joining porion and orbitale.

2. Long axis of lower incisor: Obtained by drawing a line along the long axis of incisors.

3. Mandibular plane: Obtained by drawing a tangent to lower border of mandible.

Angles formed (fig. 14.10)

1. Frankfort mandibular plane angle (FMA): It is the angle formed at the intersection of
Frankfort horizontal plane and mandibular plane. Value is 25° in well-balanced faces.

2. Incisor mandibular plane angle (IMPA): It is the angle formed at the intersection of
mandibular plane and long axis of lower incisor. Value is 90° in well-balanced faces.

3. Frankfort mandibular incisor angle (FMIA): It is the angle formed at the intersection of
long axis of lower incisor and Frankfort horizontal plane. Value is 65° in well-balanced
faces.
 FIG. 14.10. Tweed’s diagnostic triangle.

Interpretations
➤ FMA >28° means high angle patient and mandible grows clockwise.

➤ FMA <23° means low angle patient and mandible grows counterclockwise.

➤ IMPA >110° means proclined lower incisors.

➤ IMPA <85° means retroclined lower incisors.

Clinical applications
➤ Tweed’s triangle is used in diagnosis, classification, treatment planning and
prognosis.

➤ Tweed advocated extraction of teeth to correct alveolodental prognathism and to

position the lower incisors upright over basal bone.

➤ When the Frankfort mandibular plane angle is in the range of 20–30°, the prognosis
for orthodontic treatment with extractions is excellent to good.

➤ When the Frankfort mandibular plane angle is in the range of 30–35°, the prognosis
for orthodontic treatment with extractions is good to fair.

➤ When the Frankfort mandibular plane angle is in the range of 35–40°, the prognosis
for orthodontic treatment with extractions is unfavourable.
Wits appraisal/analysis
➤ Alexander Jacobson found that measurements from the cranial base are inconsistent
in estimating anteroposterior jaw relation.

➤ He developed Wits analysis to overcome the drawbacks of Steiner’s analysis.

➤ Wits analysis was developed in university of Witwatersrand.

➤ Wits analysis was developed primarily to study the inter-relationship of maxilla and
mandible anteroposteriorly.

Landmarks used in wits analysis (fig. 14.11)

➤ Occlusal plane: Jacobson constructed occlusal plane by bisecting the overlapping
cusps of first premolars and first molars.

➤ AO point is obtained by dropping a perpendicular from point A to the occlusal

plane.

➤ BO point is obtained by dropping a perpendicular from point B to occlusal plane.

 FIG. 14.11. Wits analysis: Landmarks.

Interpretations
➤ Normal value: BO is ahead of AO by 1 mm in men while BO and AO coincide in
women.

➤ In class II malocclusion, AO is well ahead of BO.

➤ In class III malocclusion, BO is well ahead of AO.

Drawbacks of wits appraisal

➤ Wits readings are dependent upon the inclination of occlusal plane.

➤ Clockwise rotation of occlusal plane positions AO behind BO. Counterclockwise

rotation of occlusal plane positions BO behind AO.

➤ So Wits appraisal of the jaw bones should be combined with other methods to judge
the anteroposterior relationship.
Ricketts analysis
The Ricketts’ basic analysis (1960) is a simplified version of the 32-step analysis. In this
analysis, mean values are given that change with growth and those that remain stable.

Cephalometric points used

Pt point: Located at lower border of foramen rotundum.

CC point: Intersection of facial axis and cranial axis, i.e. N to Ba.

Xi: Centroid of ramus.

Pm: Protuberance menti between point B and pogonion.

Dc: Centre of the condyle.

1. Facial axis (Fig. 14.12)

The angle formed between the basion–nasion plane and the

plane from foramen rotundum (PT) to gnathion is called
facial axis angle. The posterior angle is measured. It
describes the direction of growth of chin. Normal value: 90
±3.

Angle less than 90° (open facial axis) suggests a downward

movement of chin and bite opening and greater angle (close
facial axis) suggests an upward movement of chin and
deepening of bite.
2. Facial depth angle

The angle between the facial plane (N–Pog) and the Frankfort
plane is called facial angle. The clinical norm is 87 ±3. This
angle provides some indication of horizontal position of
chin and also suggests whether a skeletal class II or III
pattern is due to the position of the mandible. This angle
 increases 1° every 3 years.
3. Mandibular plane angle

It is the angle formed between Frankfort horizontal and Go–

Gn. The clinical norm is 26° (±4) at 9 years of age. It decreases
approximately 1° every 3 years.

High-mandibular plane angle suggests that an open bite may

be due to skeletal characteristic of mandible with weak
musculature. Low mandibular plane suggest the opposite
(deep bite).
4. Lower facial height

Angle formed by the intersection of Xi–ANS and the corpus

axis (Xi–Pm). The clinical norm is 47 ±4°. This angle does not
change with age.

High angle denotes a dolichofacial pattern with divergence

between maxilla and mandible. These patients are prone for
skeletal open bite. Lower angle denotes a brachyfacial
pattern and a deep bite with strong musculature.
5. Mandibular arch

The angle formed between the mandibular corpus and

condyle axis. It is measured at the intersection of Dc–Xi with
Xi–Pm. The clinical norm is 26 ±4°. It increases 0.5° per year.

A high angle indicates a strong square mandible (brachyfacial

pattern) and a low angle represents a short ramus with
vertical growth pattern (dolichofacial).
6. Convexity of point A (14.13A)
Convexity of the middle face is measured from point A to the
facial plane (N–Pog). The clinical norm is 2 mm at 9 years of age
with a clinical deviation of ±2 mm per year. When the convexity
values are greater than norm, it suggests a class II skeletal
pattern and conversely values less than norm suggest class
III skeletal pattern.
7. Maxillary depth

It is the angle formed by the FH plane and the Na–A line. It

indicates anteroposterior position of the maxilla (Fig.
14.13B). Normal value: 90°.

High angle indicates protrusion of maxilla while angle lesser

than 90° indicates retrusion of maxilla.
8. Lower incisor to A–Pog line

Distance measured from lower incisor edge to A–Pog line

(denture plane) (Fig. 14.14).

The clinical norm is 1 ±2 mm. It indicates the position of lower

incisors in sagittal plane. This value helps in finding out
whether the overjet is due to malpositioning of upper or
lower incisors or both.
9. Lower incisor inclination

Angle formed by the intersection of long axis of lower central

incisors and the A–Pog plane (Fig. 14.14).

The clinical norm is 22 ±4°. It remains constant with age.

10. Upper molar to PTV
It is the distance between the pterygoid vertical and the most
distal point of the upper first permanent molar measured
parallel to the occlusal plane (Fig. 14.14).

The clinical norm is age of the patient + 3 mm. This measurement

assists in determining whether the malocclusion is due to
the position of upper or lower molar. It is also helpful in
determining adequate space for erupting second and third
molars.
11. Lower incisor to occlusal plane

It is the distance between the incisal edge of lower incisor and

the occlusal plane. It is also called lower incisor extrusion
(Fig. 14.14).

The clinical norm is +1.25 ±2 mm.

12. Interincisal angle

It is the measured angle between the long axis of upper and

lower incisors. The clinical norm is 130 ±10°. Increased angle
denotes proclined upper and lower incisors. The values 8–12
are concerned with the analysis of dental arch (Fig. 14.14).
13. Lower lip and E line (Fig. 14.15)

Lower lip proclination is the measured distance between the

lower lip and the aesthetic plane (nose–chin). The clinical
norm is –2 ±2 mm. Values greater than norms indicate
protrusive lower lip and less than norms indicate retrusive
lower lip.
FIG. 14.12. Ricketts’ analysis. 1, Facial axis; 2, facial depth; 3, mandibular plane angle; 4,
lower facial height; 5, mandibular arch.
FIG. 14.13. (A) Convexity; (B) maxillary depth.
FIG. 14.14. Analysis of dental arch. 8, Lower incisor to A-Pog; 9, lower incisor inclination; 10,
upper molar to PTv; 11, lower incisor to occlusal plane; 12, interincisal angle.
 FIG. 14.15. Lip protrusion

The summary of Ricketts’ analysis is given in Table 14.3.

Table 14.3.
Summary of Ricketts’ analysis

Mandible Norms
Facial axis 90 ±3°
Facial depth 87 ±3°
Mandibular plane angle 26 ±4°
Lower face height 47 ±4°
Mandibular arch 26 ±4°
Maxilla
Facial convexity 2 ±2 mm
Maxillary depth 90 ±3°
Teeth
Lower incisor to A–Pog 1 ±2 mm
Lower incisor inclination 22 ±4°
Upper first molar to PTV Age + 3 (±3 mm)
Lower incisor to occlusal plane 1 mm ±1.25
Interincisal angle 130 ±10°
Soft tissue profile
Lower lip protrusion –2 ±2 mm
Mcnamara’s analysis
This analysis was developed by Dr James McNamara at the University of Michigan in
the year 1984. It is a combination of Ricketts’ and Harvold’s analyses.
It is a powerful aid in diagnosis, evaluation and treatment planning.
Planes and measurements used: The planes and measurements used in the analysis
are given in Table 14.4.

Table 14.4.
Planes and measurements used in McNamara analysis

Analysis of skeletal structures Analysis of the airways

1. Nasion perpendicular (McNamara’s line) 7. Upper pharynx diameter
2. Point A to nasion perpendicular 8. Lower pharynx diameter
3. Point pogonion to nasion perpendicular
4. Maxillary length
5. Mandibular length
6. Lower facial height

Skeletal measurements (fig. 14.16)

1. Point A to N perpendicular

It is the linear distance between point A and nasion

perpendicular. It relates maxilla to the cranial base. If point
A is anterior to N perpendicular, the measurement will be
positive indicating a prognathic maxilla, and if the point A
is posterior to N perpendicular, the measurement will be
negative indicating a retrognathic maxilla.
Normal values: Mixed dentition 0 mm
Adult 1 mm

2. Pog to nasion perpendicular

It is the linear distance from pogonion to nasion

perpendicular. It relates the cranial base to mandible.

If pogonion lies anterior to N perpendicular, the measurement

is positive and if pogonion lies posterior to N perpendicular,
the measurement is negative.
Values lesser than the norms indicate retrognathic mandible.
Values greater than the norms indicate the prognathic
mandible.
Normal values: Mixed dentition –8 to –6 mm
Adult 0 to –4 mm (up to +2 for males)

FIG. 14.16. Nasion perpendicular to point A and pogonion.

Maxilla–mandibular relationship (fig.14.17)

Effective maxillary length
It is the measured distance from condylion (the most superior point on the outline of
the mandibular condyle) to point A. It is otherwise called midfacial length.
 FIG. 14.17. Measurement of maxillary and mandibular lengths.

Effective mandibular length

The measured distance from condylion to anatomical gnathion is the mandibular
length.
A linear relationship exists between effective length of maxilla and mandible. Any
given effective midfacial length corresponds to an effective mandibular length within a
given range.
According to McNamara’s analysis, maxillary length should be compared to its
mandibular counterpart. If the effective mandibular length of the patient exceeds the
norms, it indicates longer mandible and if it is lesser than the norms, it indicates shorter
mandible.
McNamara differential: Effective midfacial length subtracted from the effective
mandibular length is the differential.

Normal mcnamara differentials

➤ Small individual: 20–23 mm

➤ Medium-sized individual: 26–30 mm

➤ Large individual: 30–33 mm

Lower anterior facial height
Measured distance from ANS to menton is lower anterior facial height (LAFH). A
change in the LAFH has a profound effect on the horizontal relationship of maxilla and
mandible (Fig. 14.18).

FIG. 14.18. Lower anterior facial height is influenced by both the maxillary and mandibular
lengths.

An increase in the LAFH to the corresponding midfacial height results in a

downward and backward rotation of mandible, and thus the mandible will appear
more retrognathic.
A decrease in LAFH to the corresponding effective maxillary length leads to an
autorotation of the chin in a forward and upward direction.
There is a 1:1 relationship in the change of LAFH when there is either mandibular
protrusion or retrusion.

Mandibular plane angle

It is the angle formed between the anatomic Frankfort horizontal plane and line drawn
along the lower border of the mandible through gonion and menton. Normal value: FH to
Go–Me = 22° ±4°. Higher measurement indicates excessive LAFH. Lower measurement
indicates a deficient LAFH.
Composite norms
McNamara established composite norms with the values of effective midfacial length
that corresponds to the effective mandibular length and LAFH. They are not age or sex
related. The composite norms are given in Table 14. 5.

Table 14.5.
Composite norms for McNamara analysis in millimetres

Maxillary length Mandibular length Lower anterior face height

80 97–100 57–58
81 99–102 57–58
82 101–104 58–59
83 103–106 58–59
84 104–107 59–60
85 105–108 60–62
86 107–110 60–62
87 109–112 61–63
88 111–114 61–63
89 112–115 62–64
90 113–116 63–64
91 115–118 63–64
92 117–120 64–65
93 119–122 65–66
94 121–124 66–67
95 122–125 67–69
96 124–127 67–69
97 126–129 68–70
98 128–141 68–70
99 129–132 69–71
100 130–133 70–74
101 132–135 71–75

Dental measurements
Maxillary incisor position: Upper incisor to point A-vertical
It is the horizontal distance between point A-vertical (a vertical line is drawn through
point A parallel to nasion perpendicular) and the facial surface of upper incisors.
Normal value: 4–6 mm.
If the values are greater than 6 mm, it indicates protrusion of the upper incisors and
values lesser than 4 mm indicate retrusion of the upper incisors.
Mandibular incisor position: Lower incisor to A–Pog
It is the horizontal distance between the edge of the mandibular incisor and a line
drawn from point A to pogonion (A–Pog line). Normal value: 1–3 mm.

Soft tissue measurements

Nasolabial angle
Angle formed by drawing a line tangent to the base of the nose and a line tangent to the
upper lip.
Acute nasolabial angle indicates dentoalveolar protrusion. It may also be due to
orientation of the base of the nose (upturned nose).
Average: 102° ±8°.
Cant of upper lip
It is the angle formed between the nasion perpendicular and a line tangent to the upper
lip.
Normal: Female: 14 ±8°
Male: 8 ±8°

Airway analysis (fig. 14.19)

Upper pharynx diameter
It is the smallest distance from posterior pharyngeal wall to anterior half of the soft
palate. The average value is 15–20 mm. A width of 2 mm or less in this region may
indicate airway impairment.

FIG. 14.19. Upper and lower pharynx diameters.

Lower pharynx diameter

It is measured on the mandibular plane from the point of intersection of the posterior
border of the tongue and the inferior border of the mandible to the closest point on the
posterior pharyngeal wall. The average value: 11–14 mm.
Smaller than average value for the lower pharynx is of little consequence. An
obstruction of lower pharyngeal area because of the posterior positioning of the tongue
against posterior pharyngeal wall is rare.
Greater value suggests a possibility of anterior positioning of the tongue either as a
result of habitual posture or due to tonsillar enlargement.

Advantages of mcnamara analysis

1. It depends primarily on the linear measurements rather than angles, facilitating
orthopaedic study and communication to patients and parents is made easy.

2. It analyses the interarch relationship in the vertical plane as well as the sagittal,
integrating them into a single unit.

3. It helps in diagnosing the external condition of airway.

Role of cephalometry in orthodontic diagnosis
and treatment planning
➤ Radiographic cephalometry is an invaluable diagnostic tool in orthodontics.

➤ It is extensively used for diagnosis and treatment planning purposes.

➤ The role of cephalometric radiographs for diagnosis and treatment purpose can be
divided into four areas:

1. Anteroposterior relationships (Table 14.6)

2. Vertical relationships (Table 14.7)

3. Dentoalveolar relationships (Table 14. 8)

4. Soft tissue relationships

Table 14.6.
Analysis for anteroposterior relationships

Table 14.7.
Analysis of vertical relationships
Table 14.8.
Assessment of dentoalveolar relationships

Analysis of soft tissues

Steiner’s soft tissue analysis
➤ Steiner’s ‘S’ line is drawn from the middle of S-shaped curve formed by lower border
of nose to the soft tissue contour of the chin.

➤ The lips in well-balanced faces should lie along this line.

➤ Lips located anterior to this line are labelled protrusive. Orthodontic treatment may
be undertaken to reduce protrusion.

Other uses of cephalometry in treatment planning

➤ Assessment of functional analysis
➤ Assessment of lip configuration

➤ Assessment of tongue position and dysfunction

➤ Assessment of airway

➤ Assessment of growth
Visualized treatment objective
There are two types of visualized treatment objective (VTO):

➤ Clinical VTO

➤ Cephalometric VTO

Clinical VTO
➤ Clinical VTO was advocated by Thomas D Creekmore as an aid to decide about the
type of appliance in skeletal class II malocclusion.

➤ Procedure consists of asking the patient to bring the mandible to an edge-to-edge bite
relationship.

➤ Change in the appearance of the patient is noted at two levels.

➤ One at edge-to-edge position and the other at a position midway between the
existing occlusion and edge-to-edge position.

➤ If the profile worsens at edge-to-edge position, it means the fault lies in maxilla. It is
a case of maxillary prognathism and appliances like maxillary intrusion splint or
headgears are advised.

➤ If the profile improves at edge-to-edge position, it means the fault lies in the
mandible. It is a case of mandibular retrognathism. Functional appliances to stimulate
mandibular growth are indicated.

➤ If the profile improves midway, it is a case of combination of maxillary prognathism

and mandibular retrognathism. Appliances like activator, headgear, twin block with
headgears are indicated.

Cephalometric VTO
➤ A VTO is like a blueprint used in building a house.

➤ It is a visual plan to predict the normal growth of the patient and the anticipated
effects of treatment in order to establish the objectives of treatment for that particular
patient.

➤ VTO permits the development of alternative treatment plans.

➤ VTO permits an orthodontist to set his/her goals in advance for the treatment.
➤ Robert Murray Ricketts advocated VTO in the following sequences:

1. Cranial base prediction

2. Mandibular growth prediction

3. Maxillary growth prediction

4. Occlusal plane position

5. Location of the dentition

6. Soft tissues of the face

ACCESSORY POINTS
➤ The first X-ray picture of the skull in the standard lateral view skull was taken by
Pacini AJ.

➤ Cephalometric radiography was introduced by Broadbent BH and Hofrath H in 1931.

➤ The original purpose of cephalometrics was to study the growth patterns.

Cephalometric radiograph: Technical specifications

➤ Distance between X-ray source and object in the mid-sagittal plane is 5 feet or 60
inches.

➤ Distance from the mid-sagittal plane to the cassette or X-ray film is 18 cm.

➤ Technical specifications are 80 kVp; 8 mA and 0.8 second exposure time.

➤ Acceptable magnification is 5–7%.

➤ Usually cephalograms are taken of the left side of the skull.

➤ Film size is 8 × 10 inches.

➤ The head positioner used is called cephalostat.

➤ Cephalometric tracing is usually done with acetate matt paper.

Facial height: Jarabak’s ratio

➤ Normal range = 62–65%

➤ Ratio <62% expresses vertical growth

➤ Ratio >65% means horizontal growth

Cranial base lengths

➤ The cranial base is represented by Ba–Na plane.

➤ The anterior limit of the cranial base is nasion.

➤ Anterior cranial base length (N–S) is increased in horizontal growth.

➤ Posterior cranial base length (S–Ar) is also increased in horizontal growth (Fig.
14.20).

Angle of convexity (Subtelny)

1. Skeletal convexity is represented by N–A–Pog with mean value of 175°.

2. Soft tissue convexity is represented by n–sn–Pog. Mean value is 161°.

3. Full soft tissue convexity is represented by n–no–Pog. Mean is 133–137°.

• The value of ANB angle is very much affected by location of

nasion.

• A graphic representation of the measurements in Steiner’s

analysis is called Steiner’s sticks.

• ANB angle helps to find out the relationship between maxilla

and mandible.

• In a well-proportioned face, all the horizontal lines of the

 face project towards a common point. This concept was
given by Sassouni V.

• The counterpart analysis was given by Enlow DH.

• Mandibular plane in Tweed’s analysis is tangent to the lower

border of mandible.

• Normal value of nasolabial angle is 102 ±2°.

• A combination of long anterior facial height with small

posterior facial height leads to skeletal open bite.

• Ratio of upper face height to lower face height is 45:55.

Bjork’s value
1. It is the sum of the three angles, namely N–S–Ar + S–Ar–Go + Ar–Go–Me.

2. Normal value is 396°.

3. If the value is >396°, it means vertical growth pattern.

4. If the value is <396°, it means horizontal growth pattern.

• Broadbent’s registration point (R point) is the point where a

perpendicular drawn from sella meets the Bolton–nasion
plane.

• Incision cephalometric head plate analyses (end-to-end bite)

curve of Spee and freeway space.

• Rest position cephalogram in open mouth position is

indicated in functional problems.

• A Forty-five-degree lateral projection cephalometric plate

 gives more accurate picture of the relationship of erupted and
unerupted teeth.

• Sella turcica is located at the geometric midpoint of pituitary or

hypophyseal fossa.

• Frankfort plane joins porion and orbitale.

FIG. 14.20. Cranial base lengths.

Advanced Learning
Holdaway’s lip analysis
➤ Reed Holdaway introduced a quantitative analysis to assess the lip configuration.

➤ The cephalometric landmarks used are sella (S), point A and point B.

Method (fig. 14.21)

➤ Draw a tangent to upper lip from soft tissue pogonion. This is the ‘H’ line of
Holdaway.
➤ Draw SN plane. From SN plane, drop line to point A and point B.

➤ Measure SNA, SNB and ANB.

➤ Measure the angulations between the H line and NB line. This is the ‘H’ angle of
Holdaway.

➤ H angle is affected by ANB angulations.

➤ The perfect profile will meet the following criteria according to him.

• With ANB angle in the range of 1–3°, the H angle is 7–8°.

• Lower lip touches the soft tissue line extending from soft
tissue pogonion to upper lip.

• The soft tissue line bisects the S-shaped curve formed by the
lower border of nose to upper lip. This is an indicator for
balance in the relative proportions of upper lip and nose.

FIG. 14.21. Holdaway’s lip analysis.

Holdaway ratio
➤ The relative prominence of lower incisor and bony chin determines the balance
between them. The more prominent the chin, the more prominent the lower incisors
and vice versa.

➤ According to Holdaway, the distance the lower incisors are in front of NB line should
equal the distance the bony chin is in front of NB line. This 1:1 relationship is called
Holdaway ratio (Fig. 14.22).

FIG. 14.22. Holdaway ratio.

Method
➤ Draw the NB line connecting the cephalometric landmarks nasion and point B.

➤ Measure the distance by which the bony chin is lying anterior to the NB line. This
value is the thickness of ‘effective chin’.

➤ Measure the distance by which the lower incisor is lying anterior to the NB line.

➤ According to Holdaway:

• Effective chin = Distance of lower incisor to NB line.

• On an average, it should be 4 mm.
Down’s analysis
➤ WB Down noted that the best harmony of features in the face occur when the
mandible is orthognathic, i.e. neither protrusive nor retrusive.

➤ He classified the face into four types based on the position of lower jaw in
anteroposterior plane.

i. Retrognathic – recessive mandible

ii. Orthognathic – ideal or average mandible

iii. Prognathic – protrusive mandible

iv. True prognathic – pronounced protrusion of mandible

➤ The cephalometric landmarks used are orbitale, porion, gonion, pogonion, nasion,
sella, point A, point B and gnathion.

➤ The cephalometric planes and lines used are Frankfort horizontal plane, mandibular
plane, facial plane, A–B plane, S–Gn line and A–Pog line.

➤ Down’s analysis measures the skeletal pattern and dental pattern of the patient using
five variables each. His mean values are obtained from 20 white boys and girls who
possessed clinically excellent occlusions.

Skeletal pattern
1. Facial angle (Fig. 14.23)

• It is formed by the facial plane (nasion–pogonion line) and

Frankfort horizontal plane. The inferior inside angle at the
point of intersection is called facial angle.
 FIG. 14.23. Skeletal pattern: Facial angle.

• The mean reading for this angle is 87.8°.

• Facial angle denotes the degree of recession or protrusion of

the mandible in relation to the upper face.

• The facial angle is increased in mandibular prognathism and

decreased in retrognathism.

• Pogonion is a landmark located on the chin. Chin position

can affect facial plane thereby influencing facial angle.
Prominent chin increases the facial angle whereas small chin
decreases facial angle.
2. Angle of convexity (Fig. 14.24)

• The angle of convexity is formed by intersection of N–A line

to A–Pog line.
 FIG. 14.24. Skeletal pattern: Angle of convexity.

• The angle measures the extent of the maxillary basal arch at

its anterior limit relative to the total facial profile.

• The angle is read in positive or negative degrees from zero.

Mean value of angle of convexity is 0°.

• The A–Pog line is extended towards nasion. If it is located

anterior to nasion, the angle is read as positive. Positive
angle of convexity suggests prominence of maxillary dental
base relative to the mandible.

• If the A–Pog line is located posterior to nasion, the angle is

read as negative. Negative angle of convexity suggests
prominence of mandibular dental base relative to the
mandible.
3. A–B plane angle (Fig. 14.25)
• AB plane angle is formed by a line connecting point A to
point B and N–Pog line.

FIG. 14.25. AB plane angle.

• The AB plane angle is a measure of the anterior limit of

apical bases to each other relative to the facial line.

• The angle is read in positive or negative degrees from zero.

Mean value of AB plane angle is –4.6°.

• Increase in the AB plane angle occurs when there is a

discrepancy in the position of jaw bases in the
anteroposterior plane. Hence, AB plane angle is an indicator
of the difficulty in obtaining correct axial inclination, overjet
and overbite after orthodontic therapy.
4. Y-axis (Fig. 14.26)

• Y-axis or growth axis is an integral part of assessment of

skeletal pattern in Down’s analysis.

FIG. 14.26. Y-axis and mandibular plane angle.

• Cephalometric landmarks used in Y-axis are sella, gnathion,

porion and orbitale.

• The cephalometric plane used is Frankfort horizontal plane.

• Y-axis is formed by the acute angle at the intersection of

Frankfort horizontal plane and the line connecting sella and
 gnathion.

• The mean value for Y-axis is 59.4°.

• Increase in Y-axis is suggestive of vertical growth pattern.

• Decrease in Y-axis is suggestive of horizontal growth

pattern.

• Y-axis indicates the position of chin in anteroposterior and

vertical plane.

• In other words, Y-axis indicates the downward, rearward or

forward position of the chin.
5. Mandibular plane angle (MPA)

• The Down’s mandibular plane is formed by a tangent

through the gonial angle and the lowest point on the
symphysis (menton).

• The mandibular plane angle is the angle formed by

mandibular plane and Frankfort horizontal plane (Fig.
14.26).

• The mean value for mandibular plane angle is 21.9°.

• High-mandibular plane angles are suggestive of

hyperdivergent (vertical) growth pattern.

Dental pattern
1. Cant of occlusal plane

• The cant of occlusal plane is the measure of the slope of

 occlusal plane to the Frankfort horizontal plane (Fig. 14.27).

FIG. 14.27. Cant of occlusal plane.

• The occlusal plane is drawn bisecting the overlapping cusps

of first molars and the incisor overbite. The angle between
occlusal plane and Frankfort horizontal plane is measured to
obtain the cant of occlusal plane.

• Mean value is 9.3° in the Down’s sample. Long mandibular

ramus decreases the cant of occlusal plane. Increased cant is
seen in class II malocclusions.
2. Interincisal angle (Fig. 14.28)

• Interincisal angle is formed by long axis of the upper incisor

and long axis of the lower incisor.
 FIG. 14.28. Interincisal angle.

• Mean value is 135.4°. The angle is small in individuals

whose incisors have tipped forward.
3. Incisor occlusal plane angle (Fig. 14.29)

• Incisor occlusal plane angle is formed at the intersection of

occlusal plane and the long axis of lower incisor. The
inferior inside angle at the point of intersection is read as
positive or negative deviation from right angle.
 FIG. 14.29. Incisor occlusal plane angle.

• The range is +3.5 to +20°. The mean angulation is +14.5° from

right angle.

• Increased incisor occlusal plane angle is seen with proclined

lower incisors.
4. Incisor mandibular plane angle (Fig. 14.30)

• Incisor mandibular plane angle is formed at the intersection

of mandibular plane and the long axis of lower incisor.
 FIG. 14.30. Incisor mandibular plane angle.

• The inside angle at the point of intersection is read as

positive or negative deviation from right angle. The mean
value is +1.4°. It increases in lower incisor proclination.
5. Protrusion of maxillary incisors (Fig. 14.31)

• Protrusion of maxillary incisors are evaluated by drawing a

line from point A to pogonion and measuring the distance
between the incisal edge of the maxillary central incisor and
A–Pog line.
 FIG. 14.31. Protrusion of maxillary incisors.

• If the incisal edge is ahead of the A–Pog line, the

measurement is given a positive value.

• The mean value is +2.7 mm. Increased values suggest

protrusion of maxillary incisors. Decreased or negative
values suggest retrusion of maxillary incisors.
Summary of down’s analysis (table 14.9)

Table 14.9.
Down’s analysis: Summary
Utility of cephalometrics in growth
Cephalometrics is mainly used for the assessment of growth in the following ways:

1. Assessment of expected growth

2. Timetable for growth

3. Localization of growth rates

4. Direction of growth

5. Prediction of growth

6. Treatment versus growth changes

7. Growth following conclusion of treatment.

1. Assessment of expected growth

Quantitative assessment of growth is an important part in

treatment planning. Biological age is determined chiefly by
hand–wrist radiographs. Table 14.10 depicts modified
Bjork’s method for hand–wrist radiograph assessment.

Table 14.10.
Modified Bjork’s method for hand–wrist radiograph assessment
2. Timetable for growth

• Developmental stages, apart from providing qualitative

assessment of growth, also provide information about the
timing of growth rates.

• It is possible to estimate when growth spurts will occur with

the knowledge of timing of puberty.
3. Localization of growth rates

• Increase in size correlates with growth rates in certain

regions which can be assessed by means of cephalometrics.

• Noticeable increase in linear dimension is seen in the

following areas:

• N–Me

• S–Gn

• Ar–Gn ( Table 14.11).

Table 14.11.
Mean increase in linear growth in various areas
4. Direction of growth

Cephalometric radiography is used to differentiate between

horizontal and vertical growth patterns.

Horizontal growth

• A broad mandibular base and ramus with a thick symphysis

is suggestive of horizontal growth.

• Frankfort mandibular angle and Go–Gn to SN will be less

than normal in horizontal growth.

Vertical growth

• Narrow mandible with thin symphysis is suggestive of

vertical growth.

• Frankfort mandibular angle and Go–Gn to SN will be more

than normal in vertical growth.
5. Growth prediction methods

• Johnston grid method

• Ricketts’ prediction method

• Holdaway’s prediction

A Visualized treatment objective (VTO) is like a blueprint used

in building a house. It is a visual plan to predict the normal
 growth of the patient and the anticipated effects of
treatment in order to establish the objectives of treatment for
that particular patient. VTO permits the development of
alternative treatment plans. VTO permits orthodontists to
set their goals in advance for the treatment. Ricketts
advocated VTO in the following sequence:

1. Cranial base prediction

2. Mandibular growth prediction

3. Maxillary growth prediction

4. Occlusal plane position

5. Location of the dentition

6. Soft tissues of the face

6. Treatment versus growth changes

Ricketts’ four-step analysis is used to study growth changes

versus treatment changes.
7. Growth following conclusion of treatment

• Growth changes which take place after active treatment can

be predicted using cephalograms.

• Continuous anterior growth of mandible results in decrease

of SN–MP, ANB and SNB angles.

• Mesial inclination of upper first molars takes place to

accommodate the mesial relocation of mandible. This is
 about 7° on the average.
Computerized cephalometric system
Computerized cephalometric systems are employed for diagnostic, prognostic and
treatment evaluation in orthodontics.
Advantages of computerized cephalometry
➤ Less time consuming than conventional manual cephalometry

➤ Efficient in research applications

➤ Reliability of the analyses is increased as the chances for errors are minimized

➤ Easy retrieval of old records

➤ Easy storage of bulk records

➤ Patient’s other data, like photographs and casts, can be combined and evaluated.

➤ Cephalometric prediction for orthognathic surgery is better when compared to

manual method.

Components of computerized cephalometric system

There are two basic components namely:

1. Data acquisition

2. Data management.

Data acquisition
Data acquisition is done by different methods like ionizing radiation, magnets, sound
and light.

➤ Ionizing radiographs: Regular radiographs are used to create the X–Y coordinates
by means of a digitizer. The cephalometric points or landmarks are marked in the
radiographs and the points are digitized. The drawback of this procedure is manual
error in locating the landmarks.

➤ Digital radiographs: With the introduction of digital radiographs in which the X-ray
beam attenuation is recorded directly and converted to a digital image has reduced
the margin of errors when compared to manual tracing. The points are marked
directly into the digital images on a computer.

Data management
Following are the commercially available data management programmes:
➤ RMO’s Jiffy orthodontic evaluation

➤ Pordios

➤ Dentofacial planner

➤ Quick ceph image

➤ Digigraph.

RMO’s jiffy orthodontic evaluation

➤ Rocky Mountain Orthodontics (RMO) was the first to provide the orthodontic
profession with a computer-aided cephalometric diagnosis.

➤ Jiffy orthodontic evaluation (JOE) introduced recently by RMO is a static analysis

programme.

➤ JOE creates tracings of lateral and frontal cephalograms using Steiner, Ricketts and
Jarabak’s analyses.

➤ JOE gives a detailed cephalometric analysis with deviations from normal for a given
patient.

Pordios

➤ Pordios is an acronym for purpose on request digitizer input–output system.

➤ It works with a digitizer. Video and scanner can be used as means of digitization.

➤ Bjork, Burstone, Down’s, McNamara, Tweed’s, Steiner’s analyses can be performed

with Pordios.

➤ It has a built-in feature to show the normal and amount of deviation from normal.

➤ Since double digitization is employed, the margin of error is reduced.

➤ Results can be printed.

➤ Occlusograms from photocopies of models can also be analysed using this

programme.

Dentofacial planner

➤ Used for both orthodontic and orthognathic surgery purposes.

➤ Similar to Pordios except that separate programmes for orthognathic surgery are
included in this.
➤ Surgical treatment objective (STO) can be performed by using this programme.

Quick ceph image

➤ Thirteen cephalometric analyses can be performed with this software.

➤ Model analysis can also be performed.

➤ Extra features include growth prediction, treatment simulation for both orthodontics
and orthognathic surgery.

➤ Photograph of the patients can be analysed.

➤ Used for storage of data also.

Digigraph (dolphin imaging system)

Digigraph is a mixture of video imaging, computer technology and three-dimensional
sonic displays.
Components of digigraph

➤ Cabinet with the digitizer probe

➤ Monitor

➤ Head-holder

➤ Camera

➤ Software

Procedure

➤ Patient sits in a chair next to the cabinet.

➤ Head is adjusted to the head-holder device which has camera attached to it.

➤ With the help of digitizing probe, the cephalometric landmarks are recorded by
lightly touching the patient’s skin.

➤ Recordings are transferred to the computer.

➤ Cephalometric analysis and patient monitoring can be done simultaneously.

➤ This is a noninvasive technique without radiation exposure.

Advantages of digigraph

➤ Landmarks can be marked in all the three dimensions.

➤ Cephalometric analyses can be done without considerations to head posture.

➤ Parallelism of the X-ray will not affect the procedure.

➤ Symmetry of the anatomic structure does not interfere with the procedure.

➤ Cephalometric analyses, tracings, superimpositions and VTOs can be performed.

➤ A total number of 14 cephalometric analyses can be done.

➤ Storage media for cephalograms, photos and models.

➤ As a communication media with the patient.

SECTION V
Biology, Mechanics and Orthodontic
Materials
OUTLINE

15. Biology of tooth movement

16. Biomechanics of orthodontic tooth movement

17. Materials used in orthodontics

CHAPTER 15
Biology of tooth movement

CHAPTER OUTLINE
❖ Physiologic tooth movement
❖ Structure of PDL and its response to physiologic force
❖ Theories of tooth movement
❖ Mechanochemical hypothesis
❖ Bioelectric theory
❖ Piezoelectric theory
❖ Streaming potential
❖ Bioelectric potential
❖ Pressure–tension theory
❖ Biological tissue reaction to the application of orthodontic force
❖ Tissue changes at pressure zone
❖ Tissue changes at tension zone
❖ Tissue changes in other areas
❖ Stages of tooth movement
❖ Different types of orthodontic force
❖ Orthopaedic force
❖ Accessory points
❖ Advanced learning
❖ Deleterious effects of orthodontic force
❖ Influence of drugs during orthodontic tooth movement
Physiologic tooth movement
Definition
➤ Physiologic tooth movement designates primarily the slight tipping of the
functioning tooth in its socket and secondarily, the changes in tooth position that
occur in young persons during and after tooth eruption. It is of three types:

1. Movement during mastication

2. Eruption of tooth

3. Tooth migration
1. Movement during mastication

• Tooth movement during masticatory function depends upon

the location of neutral axis of the functioning tooth.

• Neutral axis is located between the middle and apical

regions of the roots in an adult tooth.

• For younger persons, the neutral axis is either located in the

marginal region or closer to the middle of the root, if the
root is fully developed.

• During chewing, the teeth tip slightly around the neutral

axis as fulcrum.

• Tooth is displaced because of bending of the alveolar process

also.

• Movement during mastication is transient. Once the occlusal

load is removed, it reverts to normal position.
2. Eruption of tooth

• Different teeth move in different directions during eruption.

• During eruption, upper molar teeth move mainly in mesial

direction.

• Lower molar teeth show variations in the direction of

movement. Sometimes even a distal direction of movement
is observed.

• Premolars sometimes show lingual movement during

eruption.
3. Migration of teeth

• Migration of teeth is a slow tooth movement.

• Direction of movement is usually mesial and occlusal.

• This corresponds to the adult equilibrium stage of tooth

eruption.

• These movements take place to compensate for

interproximal attrition and occlusal wear.
Structure of periodontal ligament and its
response to physiological force
Periodontal ligament
➤ Periodontal ligament (PDL) serves the dual function of providing attachment of the
tooth to the alveolar bone and also detachment from the bone (Fig. 15.1).

➤ The width of the PDL is approximately 0.5 mm throughout.

➤ Collagen fibres form the major constituent of the PDL. They are inserted into
cementum of the root surface on the tooth side and into lamina dura of the alveolar
bone.

FIG. 15.1. Tooth and supporting structures.

Components of PDL
1. Fibres

2. Cellular components, which include:

i. Undifferentiated mesenchymal cells

 ii. Fibroblasts, osteoblasts, osteoclasts

iii. Blood vessels

iv. Nerve endings associated with pain and proprioception

3. Tissue fluids act as shock absorber

The different types of periodontal fibres:

1. Trans-septal group

2. Alveolar crest group

3. Horizontal group

4. Oblique

5. Apical group

6. Inter-radicular fibres

Response to physiologic forces

➤ During eating, heavy forces are loaded on to the teeth. These forces are not
continuous but intermittent.

➤ Response to force can be observed both in PDL and in alveolar bone individually.
The findings are depicted in Table 15.1.

Table 15.1.
Changes in PDL and bone in response to physiologic forces

Time Changes in PDL Changes in bone

<1 second • PDL fluid not compressed • Alveolar bone bends
• PDL fluid squeezing begins • Formation of piezoelectric signals
1–2 seconds • Tooth moves in the PDL space
• PDL fluid squeezed out
3–5 seconds • Tissues compressed
• Pain elicited, if pressure is heavy
Theories of tooth movement
Introduction
➤ Orthodontic treatment is based on the fact that it is possible to move the teeth
through the alveolar bone by the application of force.

➤ Orthodontic tooth movement is a complex and wonderful process, wherein one

calcified structure (tooth) moves through another calcified structure (bone).

➤ Application of a force system to the crown of a tooth produces a cascade of events

within the PDL and alveolar bone.

➤ The final event which is responsible for tooth movement is remodelling, which
includes resorption of bone on one surface and deposition of bone on another surface
(Fig. 15.2).

➤ For the cellular changes to take place or to initiate remodelling, the force which is a
mechanical energy has to be converted into a biological signal.

➤ The process by which conversion of mechanical energy into a biological signal

affecting a remodelling response to take place is called transduction.

➤ Based on how the signals are elicited to induce remodelling response, various
theories of tooth movement have been put forward.

FIG. 15.2. Pressure and tension site following force application. Bone gets deposited in
 tension zones and undergoes resorption in pressure zone.

Theories
1. Mechanochemical hypothesis

This hypothesis was put forward by Justus R, Luft JH (1970).

• According to this hypothesis, application of physical stress

to the bones changes the solubility of the hydroxyapatite
crystals.

• Change in solubility of the hydroxyapatite results in

remodelling of bone.

• This hypothesis is not widely accepted.

2. Bioelectric theory

• When there is application of orthodontic force, alveolar bone

flexes and bends.

• This flexing and bending generates electric signals that alter

the metabolism of bone. This is the basis of bioelectric
theory.

• There are different types of electric signals generated:

a. Piezoelectricity

• One type of electric signal that is thought to be responsible

for tooth movement is piezoelectricity.

• Piezoelectricity is a phenomenon observed in crystalline

materials.
• Deformation of the crystal structure causes displacement of
electrons from one part to another.

• This flow of electrons causes generation of electric current.

• Bone and collagen both have piezoelectric property.

• Two features of piezoelectricity are shown in Fig. 15.3.

i. Quick decay rate: When a force is applied, piezoelectricity

is generated which immediately goes to zero level, even if
the force is continuously applied. This property is called
quick decay rate.

ii. Reverse piezoelectricity: When the crystals are deformed,

electrons flow from one location to another and electric
current is produced. When the force is removed, the
crystals after returning to its original positions produce
flow of electrons in the opposite direction. This is reverse
piezoelectricity.

• Piezoelectricity produces a rhythmic and constant interplay

of electric signals.

• The role of piezoelectricity in orthodontic tooth movement is

doubtful.

• But piezoelectricity is important in the normal homeostasis

of the skeleton.

• Without piezoelectricity, bone mineral will be lost and

atrophy of skeleton occurs (e.g. in astronauts).

• Piezoelectric effect was described by Fukada E and Yasuda I

 in 1957.

b. Streaming potential

In hydrated tissues, streaming potentials predominate; these

are electrokinetic effects that arise when the electrical double
layer overlying a charged surface is displaced as the
interstitial fluid moves.

It has been suggested that ions in the fluids surrounding living

bone interact with the electrical fields generated when the
bone is bent. These currents of small voltages are called
streaming potentials.

In contrast to piezoelectric spikes, the streaming potentials had

long decay periods. The other features, like rapid onset and
alteration, are similar to piezoelectricity.

Davidovitch Z stated that in hydrated tissues, streaming

potentials (the electrokinetic effects that arise when the
electrical double layer overlying a charged surface is
displaced) predominate as the interstitial fluid moves.

The role of streaming potential in orthodontic tooth movement

is also doubtful.

c. Bioelectric potential (Fig. 15.4)

Explanation:

• Application of orthodontic force by the appliance will cause

physical distortion of the alveolar bone which is
accompanied by bending of bone.
• Bone which is deformed by stress becomes electrically
charged.

• Concave surfaces take a negative polarity and convex

surfaces a positive polarity.

• As a result of these electric signals, cell membrane receptors

and cell permeability are affected leading to remodelling
response.

• Bone is added to the concave surfaces and resorbed from

convex surfaces.
3. Pressure–tension theory/classic theory/blood flow theory
• Pressure–tension theory gives more importance to chemical
messengers as the stimulus for cellular changes to take place
and ultimately orthodontic tooth movement.

• Mechanism by which force application leads to release of

chemical messengers is given in flowchart below.

• Decreased vascularity and overstretching of PDL induces

chemical changes and inflammatory type of response is
elicited.

• Oxygen levels are altered.

• Because of inflammatory type of reactions, mediators like

prostaglandins are released.
 FIG. 15.3. Piezoelectricity – shows both quick decay rate and reverse piezoelectricity.

FIG. 15.4. Bioelectric potential. Bone deposition occurs in negatively charged areas and bone
resportion in positively charged areas.

First messengers
➤ Prostaglandin E plays a major role in the cellular differentiation. Prostaglandin
becomes the first messenger.

➤ The role or functions of first messengers are to activate the extracellular signals.

➤ The first messengers bind to the cell surface receptors and the extracellular signals
are activated.
➤ Other first messengers are parathormone (PTH), substance P and vasoactive
peptides.

Second messengers
➤ Next step in cellular differentiation is conversion of extracellular signal into an
intracellular signal.

➤ The conversion into intracellular signal takes place by two pathways:

1. Conversion of ATP into cyclic-AMP.

2. Opening of calcium ion channel and activate Ca++

➤ Ca++ and cAMP act as second messengers.

➤ It takes nearly 4 h of sustained pressure to produce second messenger.

➤ Any appliance, therefore, has to be worn for a minimum period of 4–6 h to produce
effects.

Third messengers
➤ The cAMP and Ca++ act on the protein kinase enzymes within the cells.

➤ Protein kinase enzymes are the third messenger.

➤ Protein kinase causes phosphorylation of the cells. Phosphorylation results in

differentiation and activation of osteoclasts and osteoblast which ultimately produce
remodelling.

➤ Tooth movement begins as the osteoclasts and osteoblasts remodel the bony socket.
Biological tissue reaction to the application of
orthodontic force
Introduction
➤ Tooth movement is a unique and wonderful process in which application of
orthodontic force causes alveolar translocation.

➤ Alveolar translocation is a special type of remodelling in which bone formation and

resorption takes place simultaneously on the opposite side of the alveolar bone.

➤ This results in the movement of the tooth along with the whole attachment
apparatus.

➤ The movement of the tooth along with its attachment apparatus due to application of
force is called alveolar translocation.

➤ The biologic response or histological changes during orthodontic treatment can be

explained under three headings.

Tissue changes
1. At pressure zone

2. At tension zone

3. Other areas

• Pulp

• Gingiva

• Dentin

• Cementum

• Temporo-mandibular joint

1. Tissue changes at pressure zone

• Light force – frontal resorption

• Heavy force – hyalinization, undermining resorption

The sequence of changes that are seen following orthodontic force is as follows:

Frontal resorption
The first step in orthodontic tooth movement is activation of osteoclasts.

➤ Osteoclasts initiate the process of resorption.

➤ The osteoclasts come in two ways:

1. Some of the osteoclasts are derived from local population.

2. Others are brought from distant areas through blood

supply.
➤ The activated osteoclasts start the resorption process by attacking the adjacent lamina
dura, removing bone in the process. This is called frontal resorption.

➤ Frontal resorption is also called periosteal resorption or direct resorption or forward

resorption.

➤ In frontal resorption, resorption is initiated from the PDL side of the alveolar bone.

➤ Frontal resorption usually takes place after 2 days.

Hyalinization
The ideal orthodontic force should not exceed the capillary pulse pressure, which is about
20–26 g/cm2.

➤ When the force increases more than the capillary pressure, the blood vessels get
compressed or occluded (Fig. 15.5).

➤ The blood supply to the area of the compressed PDL is cut off.

➤ When this happens, the cells which normally get stimulated into osteoclasts do not
get activated.

➤ Instead, an area of sterile necrosis is seen in the compressed area.

➤ When seen under a microscope, the histological appearance will be that of an area
without any cells and such an area is called hyalinized area and the process is called
‘hyalinization’ (Fig. 15.6).

➤ Though called as hyalinization, the process has nothing to do with the formation of
hyaline connective tissue.

➤ It simply means a sterile cell-free zone.

➤ It is a reversible process.

➤ Hyalinization results in a standstill of the tooth moved (Fig. 15.7).

➤ Tooth will move again only after the bone beneath the hyalinized area undergoes
resorption.
FIG. 15.5. Effect of increasing the orthodontic force: Blood vessels get occluded and
hyalinization results.

FIG. 15.6. Undermining resorption.

 FIG. 15.7. Tooth movement: stages. Light forces produce no lag phase, whereas heavy forces
show all three phases.

Reasons for hyalinization

1. Anatomical factors: One of the anatomic factors is the form and outline. If there are
open clefts and space, there will be short period of hyalinization.

2. Mechanical factors:

• Amount of force imparted to the surface of the tissue

• Type of tooth movement

Microscopic features of hyalinization

1. Disappearance or shrinkage of nuclei (pyknosis).

2. Compressed collagenous fibres unite together but without cell mass.

3. The uniform hyaline appearance is because of changes in the ground substance.

4. Collagen fibres gradually merge with the surrounding jelly-like ground substance.

5. Destruction of capillaries.

6. Inflammatory type of reaction.

Hyalinization period usually lasts 7–14 days after which resorption takes place by
undermining resorption.
Undermining resorption/endosteal resorption/rearward
resorption/indirect resorption
➤ Undermining resorption or indirect resorption was named by Sandstedt C.

➤ Once hyalinization occurs in PDL, frontal resorption is not possible.

➤ After a gap of few days, the hyalinized zone will be invaded by the cells from the
adjacent normal areas of PDL.

➤ Along with that osteoclasts also begin to appear in the adjacent bone marrow spaces.

➤ They initiate resorption from the underside of the bone adjacent to the hyalinized
PDL zone.

➤ This method of resorption is called undermining resorption because the attack is

from the underside of lamina dura (Fig. 15.6).

Summary of changes in pressure side

Force
1. Light force

i. Compression of PDL

ii. Activation of first, second and third messengers

iii. Activation of osteoclasts

iv. Resorption from PDL side of alveolar bone

v. Attacking the adjacent lamina dura

vi. Frontal resorption

2. Heavy force

i. Compression of PDL

ii. Occlusion of blood vessels

iii. Area of sterile necrosis (hyalinization)

iv. Tooth movement impeded

v. Resorption takes place by activation of osteoclasts adjacent

to medullary spaces

vi. Resorption from the underside of the bone adjacent to

hyalinized PDL zone – endosteal resorption
➤ Bone resorption occurs not from the inner wall of the tooth but from the endosteal
side.

➤ Tooth movement is delayed because of hyalinization and undermining resorption.

There are two reasons for delayed tooth movement:

1. Differentiation and activation of osteoclasts from marrow

spaces take more time.

2. The thickness of bone to be removed from the underside

is more.
➤ Tooth movement is efficient with frontal resorption. But in clinical practice, it is
extremely difficult to avoid hyalinization and undermining resorption.

➤ The rate of resorption is about 10–15 microns/day.

➤ Onset of resorption is faster. It occurs in about 12 hours after force application.

2. Tissue changes at tension zone

➤ Cellular activity is delayed in areas of tension when compared to pressure zones.

➤ It takes 30 hours for increased cellular activity to be seen in tension zone.

➤ The stretched periodontal fibres are reconstructed by changes of the original fibrils.

➤ Macrophages are found in great numbers in tension zone.

➤ There is inflammatory-like breakdown and rebuilding of fibrous elements in areas of

tension.
➤ New unmineralized matrix is laid down around the parts of the fibres that are close
to the alveolar wall.

➤ After some time, osteoid is laid on the whole of the alveolar wall on the tension side.

➤ Osteoblasts synthesize the osteoid.

➤ Subsequently, mineralization of osteoid takes place.

➤ Rate of bone deposition is about 30 microns/day.

3. Tissue changes in other areas

Cementum:

• Bays of osteoclastic resorption may appear in the cementum adjacent to PDL.

• These areas are repaired by cementoblasts either during the process of tooth
movement or during rest period.

Dentin:

• In extremely rare cases, resorption pattern is seen in dentin.

• The exact reason for the dentin resorption is not known.

Pulp:

• With mild force, hyperaemia of pulp will be evident.

• Extreme force will show signs of degeneration or necrosis.

Gingival tissues:

• Gingival tissues get adapted to the new position of the tooth.

• But the adaptation takes more time.

• Gingival tissues tend to pile up on the side of movement of the tooth.

• Irritation of the gingival tissues by the appliance can cause gingival enlargement.

Temporomandibular joint:

• Changes in occlusion of teeth may bring about changes in TMJ.

• Areas of bone resorption and deposition are reported in glenoid fossa.

• Changes in position of condyle within the glenoid fossa are also seen.
Stages of tooth movement
Tooth movement
➤ Initial period:

i. Initial phase

ii. Lag phase

➤ Secondary period (or) post-lag phase

➤ Tooth movement occurs in two principal stages (Fig. 15.7):

➤ Initial period: Starts from the time of application of force till elimination of the bone
below the hyalinized tissue.

➤ Tooth movement occurring after hyalinization is called secondary period.

Initial phase
➤ This is a period of rapid tooth movement for a short time and distance.

➤ It is due to displacement of the tooth in the PDL space.

➤ Bending of alveolar bone also contributes little to this phase of tooth movement.

➤ Magnitude of force has no effect on this stage. Both light and heavy forces produce
the same amount of tooth movement. Tooth movement is approximately 0.4–0.9 mm
in this stage.

Lag phase
➤ Lag phase represents the period of hyalinization.

➤ Naturally, lag phase exists only when the applied orthodontic force is heavy.

➤ During the lag phase, little or no tooth movement occurs.

➤ Lag phase usually extends up to 14 days.

➤ Undermining resorption starts after a considerable delay.

➤ This period lasts till the elimination of bone below the hyalinized tissue.

Stages of tooth movement: Summary (table 15.2)

Table 15.2.
Summary of stages of tooth movement

Post-lag phase
➤ In the secondary period of tooth movement after hyalinization, PDL is considerably
widened.

➤ Osteoclasts attack the bone over a larger area.

➤ If the force is not increased, further resorption will be of the periosteal type.
Different types of orthodontic force
➤ Orthodontic treatment consists of moving teeth to the desirable position.

➤ The medicine or prescription in orthodontics is ‘force’.

➤ Orthodontic force induces changes only in the dentoalveolar area whereas

orthopaedic force produces changes in the basal bone.

Optimum orthodontic force/ideal orthodontic force

Definition
Optimum orthodontic force is one that produces maximum tooth movement in the
desired direction with minimum damage to the supporting tissues and without any
discomfort to the patient.

➤ The orthodontic force should not occlude the blood vessels in the PDL. Ideally, it
should be less than the capillary pulse pressure.

➤ According to Schwarz A M and Oppenheim A, the optimum orthodontic force

should be in the range of 20–26 g/cm2 of root surface.

➤ Schwarz further stated that optimum force for tooth movement is 15–20 mm Hg of
vascular pressure.

Types of orthodontic force (table 15.3)

➤ Orthodontic force is classified into continuous, interrupted and intermittent based on
the duration and decay rate of orthodontic force by Proffit WR (Fig. 15.8).

Table 15.3.
Optimum forces for different types of tooth movement

Type of movement Force (in g)

Tipping 35–60
Bodily movement 75–120
Root uprighting 50–100
Rotation 35–60
Extrusion 35–60
Intrusion 10–20
 FIG. 15.8. Orthodontic force types: (A) continuous orthodontic force, (B) interrupted force and
(C) intermittent force.

Continuous force
➤ In this type, force is maintained at some appreciable fraction of the original force
between the two successive visits of the patient. The force level does not decline to
zero.

➤ For the continuous force to be effective, it has to be a light continuous force. Light
continuous force produces smooth progression of tooth movement. Resorption
pattern will be of direct type.

➤ Heavy continuous force can be detrimental to the tissues because of the effects as
depicted in Fig. 15.9.
 FIG. 15.9. Effects of applying continuous force.

Interrupted force
➤ In this type of force, the force level reduces to zero between the two successive visits
(Fig. 15.8B). The effects of light interrupted and heavy interrupted forces are depicted
in Fig. 15.10.

➤ Light interrupted forces and heavy interrupted forces are clinically acceptable, e.g.
fixed appliance.
 FIG. 15.10. Effects of applying interrupted force.

Intermittent force
➤ In this type of force, there is a sudden drop of force to zero level when the
orthodontic appliance is removed by the patient (Fig. 15.8C).

➤ Intermittent force acts as an impulse or a shock for short periods with a series of
interruptions.

➤ Striking difference in tissue reaction with intermittent force is seen. During the
period, when the appliance is not worn, teeth move slightly to the tension side.

➤ Intermittent forces act as a stimulus and elicit bone formative changes in areas not
subjected to pressure.

Functional type of intermittent forces

➤ The impulses or shocks of forces occur more frequently with functional appliances.

➤ It is more during day time because of the swallowing process.

➤ When a functional appliance is worn only at night, osteoid formation occurs after 2–3
days on the tension side. The osteoid is resistant to resorption. Further deposition of
osteoid leads to reorganization of the bone tissue. Since the appliances are not worn
in normal function, there is functional adaptation of the newly formed structures, e.g.
all removable appliances, headgears, functional appliance, and elastics.
Advantages of optimum orthodontic force
➤ Tooth movement is efficient with optimum orthodontic force.

➤ Resorption is mainly of the periosteal type.

➤ Elimination of lag phase.

➤ Elimination of hyalinized zone with optimum force.

➤ Pain is lessened.

➤ Damage to the supporting structures is avoided.

➤ Chances for root resorption are minimized.

Orthopaedic force
➤ Orthopaedic forces induce changes in the basal bone and bring about desired
correction.

➤ Application of heavy force through the teeth or by means of an acrylic splint has the
potential to bring about changes in the skeletal base.

➤ Orthopaedic force helps in correction of skeletal malocclusions.

➤ The type of force used in orthopaedic force is heavy intermittent type of force.

➤ Heavy intermittent force produces less dental changes and more skeletal changes.

➤ Part time wear of orthopaedic appliances is recommended to produce more skeletal

effects.

Orthopaedic force: Uses

For maxillary growth modification

1. To restrain maxillary growth

2. To stimulate maxillary growth

For mandibular growth modification

1. To restrain mandibular growth

2. To stimulate mandibular growth

1. Orthopaedic force for maxillary growth restriction

• Headgears or maxillary intrusion splints are used to restrict

the growth of maxilla.

Force prescription

• Magnitude of force: 250–500 g on one side (500–1000 g total)

• Duration of force: 12–14 h every day

• Direction of force: Through the centre of resistance of the
molar teeth directed above the occlusal plane

• Duration of treatment: 12–18 months

2. Orthopaedic force for maxillary growth stimulation

Force prescription

• Appliance used: Reverse pull headgear, rapid maxillary

expansion appliances are used to loosen the sutures.

• Anchorage

1. By means of acrylic splint

2. To molars

3. Implant fixed to transpalatal arch

• Magnitude of force: Minimum 1000 g total

• Duration of force: 12–14 h/day

• Direction of force: Above the occlusal plane

• Age of commencement: Ideal age of reverse pull headgear is

6–7 years

• Duration of treatment: 18–24 months

• Maximum correction achieved: 3 mm of forward

displacement of maxilla
3. Orthopaedic force for mandibular growth stimulation
• There is no extraoral appliance to stimulate mandibular
growth.

• Functional appliances are used to stimulate mandibular

growth.

• Role of functional appliances in stimulating mandibular

growth is questionable.

• Removable and fixed functional appliances are used.

4. Orthopaedic force for mandibular growth restriction

Force prescription

• Aplaceeee usd: Chin cap

• Force used: 450–700 g per side (900–1400 g total)

• Duration of force: 24 preferable, 12–14 h

• Duration of treatment: Worn for a very long period up to 15

years in girls and 17–18 years in boys.
Restrainment of mandibular growth is doubtful; there is only redirection of growth
subsequent to chin cap therapy.
ACCESSORY POINTS
➤ On wide opening of mouth, the distance between mandibular molars decreases by 2–3
mm.

➤ The first report on the histomorphology of tissues surrounding orthodontically

treated teeth was published by Sandstedt in 1904.

➤ According to pressure–tension theory, pressure side of the bone experiences

resorption.

➤ The small cell population of the PDL is the undifferentiated mesenchymal cells.
➤ The small voltages that are generated when ions in the extra-cellular fluid (ECF) of
living bone start interacting with complex electric field are called streaming potential.

➤ The principal cell population of the PDL is the undifferentiated mesenchymal cells.

➤ The small voltages that are generated when ions in the extra-cellular fluid (ECF) of
living bone start interacting with complex electric field are called streaming potential.

➤ According to the concept of bioelectric potential, metabolically active cells are

electronegative.

➤ Inactive cells or areas according to the bioelectric potential remain neutral.

➤ The threshold period of 4–6 h of wear of any appliance for the achievement of any
appreciable orthodontic tooth movement correlates with the release of cAMP.

➤ After how many hours/days of force application, does osteoblastic activity start?
Answer: 2 days.

➤ After application of heavy pressure for 1–2 s, tooth moves within the PDL space.

➤ The resorption of alveolar bone by cells from adjacent marrow spaces is called
undermining resorption.

➤ Hyalinization is seen in lag phase.

➤ Tooth movement that requires least amount of force is intrusion.

➤ In which type of tooth movements, only tension areas are seen in the PDL? Answer:
Extrusion.

➤ The simplest form of orthodontic tooth movement is tipping.

➤ In which type of tooth movements, hour glass type of distribution of pressure and
tension areas is seen in the same side? Answer: Uncontrolled tipping.

➤ The tooth movement in which whole force applied is concentrated as compression at

the apex of the root is intrusion.

➤ The tooth movement more prone to relapse is rotation.

➤ Orthodontic appliances should not be reactivated less than 3 weeks.

➤ The period of 3 weeks interval for the activation of the appliance is given for tissue
repair in the PDL.

➤ Pain after application of force is due to ischaemic necrosis in the PDL.

➤ A patient has erythema and swelling of the oral tissues 1–2 days after the start of
orthodontic treatment. The most common cause is allergy to nickel.

➤ The resorption of root is resisted by cementoid layer.

➤ As far as changes in the endocrine system are concerned, the most ideal time to start
orthodontic treatment is adolescence.

➤ Of all the natural forces generated, which one is considered the most continuous?
Answer: Posture.

➤ The width of the PDL of the impacted tooth is one-third of the thickness of the normal.

➤ The rationale for starting tooth movement as soon as extraction is completed is that
there is rich vascular supply to the area.

➤ Degree of forces by Schwarz

• First degree – gentle force or of too short duration to

produce any tooth movement

• Second degree – is ideal; produces tooth movement without

tissue damage

• Third degree – force exceeds capillary blood pressure and

causes damage but reversible

• Fourth degree – causes irreversible damage to the tissues

➤ Types of resorption

• Microresorption – confined to cementum, localized,

superficial and gets repaired

• Progressive root resorption – appears at the site of

continuous and heavy forces; may involve the whole apex

• Idiopathic root resorption – seen even before the start of

orthodontic treatment
➤ Minimum force required to cause tooth movement: 7 g/cm2

➤ Force in slow expansion : 2–4 lbs

➤ Force in rapid expansion: 10–20 lbs

➤ Basic tooth movements: Three namely tipping, translation, and rotation

➤ First messengers: PTH, PGE, substance P, VIP

➤ Second messengers: cAMP, cGMP, Ca2+.

➤ Drugs that affect prostaglandin synthesis and impede tooth movement are NSAIDs
and steroids.

➤ Squeeze film effect (by Bien): Application of heavy forces causes the tissue fluid in PDL
to be squeezed towards apex and cervical regions.

Advanced Learning
Deleterious effects of orthodontic force
The deleterious effects of orthodontic force can be studied under the following
headings.
Deleterious effects
1. Mobility

2. Pain

3. Effects on pulp

4. Effects on root

i. Generalized resorption – moderate, severe

ii. Localized resorption

5. Effects of treatment on height of alveolar bone

1. Mobility

• A moderate increase in mobility during tooth movement is

normal.
• Excessive mobility is a sign of excessive force.

• During treatment, the tooth moves into a position of

traumatic occlusion. The forces from mastication and
clenching adding to the traumatic occlusion cause increase
in mobility.

• Mobility is usually a reversible phenomenon.

• If there is excessive mobility, the affected tooth should be

cleared from occlusion and no force should be delivered to
the tooth.
2. Pain

• Development of ischaemic areas in the compressed PDL is

the reason for pain.

• Tenderness to pressure or biting is due to inflammation at

the apex and mild pulpitis.

• The degree of pain is related to magnitude of force. Higher

 the force, greater is the pain since larger areas of ischaemia
develop.

• Asking the patient to chew soft gums relieves pain since it

causes increased flow in ischaemic areas.

• Occasionally, allergic reactions to latex and nickel in

stainless steel also cause pain.

• Non-steroidal anti-inflammatory drugs (NSAIDs) should be

avoided for pain relief. Acetaminophen is a better choice
since it does not act on peripheral prostaglandins.
3. Effects on pulp

• During tooth movement, there is a modest and temporary

inflammatory response within the pulp.

• This contributes to the discomfort experienced by the patient

at the beginning of tooth movement.

• In rare cases, loss of vitality has been reported.

• Loss of vitality could be because of the discontinuity of

blood supply through the apical foramen.

• Abrupt movement of the root apex could cut the blood

supply.

• Evidences suggest that endodontically treated teeth are more

prone for root resorption.
4. Effects on root structure/root resorption
• Tissues adjacent to root undergo resorption and deposition
during tooth movement.

• In the same way, the root also gets remodelled.

• Cemental resorption and repair takes place simultaneously.

• Cemental resorption occurs in areas adjacent to hyalinized

areas.

• Hence, root resorption is more evident when heavy forces

are applied.

• Root remodelling (cemental resorption and deposition)

restores the root length during orthodontic tooth movement.

• Repair of the roots becomes impossible when islands of

cementum are created. Permanent loss of root structure
happens mostly in the root apex.

• Rarely, there is a reduction on the lateral side of the root in

the apex.

Types of resorption

1. Generalized resorption

a. Moderate

b. Severe

2. Localized resorption

Moderate generalized resorption:

• Most of the teeth exhibit some loss of root after orthodontic
treatment (Table 15.4).

• Root resorption of the maxillary incisor is greater when

compared to other teeth.

• There is generalized shortening of root seen in majority of

patients who undergo orthodontic treatment.

Severe generalized resorption:

• This is an extremely rare condition.

• Generalized resorption is seen in other situations like

hypothyroidism.

• If there are symptoms of generalized root resorption, before

treatment, orthodontic treatment is contraindicated.

Localized resorption:

• Orthodontic treatment causes severe localized resorption.

• Excessive orthodontic force and prolonged duration of

treatment increase the chance for resorption.

• Maxillary incisors are more prone for resorption.

• Root resorption is more in maxillary incisors where the

thickness of labial cortical plate is less.

• Pressing of the roots against the cortical plate is one of the

most important causes of root resorption in anteriors and
molars.
Risk factors for severe root resorption:

• Lingual plate contact

• Torque

• Extraction

• Maxillary surgery

• Mandibular surgery

Root resorption index:

• Grade 1: Root contour is irregular

• Grade 2: Root resorption <2 mm at the apex

• Grade 3: Root resorption 2 mm to one-third of length of root

• Grade 4: Root resorption >one-third of root length.

5. Effect of treatment on the height of alveolar bone

• Loss of alveolar height averages about 0.5 mm.

• Fortunately, there is no excessive loss of alveolar bone

following orthodontic treatment.

• Alveolar height can be increased by extrusion of a tooth.

Table 15.4.
Average root length decrease following orthodontic tooth movement
Influence of drugs during orthodontic tooth movement
Two types of drugs are known to depress the response of orthodontic forces:

1. Prostaglandin inhibitors

2. Bisphosphonates

Prostaglandin inhibitors
➤ As prostaglandins play an important role in the cascade of signals that lead to tooth
movement, so inhibitors of its activity affect tooth movement.

➤ A drug that affects prostaglandins activity falls in two categories—corticosteroids

and NSAIDs.

➤ The fact that analgesics often are prostaglandin inhibitors raises the possibility that
the medication used for pain after orthodontic treatment could interfere with tooth
movement.

➤ Corticosteroid inhibits the phospholipase activity.

➤ Indomethacin inhibits cyclo-oxygenase and may also inhibit the total homeostasis in
the body, provided the dose is high.

➤ Aspirin and other acetylsalicylic acids inhibit the cyclo-oxygenase irreversibly.

➤ Both children and adult on steroids and NSAIDs may encounter possibilities of
difficulties in tooth movement.

➤ To control pain during orthodontic tooth movement, acetaminophen (paracetamol) is

recommended since it acts on central prostaglandins and not on peripheral
prostaglandins.

Bisphosphonates
➤ These are drugs which are used to treat osteoporosis. They act as specific inhibitors
of osteoclast-mediated bone resorption, so that bone remodelling is slower during
 this medication.

➤ If orthodontic treatment is necessary in older women taking medication for

osteoporosis, it is worthwhile to refer to her physician for the possibility of switching
to oestrogen as replacement for drug which inhibits tooth movement.

Other drugs
Various other drugs which affect tooth movement:

➤ Tricyclic antidepressants like imipramine and amitriptyline

➤ Anti-arrhythmic agents (procaine)

➤ Antimalarial drugs like quinine, quinidine and chloroquine

➤ Anticonvulsant drug like phenytoin

➤ Tetracyclines and doxycycline

CHAPTER 16
Biomechanics of orthodontic tooth
movement

CHAPTER OUTLINE
❖ Newton’s laws of motion and its relevance to tooth movement
❖ Terminologies in biomechanics of tooth movement
❖ Biomechanics
❖ Force
❖ Centre of resistance
❖ Moment
❖ Couple
❖ Centre of rotation
❖ Moment to force ratio
❖ Types of tooth movement
❖ Definition and classification of anchorage
❖ Sources of anchorage/anchorage sites
❖ Factors affecting anchorage
❖ Anchorage loss
❖ Various types of anchorage with suitable examples
❖ Implant as anchorage units/absolute anchorage/temporary anchorage devices
❖ Accessory points
❖ Advanced learning
❖ Friction in orthodontics
❖ Planning of anchorage
Newton’s laws of motion and its relevance to
tooth movement
There are three laws of motion given by Newton: (1) law of inertia (2) law of
acceleration and (3) law of action and reaction.

1. Newton’s first law of motion or law of inertia: Every body continues in its state of rest or
uniform motion in a straight line unless it is forced to change by the forces acting on it.

2. Newton’s second law or law of acceleration: The change in motion is directly proportional
to the force acting on it and is made in the direction of the straight line in which the
force is delivered.

3. Newton’s third law of motion or law of action and reaction: To every action, there is always
an equal and opposite reaction.

The laws can be explained with a simple example of tying an archwire into the
bracket slot of a tooth which is lingually placed.

➤ Once the wire is inserted, the law of inertia and law of reaction become apparent.

➤ Initially, the wire and teeth are at rest; both the wire and tooth are not moving. Thus,
law of inertia is demonstrated.

➤ Next, the law of reaction is demonstrated. Deflected wire will apply a force to the
tooth and tooth will apply equal and opposite force. If both are equal, no movement
occurs.

➤ But since there is no equilibrium, second law is demonstrated, tooth moves in the
direction of force.
Terminologies in biomechanics of tooth
movement
1. Biomechanics

Mechanics is the field that describes the effect of forces on

bodies.

• Definition 1: Biomechanics refers to the science of

mechanics in relation to biologic systems.

• Definition 2: Biomechanics is the study and analysis of

mechanical functions in living bodies and the effect of forces
on the form and motion of living bodies.
2. Force

Force is a load or external influence applied to a body that

changes or tends to change the position of that body.

Force types are (i) compression (squeezing together), (ii)

tension (stretch a body) and (iii) shear force (lateral shifting
of the body). Force is measured in grams or ounces.
3. Centre of resistance (Cres) (Fig. 16.1)

• Centre of resistance is defined as the point in the object at

which the resistance to movement is at the maximum.

• If a force is applied to the centre of resistance, the whole

body moves equally in the direction of the force applied.

• The centre of resistance of tooth is variable. It depends on:

 1. Root morphology

2. Number of roots

3. Level of alveolar bone support

4. Root length

• Application of force to the centre of resistance of the tooth

produces true bodily movement.

• Centre of resistance for different structures is given in Table

16.1.
4. Moment

• Moment is defined as the tendency or measure of a tendency

to produce movement around a particular axis.

• Moment is force acting at a distance.

• It is calculated by the formula (Fig. 16.2):

• Moment = F × d

• Where F is the magnitude of force.

• d is the perpendicular distance between the point of force

application and centre of resistance.

• The unit for moment is grams millimetre.

• When orthodontic force is applied, a moment is created

when the line of force does not pass through the centre of
 resistance. When the moment is created, the force tends to
move the object plus it tends to rotate the object through the
centre of resistance.

• By altering the moment to force ratio, the desired tooth

movement can be achieved.
5. Couple

Couple are two forces which are equal in magnitude but

opposite in direction (Fig. 16.3).

• Application of two forces in this manner produces pure

moment, because the bodily movements get cancelled as the
forces are acting in opposite directions.

• Rotation can be achieved by applying a couple.

6. Centre of rotation (C rot) of tooth

• Centre of rotation is any point around which rotations occur

when the tooth is being moved.

• Centre of rotation can be varied by applying a force and

couple.

• Centre of rotation differs for each tooth movement (Table

16.2).
7. Moment to force ratio (Fig. 16.4)

• The relationship between the applied force system and the

type of tooth movement can be explained by moment to
force ratio (Table 16.3).
• M/F ratio determines the centre of rotation, and thereby the
type of tooth movement also.

FIG. 16.1. Centre of resistance. Application of force through centre of resistance causes the
body to move equally in the direction of force applied.

FIG. 16.2. Calculation of moment: If 50 g is applied, moment is equal to F × d, i.e. 50

multiplied by L or moment arm. Moment arm is the distance between point of force application
and centre of resistance.
 FIG. 16.3. Application of couple.

FIG. 16.4. Moment to force ratio: (A) uncontrolled tipping, (B) controlled tipping, (C) translation
and (D) root movement.

Table 16.1.
Centre of resistance for different structures

Structure Centre of resistance

Single-rooted tooth One-third to one-fourth the distance from alveolar crest to apex
Molars At furcation
Maxillary dentition Apical to and between the roots of premolars (Poulton DR, 1959)
Maxilla Posterosuperior to zygomaxillary suture or slightly inferior to orbitale
For intrusion of maxillary anteriors Distal to the lateral incisor roots
Mandibular dentition Apical and between the roots of premolars

Table 16.2.
Tooth movement: Centre of rotation

Type of tooth movement Centre of rotation

Uncontrolled tipping Between centre of resistance and apex
Controlled tipping At the root apex
Bodily movement At infinity
Root movement At incisal edge
Rotation No net force acts at Cres

Table 16.3.
Tooth movement: Moment to force ratio

Tooth movement Moment to force ratio

Uncontrolled tipping 0:1 to 5:1
Controlled tipping 7:1
Translation 10:1
Root movement 12:1
Types of tooth movement
Tooth movement can be described in many ways. The basic types of tooth movement
are (i) tipping, (ii) translation, (iii) root movement and (iv) rotation.

1. Tipping

• Tipping is the simplest tooth movement and the one easily

carried out.

• In tipping, there is greater movement of the crown than that

of the root.

• There are two types of tipping—uncontrolled tipping and

controlled tipping.

a. Uncontrolled tipping (Fig. 16.5)

• Uncontrolled tipping is produced when a single force is

applied to the crown of a tooth.

• Crown moves in one direction and the root moves in

opposite direction.

• Centre of rotation: It is in between the centre of resistance and

apex of the root.

• Force required: 35–60 g

• Moment to force ratio: 0:1–5:1

• Loading pattern: The PDL is stressed near the apex on the

same side as the applied force and at the crest of the alveolar
bone on the opposite side (Fig. 16.5).
• Uncontrolled tipping is useful when incisors have to be
proclined.

b. Controlled tipping (Fig. 16.6)

• This is a desirable tooth movement when compared to

uncontrolled tipping.

• Crown moves in one direction and there is minimal or no

movement of the root in opposite direction.

• Centre of rotation is at the root apex.

• Force required: 35–60 g.

• Moment to force ratio = 7:1.

• Loading pattern: Minimum stress of the PDL at root apex; this

prevents root movement (Fig. 16.6).

• Stress pattern is more in cervical areas.

• Controlled tipping is useful in retraction of excessively

proclined incisors when roots are normally positioned.
 FIG. 16.5. (A) Uncontrolled tipping. (B) Arrows show the loading areas in the apex on one
side and crest of alveolar bone on opposite side.

FIG. 16.6. Controlled tipping.

2. Translation

• Pure translation of a tooth occurs when two forces are

applied simultaneously to the crown of the tooth.

• In translation, crown and root move the same distance in the

same direction.

• Applied force passes through the centre of resistance.

• Pure translation is of three types: (a) bodily movement, (b)
intrusion and (c) extrusion.

a. Bodily movement (Fig. 16.7)

• This is the most desirable type of tooth movement.

• In bodily movement, crown and root move the same

distance either lingually or labially.

• Centre of rotation is at infinity.

• Force applied: 70–120 g

• Moment to force ratio: 10:1

• Loading pattern: Uniform stress pattern in the periodontal

ligament (Fig. 16.7).

b. Intrusion (Fig. 16.8)

• This is defined as the axial movement of the tooth along the

long axis towards the apex of the root.

• Intrusion is the tooth movement which requires minimum

force.

• Centre of rotation: Force passes through the centre of

resistance.

• Force required: 10–20 g.

• Loading pattern: PDL in the apex is compressed over a small

area.
• No areas of tension.

c. Extrusion

• Extrusion is defined as the axial movement of the tooth

along the long axis towards the coronal part (Fig. 16.9).

• Force required: 35–60 g.

• Loading pattern: No areas of compression in PDL, only

stretched areas.

FIG. 16.7. Bodily movement.

 FIG. 16.8. Intrusion.

FIG. 16.9. (a) Extrusion and (b) apical stretching of PDL.

3. Root movement (Fig. 16.10)

• This is the opposite of crown tipping.

• Crown of a tooth is kept stationary, while the root moves

labiolingually or mesiodistally.
• There are two types of root movement:

a. Torque

• Labiolingual root movement

b. Uprighting

• Mesiodistal root movement

• Centre of rotation: At incisal edge

• Force required: 50–100 g

• Moment to force ratio: 12:1

• Loading pattern: The stress is greatest at the apex and

decreases gradually to the cervical level (Fig. 16.10).

• Root movement is used to torque the incisor and upright

tipped teeth.
4. Rotation

• Rotation can be defined as the spinning of the tooth around

its long axis (Fig. 16.11).

• Rotation can be achieved by applying a couple.

• The forces get nullified and only moment exists which

causes rotation.

• Force required for rotation correction: 35–60 g

• There is greater tendency for the rotated teeth to relapse

 after correction.

• Rotation can be achieved by two ways:

1. By using a couple force (Fig. 16.12A)

2. By using a single force and a stop (Fig. 16.12B)

FIG. 16.10. Root movement.

FIG. 16.11. Rotation.

FIG. 16.12. Methods to achieve rotation: (A) rotation achieved by using couple force and (B)
rotation achieved by single force and application of stop.
Definition and classification of anchorage
➤ Graber’s definition: Anchorage refers to the nature and degree of resistance to
displacement offered by an anatomic unit when used for the purpose of effecting
tooth movement.

➤ Proffit WR defines anchorage as resistance to unwanted tooth movement.

Classification of anchorage
➤ Robert E Moyers has classified anchorage in the following ways.

I. According to manner of force application

a. Simple anchorage

b. Stationary anchorage

c. Reciprocal anchorage
II. According to jaws involved

a. Intramaxillary (anchorage from the same jaw)

b. Intermaxillary (anchorage from both jaws)

III. According to site of anchorage

a. Intraoral

i. Intramaxillary

• Simple

• Stationary

• Reciprocal
 ii. Intermaxillary

• Simple

• Stationary

• Reciprocal

b. Extraoral

i. Cervical

ii. Cranial

iii. Occipital

iv. Facial

c. Muscular
IV. According to number of anchorage units

a. Single or primary anchorage (anchorage involving one

tooth)

b. Compound anchorage (multiple teeth)

c. Reinforced anchorage
Sources of anchorage/anchorage sites
➤ Anchorage is the site or place from which a force is delivered to the teeth to be
moved.

➤ The sources of anchorage can be broadly classified into intraoral and extraoral.

1. Intraoral sources
a. Teeth

• Teeth are the most frequently used anatomic unit for

anchorage purpose.

• Anchorage resistance of a tooth depends on various factors

like: (i) number of roots, (ii) shape of the roots, (iii) size of
the roots and (iv) length of the roots.

• The resistance to movement is primarily dependent on the

root surface area or PDL area. This is called the ‘anchorage
value’.

• The anchorage values of the different teeth are depicted in

Fig. 16.13.

• A tooth with increased or more surface area offers better

resistance to movement (Hixon EH, Aasen TO, Clark RA,
Klosterman R et al, 1970).

• A multirooted tooth offers more resistance when compared

to single-rooted teeth.

• Teeth with longer roots better resist the forces of

displacement.
• Triangular-shaped roots resist displacement more efficiently
when compared to conical and ovoid roots.

• Incorporation of as many teeth as possible into anchor unit

(Quinn RS and Yoshikawa DK, 1985).

• Other factors affecting anchorage of a tooth:

• Force from occlusion

• Relationship with adjacent teeth

• Age of the patient

• Variable individual response

b. Palate

• The vast expanse of palate provides a suitable source of

anchorage mainly in removable appliances.

• Acrylic plate covers the whole of palate and provides the site
of force for the active components.
c. Lingual alveolar supporting bone

• Provides tissue-borne anchorage source for removable

appliances.
d. Cortical bone/cortical anchorage

• The response of cortical bone when compared to medullary

bone is different.

• Cortical bone offers more resistance to resorption.

• If the roots are torqued lingually or buccally, the resistance
to movement is increased.

• This principle was being used by Robert M Ricketts and is

called cortical anchorage.

• An example for cortical anchorage is seen in old extraction

sites. Space closure in old extraction site is difficult as the
roots encounter cortical bone along the residual ridge.
e. Implants as anchorage units

• Osseointegrated titanium implants have been described

clinically for reinforcement of anchorage (Wehrbein H,
Glatzmaier J, Mundwiller U, Diedrich P. 1999).

• Recently microimplants are being used for anchorage

purpose.

• Implants can be used as anchorage unit for dental as well as

skeletal corrections.
f. Muscular anchorage

• Muscular forces can be used for anchorage purpose, e.g.

vestibular shield, lip bumper.
g. Ankylosed tooth

• Ankylosed tooth acts as a good anchor unit. Since the

ankylosed tooth does not move, the resistance is more.
 FIG. 16.13. Anchorage values.

2. Extraoral sources
Extraoral sites are used for extraoral appliances like headgears, reverse pull headgears
and chin cap.

Occipital: In case of high-pull headgear and chin cap, support is taken from the occiput.

Parietal: From the parietal region for headgear purpose.

Forehead: Reverse pull headgear derive force from the forehead.

Chin: Reverse pull headgears and chin cap take support from chin.

Back of neck: Cervical pull headgears take anchorage from the back of the neck.
Factors affecting anchorage
Factors affecting anchorage can be considered under two headings: (i) biological factors
and (ii) mechanical factors.

Biological factors
1. Size of the anchor unit: Anchorage value depends on the size of the anchor unit.
Increasing the number of teeth in the anchor unit improves the anchorage and
minimizes unwanted tooth movement.

2. Axial inclination of teeth: Distoaxial inclination of lower posterior teeth is better in

anchorage control when compared to mesial inclination.

3. Delaying extraction of teeth.

4. Use of optimum force.

5. Differential force system.

6. Abnormal muscular force or persistent habits.

7. Anchorage savers: These are adjunctive procedures employed during tooth

movement that reduces the burden on tooth anchorage, e.g. (i) transpalatal arches,
Nance palatal arch, headgear, (ii) lip bumpers and functional appliance with fixed
appliance and (iii) delaying extractions.

8. Teeth (refer to Intraoral Sources of Anchorage).

Mechanical factors
1. Friction

• Most important mechanical factor is friction. Tidy DC (1989)

is of the opinion that frictional resistance increases the strain
on anchorage unit (Fig. 16.14).

• Frictional resistance is high with nitinol wires and ceramic

brackets.

• Frictional resistance is low with stainless steel wires and SS

 brackets.
2. Type of tooth movement planned

• Frictional resistance is more with bodily movement and

during space closure.
3. Technique employed

• Friction varies depending upon the retraction mechanics

employed in fixed appliances.

• It is more in sliding mechanics.

FIG. 16.14. Effect of friction: Friction between wire and bracket causes plastic deformation in
their junction resulting in asperities or roughened areas.
Anchorage loss
Anchorage loss is defined as the undesirable movement of the anchor tooth in excess to
that of the planned treatment.

Reasons for anchorage loss

1. Excessive force.

2. Impingement of the roots of the incisors or anterior teeth to the labial cortical plate.

3. Improper anchorage preparation.

4. Improper treatment planning.

5. Resistance between the archwire and brackets.

Methods to prevent anchorage loss

1. By using anchorage savers like transpalatal arches, lingual arches, Nance palatal
arches.

2. Use of optimum force

3. Usage of differential force

4. Delayed extraction

5. Reinforcement of anchorage

6. Utilizing muscular forces

Various types of anchorage with suitable
examples
For different types of anchorage, refer to Classification of Anchorage.

1. Simple anchorage
Simple anchorage is the dental anchorage in which the manner and application of force
tends to change the axial inclination of the tooth or teeth that form the anchorage unit
(Fig. 16.15).

➤ In simple terms, simple anchorage is the resistance of the anchorage unit to tipping.

➤ This resistance to tipping is used to move teeth.

➤ Simple anchorage has lower resistance value.

➤ Orthodontic anchorage is usually a combination of several types.

➤ One single type of anchorage is not used. It is always combination of anchorage

types that come into effect when teeth are being moved.

FIG. 16.15. Simple anchorage. Resistance to tipping movement is used.

2. Stationary anchorage
Dental anchorage in which the manner and application of force tends to displace the
 anchorage unit bodily is called stationary anchorage (Fig. 16.16).

➤ In simple words, resistance to bodily movement is called stationary anchorage.

➤ Resistance to bodily movement is greater than the resistance to tipping.

➤ A classical example for stationary anchorage is the retraction of maxillary incisors

using the molars as the anchor teeth.

➤ Advantage of pitting bodily movement of the molars against tipping of incisors is

used.

➤ For this to be achieved differential light force has to be utilized.

FIG. 16.16. Stationary anchorage. Pitting of bodily movement of molars against tipping of
incisors.

3. Reciprocal anchorage
In a reciprocal anchorage situation, the force applied for tooth movement is dissipated
to both the active and reactive components.

➤ The dissipation of equal and opposite force tends to move both the units towards
each other.

➤ In effect desired tooth movement occurs by movement of both the units.

Examples:

1. Corrections of class II malocclusion with intermaxillary

 elastic.

2. Corrections of single tooth crossbite through the bite

elastic (Fig. 16.17).

3. Closure of median diastema by moving both the central

incisors towards each other (Fig. 16.18).

FIG. 16.17. Reciprocal movement in crossbite correction.

 FIG. 16.18. Closure of median diastema by reciprocal movement of both the central incisors.

4. Intraoral anchorage
Intraoral anchorage is anchorage in which the anchorage units are all situated inside the
oral cavity. The sources of intraoral anchorage are as follows:

1. Teeth

2. Palate

3. Lingual alveolar bone of the mandible

Intraoral anchorage can be classified into:

1. Intramaxillary anchorage

2. Intermaxillary anchorage

Intramaxillary anchorage (fig. 16.19)

➤ Intramaxillary anchorage is an anchorage situation wherein all the anchorage units
are situated in the same jaw.

➤ When the appliances are placed in only one jaw either maxilla or mandible, it is
considered as intramaxillary anchorage units.

➤ Intramaxillary may be simple, stationary or reciprocal type of resistance.

 FIG. 16.19. Intramaxillary anchorage.

Intermaxillary anchorage (fig. 16.20)

Intermaxillary anchorage is an anchorage situation in which anchorage unit situated in
one jaw is used to bring about tooth movement in the opposite jaw, e.g. crossbite
correction with the bite elastics and usage of elastic traction in class II and class III
corrections.
 FIG. 16.20. Intermaxillary anchorage. Baker’s anchorage: (A) class II elastics from lower
molar to upper canine, (B) class III elastics from upper molar to lower canine.

Baker’s anchorage (fig. 16.20)

Baker’s anchorage is a form of intermaxillary anchorage to adjust the jaw relationship
and teeth by using elastic from maxilla to mandible.

For class II malocclusion correction, elastics are worn from lower molar to upper
anterior.

For class III malocclusion correction, elastics are worn from upper molar to lower
anterior.

5. Extraoral anchorage
➤ Extraoral anchorage is an anchorage situation wherein the anchorage units are
situated outside the mouth (Fig. 16.21; Table 16.4).

➤ Extraoral anchorage is usually used to correct skeletal problem.

➤ It is also used as a form of reinforced anchorage.

 FIG. 16.21. Extraoral anchorage: (1) high pull, (2) oblique pull and (3) cervical pull.

Table 16.4.
Extraoral anchorage: Sites and examples

Various sites used Example

Occipital region Chin cap and high-pull headgear
Parietal Combination headgear
Back of neck Cervical headgear
Forehead Reverse pull headgear
Chin Reverse pull headgear and chin cap

6. Reinforced anchorage
Reinforced anchorage is also called multiple anchorage.

➤ This is an anchorage situation where more than one resistance unit is employed.

➤ Resistance units become more effective when more units are added because the
reactionary force is distributed over a larger area.

➤ Distribution of force over a large area means keeping the force light.

➤ This minimizes trauma and pain during treatment.

Examples
1. Use of transpalatal arch, Nance space holding buttons and lingual arch reinforces the
anchorage unit.
2. Usage of headgears to augment the resistance unit.

3. In cases with upper anterior bite plane, there will be labial component of reactive
force which will cause flaring of the upper incisors. This can be prevented by the use of
labial bow. This is another example of reinforced anchorage.

4. In the same way, instead of a labial bow, the acrylic plate is constructed in such a way
that it covers the labioincisal aspect of maxillary incisors. This again prevents the labial
flaring of the maxillary incisors. This type of reinforced anchorage is called Sved-type bite
plates.

Other types of anchorage

Cortical bone/cortical anchorage
➤ Refer section on anchorage sources/sites

Muscular anchorage
➤ Muscular forces can be used for anchorage purpose, e.g. vestibular shield and lip
bumper.

➤ Implants as anchorage: Recently implants are being used as anchorage units.

Implant as anchorage units/absolute
anchorage/temporary anchorage devices
Traditionally, orthodontists have used teeth, intraoral appliances and extraoral
appliances to control anchorage; minimizing the movement of certain teeth, while
completing the desired movement of other teeth.
However, because of Newton’s third law, i.e. for every action, there is an equal and
opposite reaction, there are limitations in our ability to completely control all aspects of
tooth movement.
Conventional means to reinforce the anchorage have drawbacks, including heavy
reliance on patient compliance (headgear, elastics) and cumbersome, uncomfortable or
unhygienic attributes.
A temporary anchorage device is that which is temporarily fixed to bone for the
purpose of enhancing orthodontic anchorage, either by supporting the teeth of the
reactive unit or by obviating the need for the reactive unit altogether, and which is
subsequently removed after use.
They can be located transosteally, subperiosteally or endosteally; and they can be
fixed to bone either mechanically (cortically stabilized) or biochemically
(osseointegrated).
At a minimum, when initially placed, TADs must have primary stability and be able
to withstand orthodontic force levels. TADs are called absolute anchorage because the
extracted or available space is fully utilized for orthodontic correction without space
loss due to movement of anchor teeth.
For further details about implants in orthodontics, refer to Chapter 27 on Surgical
Orthodontics.
ACCESSORY POINTS
➤ The word anchorage was coined by Alexis Schlange.

➤ The anchorage value of a tooth depends more on PDL surface area.

➤ Root shapes which provide most resistance to tooth movement: Triangular.

➤ Removable appliances produce uncontrolled tipping.

➤ The force system produced by tissues in opposition to the force provided by the
appliance is called deactivation force.

➤ A single force through the centre of resistance would produce translation.

➤ If the root is longer, then C res is positioned coronally.

➤ The centre of rotation can be changed by altering the M:F ratio.

➤ One ounce = 28.6 g.

➤ One pound = 453.9 g.

➤ One inch = 2.54 cm.

➤ Load deflection rate in active part of appliance should be low.

➤ When a tooth is contacted by a spring at a single point, the tooth moves perpendicular
to the tangent at the point of contact.

➤ Transpalatal arch is an example for reinforced anchorage.

➤ In a maximum anchorage case, not more than one-fourth of the extraction space is lost
due to anchor loss.

➤ Baker’s anchorage is an example for intermaxillary anchorage.

➤ When implants are used as source of anchorage, it is also called skeletal anchorage or
absolute anchorage.

➤ Force produced per unit activation of an appliance is called load-deflection rate.

➤ The greatest force or moment that can be applied to the appliance without producing
permanent deformation is called maximal elastic moment.

➤ Certain sections along a wire are points of maximal stress; these sections are called
critical sections.

➤ Any sharp bends or sudden change in cross-section of wire are called stress raiser.

➤ Anchorage provided by periodontal ligament is called Hammock anchorage.

➤ Tooth with maximum anchorage value is maxillary first permanent molar.

➤ Tooth with minimum anchorage value is mandibular central incisor.

Advanced Learning
Friction in orthodontics
Friction is a clinical challenge, particularly with sliding mechanics, and must be dealt
efficiently to provide optimal orthodontic results.
Friction is a force that retards or resists the relative motion of two objects in contact.
The direction of friction is tangential to the common boundary of the two surfaces in
contact. As two surfaces in contact slide against each other, two components of total
force arise—the frictional force component (F) and the normal force component (N)
perpendicular to the contacting surfaces and to the frictional force component.
Frictional force is directly proportional to the normal force, such that F = û N, where
û = coefficient of friction.
Static frictional force is the smallest force needed to start the motion of solid surfaces
that were previously at rest with each other, whereas the kinetic frictional force is the
force that resists the sliding motion of one solid object over another at a constant speed.
As the tooth moves in the direction of the applied force, kinetic friction occurs
between the bracket and archwire. Binding of the bracket on the guiding archwire
(bracket–archwire interface) occurs through a series of tipping and uprighting
movements; it signifies orthodontic tooth movement, moreover, it creates friction.

Factors affecting friction

Variables affecting frictional resistance in orthodontic sliding mechanics include the

following:

1. Physical/mechanical factors, such as

(i) Archwire properties: (a) material, (b) cross-sectional

shape/size, (c) surface texture, (d) stiffness.

(ii) Bracket to archwire ligation: (a) ligature wires, (b)

elastomerics, (c) method of ligation.

(iii) Bracket properties: (a) material, (b) surface treatment, (c)

manufacturing process, (d) slot width and depth, (e) bracket
design, (f) bracket prescription (first-order/in-out; second-
order/toe-in; third-order/torque).

(iv) Orthodontic appliances: (a) interbracket distance, (b) level

of bracket slots between teeth, (c) forces applied for
retraction.
2. Biological factors, such as

(i) Saliva

(ii) Plaque
(iii) Acquired pellicle

(iv) Corrosion

(v) Food particles

Controlling friction
Friction is not likely to be eliminated from materials; thus, the best remedy is to control
friction by achieving two clinical objectives—maximizing both the efficiency and the
reproducibility of the orthodontic appliances.
Efficiency refers to the fraction of force delivered with respect to the force applied,
while reproducibility refers to the ability of the clinician to activate the orthodontic
appliance so that it behaves in a predictable manner.
Therefore, the clinician should be aware of the characteristics of the orthodontic
appliance that contribute to friction during sliding mechanics and the extent of the
amount of force expected to be lost to friction.
This will help allow efficient reproducible results to be achieved.
Planning of anchorage
Fundamentally, planning of anchorage consists of utilizing the space gained by
extraction to achieve the treatment goals.

➤ Extraction space should be used for correction of crowding, correction of

proclination, flattening of curve of Spee and derotation in the anterior region.

➤ Any space loss by movement of the anchor unit results in anchor loss. Depending
upon the utilization of extraction space, anchorage preparation is classified into three
types by Nanda (Fig. 16.22):

• Group A
 FIG. 16.22. Anchorage planning.

• Group B

• Group C.

Group A or maximum anchorage (80:20)

➤ Seventy-five to eighty per cent of the extraction space is needed for anterior
retraction.

➤ Molars or posterior teeth have to be maintained critically in their position.

➤ Anchorage savers, like transpalatal arch, Nance space holding arch, headgears, are
used to conserve anchorage.

➤ Also called critical anchorage.

Group B or moderate anchorage (50:50)

➤ In this type of anchorage, there is symmetric space closure.

➤ There is equal amount of movement of the anterior and posterior teeth to close the
extracted space.
➤ This is an easy condition to deal with.

➤ There are 50:50 space closures.

Group C or minimum anchorage (25:75)

➤ This is a noncritical type of anchorage.

➤ Seventy-five per cent of space closure is through mesial movement of posterior teeth.

➤ Anterior retraction is only 25%.

CHAPTER 17
Materials used in orthodontics

CHAPTER OUTLINE
❖ Classification of materials used in orthodontics
❖ Wrought alloys/orthodontic metallic materials
❖ Annealing/heat treatment of orthodontic alloys
❖ Archwires used in orthodontics
❖ Desirable properties of orthodontic wires/ideal requirements of orthodontic wire
❖ 18–8 stainless steel
❖ Elgiloy wire/cobalt–chromium–nickel wire
❖ Nitinol wires/superelastic wires/space age wires/shape memory alloys/NiTi alloy
❖ TMA wires/titanium–molybdenum alloy wire/β-Ti wires
❖ Composition and properties of orthodontic wires
❖ Soldering/brazing
❖ Welding in orthodontics
❖ Ceramic brackets in orthodontics
❖ Cements used in orthodontics
❖ Irreversible hydrocolloids/Alginate
❖ Orthodontic bonding adhesives
❖ Accessory points
❖ Advanced learning
❖ Sterilization and disinfection in orthodontics
❖ Braided or twisted or coaxial wires
❖ Newer orthodontic wires/non-metallic wires
❖ Comparison of different metallic orthodontic wire
alloys
❖ Recent advances in orthodontic adhesives
❖ Various light sources used for curing composite
❖ Magnets in orthodontics
Classification of materials used in orthodontics
I. Classification according to the structures of orthodontic materials

a. Metallic materials: These include wire alloys, band

materials and orthodontic brackets.

b. Ceramic materials: Used for making ceramic brackets and

as filler particles in cements.

c. Polymeric materials: A wide variety of polymeric materials

are used in orthodontics:

• Impression materials

• Adhesive resins for bonding

• Polycarbonates for brackets

• Polyurethane elastomers for tooth movement

II. Classification according to usage

a. Wire alloys:

(i) Metallic wires – gold alloys, stainless steel, Co–Cr–Ni

(elgiloy), beta titanium, nickel titanium.

(ii) Nonmetallic wires – optiflex, composite-coated wires.

b. Orthodontic brackets – stainless steel, titanium, plastic or

polycarbonates and ceramic.

c. Elastomeric ligatures and chains–conventional ligatures,

 fluoride-releasing elastomerics.

d. Orthodontic adhesive composite resins–chemically-cured

two paste or single paste, light-cured, dual-cured
(chemically-activated and light-cured), thermocured.

e. Cements used in orthodontics are zinc phosphate, zinc

polycarboxylate, glass ionomer.

f. Miscellaneous materials like alginate impression

materials, brass lock pins.
Wrought alloys/orthodontic metallic materials
Wrought metal can be defined as the cold-worked metal that has been plastically deformed to
alter the shape of the structure and certain mechanical properties.

➤ Alloys for archwires, bands and brackets are in the wrought alloy form.

➤ First step: An ingot is formed by melting the component metals together and then the
alloy is solidified.

➤ Once solidified, the alloys have a polycrystalline structure. This cast alloy is the
starting point which is called an ingot.

➤ The alloy is then subjected to series of thermomechanical process and drawn into
different shapes to produce the wrought alloy. In other words, the cast alloy is cold
worked to produce the wrought alloy.

Cast alloy → Cold worked → Wrought alloy

➤ Examples for wrought alloys include stainless steel, elgiloy, β-Ti and nitinol.

➤ A wrought alloy exhibits properties and microstructure that are not associated with
the same alloy when cast. Substantial permanent deformation by cold working causes
lot of dislocations within the metals. The increased stress required to produce further
dislocation to achieve permanent deformation provides, what is called strain
hardening. Strain hardening is otherwise called work hardening.

➤ Cold working alters the shapes of grains and usually in an orthodontic wire the
grains get elongated parallel to the wire axis.

➤ The effects associated with cold-working apart from strain-hardening include

distorted grains and decreased ductility.
Annealing/heat treatment of orthodontic alloys
Controlled heating and cooling process designed to produce desired properties in a
metal. The annealing process usually is intended to soften metals, to increase their
plastic deformation potential, to stabilize shape and to increase machinability.

➤ The drawbacks of cold-working a cast metal into a wrought metal include strain
hardening, lowered ductility and distorted grains.

➤ These effects can be eliminated simply by heating the metal to an appropriate

elevated temperature. This procedure is termed as annealing.

➤ Annealing takes place in three successive stages namely–recovery, recrystallization

and grain growth (Fig. 17.1).

➤ Rule of thumb during annealing is to use a temperature that is approximately half

the melting point of the metal or fusion temperature of the alloy.

FIG. 17.1. Annealing–stages.

Stage-I: Recovery
➤ In this stage, no visible changes are seen in the structure under microscopic view.

➤ Cold-work properties begin to disappear. Tensile strength is decreased slightly, and

there is negligible change in ductility.

➤ The residual stresses are eliminated in this stage. Elimination of residual stresses
reduces the tendency of warping.

➤ Subjecting the orthodontic appliances to heat to relieve the stress, stabilizes the
configuration of the appliance and allows for perfect determination of the force, the
 appliance can deliver. This kind of heat treatment where only the recovery stage is
reached is called ‘stress relief annealing’. For stainless steel, it is usually heated to a
temperature of 370–380°C for 11 min.

Stage-II: Recrystallization
➤ Recrystallization occurs after the recovery stage. During this stage, changes are
observed in the microstructure.

➤ Distorted old grains start disappearing and are replaced by fresh strain-free grains.
These new grains nucleate in the worst cold-worked areas in the metal, and their
grain boundary migration consumes the original cold-worked structure.

➤ Ductility and softness increase to the original state. That is why recrystallization has
to be avoided during stress relief heat treatment of orthodontic appliances. Resilience
also is decreased substantially.

Stage-III: Grain growth

➤ After recrystallization, the alloy/metal structure has got a certain grain size
depending upon the number of nuclei. More severe the cold-working, greater the
number of nuclei.

➤ The grain size can be fine or coarse at the end of recrystallization.

➤ If these grains are further annealed, the grain size increases. Large grains start
consuming small grains. Grain growth ceases after a certain point.

Clinical applications
➤ The properties of the wires can be altered by varying the amount of cold working
and annealing.

➤ Steel gets hardened by cold-working and is softened with annealing.

➤ Fully annealed wires are soft and highly formable. An example for such wire is the
soft ligature wires used for tying archwires into brackets.

➤ Partially annealed wires have got more strength but reduced formability. ‘Super
grade’ stainless steel wires are brittle and will break when bent acutely. Regular
grade can be bent without breaking.
Archwires used in orthodontics
Wires used in orthodontics can be classified as follows:

1. Based on structure

• Metallic

• Stainless steel, elgiloy, β-Ti, nickel titanium

• Nonmetallic

• Composites, optiflex
2. Based on filament

• Monofilament

• Polyfilament
3. Based on cross-section

• Round

• Rectangle

• Square
4. Based on diameter of the wire (inches)

• 0.009, 0.010

• 0.012

• 0.014, 0.016, 0.018

• 0.020
Desirable properties of orthodontic wires/ideal
requirements of orthodontic wire
➤ Orthodontic wires when formed into different configurations generate biomechanical
forces which are transmitted through the removable or fixed appliances to produce
tooth movement.

➤ Following are the ideal requirements of orthodontic wire:

1. Amount of force delivery: Wire should deliver low

constant force.

2. Strength: The reactionary part of the wire should have

high strength.

3. Wire should have low stiffness or good spring back.

4. Wire should exhibit high range.

5. Formability or ease of manipulation should be present.

6. Ease of joining – solderable and weldable.

7. Resistant to tarnish and corrosion in oral environment.

8. Should be stable in oral environment.

9. Biocompatible

10. Economical or low cost.

11. Should offer less frictional resistance between wire and

bracket base.
18–8 stainless steel
➤ Steel is an alloy of iron containing less than 1.2% carbon. When the chromium
content of the steel exceeds 11%, the alloy is referred to as stainless steel. The
chromium content is usually in the range of 12–30%.

➤ Stainless steel ever since it was introduced to orthodontics in 1950s has remained in
clinical use mainly because of its excellent formability, low cost, resistance to
corrosion and ease of joining.

➤ There are three major types of stainless steels classified based on their crystal
structure arrangement namely ferritic, martensitic and austenitic (Fig. 17.2).

➤ Ferritic stainless steel has little application in dentistry.

➤ Martensite steel has high strength and hardness. Hence, they are used for making
surgical and cutting instruments. Corrosion resistance of the martensite type is very
less.

➤ Austenitic SS is the most corrosion-resistant and hence widely used in dentistry.

➤ Type 302 austenite is the basic alloy which contains 17–20% chromium, 8–12% nickel
and maximum of 0.15% carbon.

➤ Type 304 also has similar composition, but the carbon content is 0.08%.

➤ Both 302 and 304 austenitic SS are often called 18–8 stainless steel.

➤ Type 316 L (low carbon) contains 16–18% chromium, 10–14% nickel, 0.03% carbon
and is utilized for making implants.
 FIG. 17.2. Stainless steel–composition and types.

Properties of stainless steel

➤ Passivating effect: Resistance to tarnish and corrosion of the stainless steel is because
of the passivating effect of the chromium.

➤ The chromium in the stainless steel forms a thin adherent, transparent but tough and
impervious oxide layer on the surface of the alloy when it is subjected to an oxidizing
atmosphere as mild as clean air.

➤ This protective layer prevents further tarnish and corrosion by blocking the diffusion
of oxygen to the underlying bulk alloy. This is called ‘passivating effect’.

➤ For this effect to take place, a minimum of 12% of chromium is required.

➤ If the oxide layer is ruptured by mechanical or chemical means, a loss of protection

against corrosion results.

Sensitization
➤ Heating of stainless steel between 400 and 900°C leads to loss of resistance to tarnish
and corrosion.

➤ Heating of SS causes reaction of chromium and carbon to form chromium carbide

(Cr3C) at the grain boundaries.

➤ When chromium combines with carbon in this way, the passivating effect of SS is lost
and, therefore, the corrosion resistance of the steel is also decreased. An intergranular
corrosion takes place and weakening of the metal occurs.

➤ There is loss of chromium from iron solid solution matrix of stainless steel. Depletion
of chromium content near grain boundaries less than 12% causes the SS to become
susceptible to corrosion. This effect of losing resistance to corrosion by forming
chromium carbide in grain boundaries is called ‘sensitization’.

Methods to reduce ‘sensitization’

➤ Reduce the carbon content of the steel to an extent that chromium carbide
precipitation cannot occur. This method is not feasible.

➤ Severe cold working of the stainless steel causes carbides to be precipitated along the
slip planes. As a consequence of this, distribution of the areas deficient in chromium
is less localized or carbides are evenly distributed. Resistance to corrosion is greater
when carbide precipitates in this way compared to when only the grain boundaries
 are involved. This procedure is employed in orthodontic stainless steel wire.

➤ Stabilization: Most successful method employed to eliminate chromium carbide

precipitation is introduction of some other element which will react with carbon.
Titanium is most often used and added 6 times that of carbon. Formation of
chromium carbide can be prevented in this manner. Stainless steel that has been
modified in this manner is said to be ‘stabilized’.
Elgiloy wire/cobalt–chromium–nickel wire
Cobalt–chromium–nickel orthodontic wire alloy (elgiloy) was developed during the
1950s by Elgiloy Corporation. This alloy was originally used for watch springs.
The composition is as follows:
Metal Percentage
Cobalt 40
Chromium 20
Nickel 15
Iron 15.8
Molybdenum 7
Manganese 2
Carbon  0.15
Beryllium  0.04

➤ Elgiloy has excellent resistance to tarnish and corrosion similar to stainless steel
because of passivating effect.

➤ It can be subjected to welding and soldering procedure.

➤ Elgiloy is available in four different tempers (levels of resistance) and is colour-

coded. They are blue (soft), yellow (ductile), green (semiresilient) and red (resilient).

➤ Composition is the same but the difference in mechanical properties is because of

variation in processing.

➤ Elgiloy has the advantage that it can be supplied in a softer (blue elgiloy) and more
formable state, and then can be hardened by heat treatment after being shaped. After
heating, the soft blue elgiloy becomes equivalent to stainless steel.

➤ Large-diameter elgiloy wires have also been fabricated into quad helix appliance and
used as expansion appliance for treatment of maxillary constriction or crossbite in the
primary and mixed dentition.
Nitinol wires/superelastic wires/space age
wires/shape memory alloys/NiTi alloy
➤ Nitinol was developed in the 1960s by William F Buehler. It was originally developed
for space programme.

➤ Nitinol is an acronym derived from Nickel Titanium Naval Ordinance Laboratory.

➤ It was Andreasen GF who introduced nitinol into orthodontics.

➤ Composition: Nitinol contains 55% nickel and 45% titanium. It also contains traces of
other elements like cobalt, copper and chromium.

➤ Nickel is available in two different crystal structures: martensite NiTi (M-NiTi) which
has a monoclinic, triclinic or hexagonal structure and austenitic NiTi (A-NiTi) has a
complex body-centred cubic (BCC) structure. A-NiTi is commercially available as
Chinese NiTi or Japanese NiTi.

Properties of nitinol
Nitinol has two distinct properties that are unique–shape memory and superelasticity. Both
shape memory and superelasticity are related to phase transitions between martensitic
and austenitic forms, and it occurs at a relatively lower transition temperature.

Shape memory (martensite → austenite)

➤ Shape memory refers to the ability of the material to remember its ‘original shape’
after being plastically deformed in the martensite form.

➤ Shape memory is because of temperature-induced crystallographic transformation. It

is associated with a reversible martensitic–austenitic transformation. It can also be
called ‘thermoelasticity’.

➤ In a typical application, when the alloy is at higher temperature, it is moulded into a

particular shape, say arch form. Subsequently, when the alloy is cooled below the
transition temperature, it is deformed from the original shape, e.g. archwires are
cooled in ice cubes and tied forcibly to engage brackets in a crowded arch. When it is
heated again, the original shape is restored. This causes correction of crowding.

➤ This is the principle of heat-activated nitinol (HANT) wires (e.g. copper NiTi). It is
available in three different variants.

➤ The 27°C variant will be useful for mouth breathers.

➤ The 35°C variant is activated at normal body temperature.

➤ The 40°C variant will provide activation only after consuming hot food and
beverages.

Superelasticity (austenite → martensite)

➤ The austenitic active nickel titanium alloys undergo a stress-induced martensitic
transformation (SIM) when activated. The elasticity of the wire increases during
activation. This is called superelasticity, which is associated with very large reversible
strain and nonelastic force deflection curves, e.g. Chinese NiTi and Japanese NiTi.

➤ When the archwire is activated over a considerable range of deflection, the force
produced remains essentially constant. This means that the archwire would exert the
same amount of force whether deflected over a small or large distance (Fig. 17.3). This
is an extremely desirable property because very low and constant forces for tooth
movement are provided by the archwire during tooth movement.

➤ The other desirable property of nitinol is its excellent spring back resiliency and range.

FIG. 17.3. Superelasticity.

Drawbacks of nitinol
1. It is not formable, i.e. it cannot be moulded into different shapes clinically.

2. Do not exhibit ease of joining – cannot be soldered or welded.

3. Frictional resistance with bracket is very high.

Clinical uses of nitinol

1. Used as initial alignment and levelling archwire

2. Used as retraction coil springs

3. Used for distalization of molars

4. NiTi palatal expanders are available

TMA wires/titanium–molybdenum alloy wire/β-Ti
wires
➤ TMA wires were introduced by Burstone CJ and Goldberg AJ.

➤ TMA is an acronym for titanium–molybdenum alloy.

➤ TMA offers a highly desirable combination of strength and springiness as well as

good formability. This makes it as an excellent choice for auxiliary springs and for
intermediate and finishing archwires.

Composition

Properties
➤ TMA delivers low biomechanical force when compared to stainless steel and elgiloy.

➤ The excellent formability of β-titanium is due to their BCC structure. The many slip
systems available for dislocation movement in BCC structure account for high
ductility and formability.

➤ Another clinical advantage of β-Ti is that it is the only orthodontic wire alloy
possessing true weldability when compared to SS and elgiloy, while SS and elgiloy
wires require reinforcement with solder.

➤ It is biocompatible.

➤ Because of the passivating effect of TiO2, resistance to tarnish and corrosion is

excellent.

➤ Stability in oral environment is also excellent.

Drawbacks
➤ Expensive
➤ Frictional resistance is high
Composition and properties of orthodontic wires
Composition and properties of various orthodontic wires are given in Table 17.1.

Table 17.1.
Orthodontic wires–composition and properties

a
Pre-heated
b
After heat treatment
Soldering/brazing
Definition
Soldering is the joining of metals by the use of a filler metal which has a substantially
lower fusion temperature than that of the metal parts being joined. Brazing is the term
used for low-temperature soldering technique.

Materials or required ingredients

Materials or required ingredients are as follows:

1. Solder

• Silver solders are alloys of silver, copper and zinc to which

tin and indium are added to lower the fusion temperature
and improve soldering.

• The soldering temperatures for orthodontic silver solder are

approximately between 620°C and 665°C.

Properties of solder:

1. Most essential requirement of a solder alloy is that the

liquidus–solidus range should be small. Liquidus is the
temperature at which first solid is formed on cooling.
Solidus is the temperature at which last liquid solidifies.

2. In simple words, it should harden instantly. Otherwise,

the operator may inadvertently move the work before the
soldering material has completely solidified and the
soldered joint will be weak.

3. It should have the ability to wet the substrate metal.

4. It should have sufficient fluidity at the low temperatures.

 5. Colour of the solder should be acceptable.

6. It should have adequate strength and hardness.

7. Resistance to tarnish and corrosion.

2. Flux

Definition: Compound applied to metal surfaces that

dissolves or prevents the formation of oxide and other
undesirable substances that may reduce the quality or
strength of a soldered or brazed area.

• ‘Flux’ is a Latin word which means ‘flow’.

• ‘Soldering’ filler metals are designed to melt, wet the surface

of the parts to be joined and flow across the metal surface.
Solders cannot wet the metal surfaces to be joined without
the use of flux.

• The purpose of flux is to eliminate any oxide coating on the

substrate metal surface when the filler metal is molten and
ready to flow into place.

Types of fluxes:

• Type 1: Surface protection – coats the metal surface and

prevents entry of oxygen so that oxides cannot form.

• Type 2: Reducing agent – reduces any oxide present and

clean metal surface is exposed.

• Type 3: Solvent – dissolves oxides present on the surface and

carries them away. Type 3 fluxes are used for orthodontic
 purpose.

Composition:

• Flux is made of borax, boric acid and potassium fluoride.

• Fluoride is added to dissolve the passivating surface film

formed by chromium. Solder will wet the surface only in the
absence of this film.

• Boric acid lowers the fusing temperature.

3. Antiflux

Definition: A substance that prevents or limits the flow of

molten solder on areas coated by the substance, e.g.
graphite.

Technical procedure
Soldering is done by the following steps:

1. Cleaning and preparing the surface to be joined.

2. Assembling of the parts to be joined. The optimum gap between parts of substrate is
not defined. If the gap is more, joint strength will be that of the strength of the solder
material. If the gap is too narrow, strength is limited by flux inclusions and porosity.

3. Application of flux to the parts to be joined.

4. Controlling the flame temperature: The ‘flame’ can be divided into four zones (Fig.
17.4).

The portion of the flame used to heat the soldering assembly is

at the tip of the reducing zone, since this produces the most
efficient burning process and most heat. Once applied the
flame should not be removed until the soldering process has
been completed because the flame provides protection from
 oxidation.

Temperature: The optimum temperature required should be the

lowest temperature sufficient to produce a sound solder
joint.
5. Controlling the time to ensure adequate flow of solder and complete fill of soldering
joint. Flame should be maintained in place until the filler metal has flowed completely
into the connection and a moment longer to allow the flux or oxide to separate from the
fluid filler metal.

FIG. 17.4. Zones of flame.

Welding in orthodontics
Definition
Welding is the process of fusing two or more metal parts through the application of
heat, pressure or both without using a filler metal to produce a localized union between
two parts.

➤ Welds are made by passing an electric current through the pieces to be joined which
are pressed together tightly.

➤ An orthodontic spot welder is used to spot weld bands, attachments to bands, and
fine springs to heavy wire in removable appliances, e.g. apron springs.

Parts of a welder (fig. 17.5)

1. Electric transformer: This reduces the voltage of the main supply to a low value which
is safe to handle.

2. Copper electrodes: These convey the current to the work pieces.

3. Pressure mechanism: To keep the work pieces pressed into contact.

4. Timer switch: To control the duration of current flow. The working voltage is variable
by means of tappings on the primary circuit of the transformer.

The heat generated is calculated by using the formula H = I2 RT

H = heat in Joules

I = current in Amperes

R = resistance in Ohms

T = duration of current in seconds.

 FIG. 17.5. Circuit diagram of a welder.

Technique
➤ When a weld is made with the band placed between the two copper electrodes, the
point of highest resistance is at the place where the work pieces are tightly pressed
into contact (electrode) and in the work pieces themselves, which have a high
resistance.

➤ Since the copper electrodes have low resistance, little heat is generated in them and
temperature rise is very small.

➤ Main heating takes place between the work pieces which soften and are welded
together by the pressure of the electrodes.
Ceramic brackets in orthodontics
Definition
Ceramic is an inorganic compound with nonmetallic properties typically composed of
metallic or semimetallic and nonmetallic elements, e.g. Al2O3 CaO and Si3N4.

➤ Ceramic materials are used in orthodontics for making brackets and as filler particles
in cements.

➤ In addition, ceramic/polymeric composite material wires are being tried in clinical

practice.

Types of ceramic
➤ Polycrystalline ceramic/zirconia

➤ Monocrystalline ceramic/sapphire

1. Polycrystalline

• Aluminium oxide particles are blended with binder.

• Moulded into different shape of brackets.

• Moulded mixture is heated (fired) to temperature more than

1800°C.

• Product machined with diamond cutting tools for slot

dimension.

• Heat treatment done to remove surface imperfections.

2. Monocrystalline

• Molten mass of Al2O3 at temperature above 2100°C is cooled

slowly.
• Resulting bulk single crystal is milled into brackets using
diamond cutting.

• Heat treated to remove surface imperfection and stresses

created.

Advantages of ceramic
➤ Hardness is high

➤ High resistance to temperature

➤ Resistance to chemical disintegration

➤ Aesthetics

➤ Resists staining

Disadvantages of ceramic
➤ Most glaring fault of ceramic is its brittleness. In ceramic materials, the atoms are not
free to move under stress as they are in metals. Hence dislocation of planes is not
possible in ceramics and this is the reason for brittleness. Fracture of ceramic brackets
is a problem in two ways: (i) loss of part of the brackets during eating and (ii)
cracking of the bracket when torque forces are applied.

➤ Wear on teeth contacting a bracket.

➤ Enamel damage during bracket removal.

➤ High friction within bracket slots.

Cements used in orthodontics
Orthodontic application of cements is limited to luting of bands and appliances. For
acceptable performance, luting material should possess the following properties:

➤ Adequate working and setting time

➤ High tensile, compressive and shear strengths

➤ Resistance to dissolution in oral environment

➤ Acceptable bond strength

➤ Low adhesive remnant index (ARI) score following debanding

➤ Anticariogenic potential

The cements that are widely used for cementation of orthodontic bands:

a. Zinc phosphate cement

b. Zinc polycarboxylate cement

c. Glass ionomer.
Table 17.2 depicts composition, reaction and properties of the three cements.

Table 17.2.
Composition, reaction and properties of the three cements
Note: Frozen slab technique: Working time can be increased by keeping the mixing slab and powder in refrigerator.
Liquid should not be kept in refrigerator.
Irreversible hydrocolloids/alginate
➤ Alginate hydrocolloid is an aqueous impression material used for recording
minimum detail; for example, as required to produce study models.

➤ Alginate was developed as a substitute for the agar impression material when its
supply became scarce during World War II.

➤ It is called linear polymer of β-d-mannuronic acid or alginic acid.

➤ Alginate is the most extensively used impression material today.

Composition (table 17.3)

Table 17.3.
Components of alginate

Components Function Weight percentage

1. Diatomaceous earth Filler particles, control consistency before setting and flexibility after setting 60
2. Potassium alginate Forms soluble alginate 15
3. Calcium sulphate Reactor 16
4. Zinc oxide Filler particles 4
5. Potassium titanium fluoride Accelerator 3
6. Sodium phosphate Retarder 2
7. Ammonium salts and chlorhexidine Provides disinfection Traces
8. Glycol Render the powder dust-free Traces

Setting reaction/gelation process

Mixing of the alginate powder with water starts the gelation process. It is simply the
reaction of soluble alginate with calcium sulphate to form an insoluble calcium alginate
gel.

1.

2.
Manipulation
Measured powder is shifted to premeasured water that is already poured into a clean
bowl. Powder is incorporated into the water. A vigorous figure of eight motion is best
for mixing.

Mixing time: 45–60 s

Setting time: 1.5–3 min (fast set alginate), 3–4.5 min (normal set alginate).

Advantages
➤ Easy to manipulate

➤ Comfortable for the patient

➤ Relatively inexpensive

➤ Hydrophilic

➤ Long shelf-life

➤ Moist field is acceptable

Disadvantages
➤ Impressions are not accurate

➤ Tears easily

➤ Models should be poured immediately

➤ Can retard setting of gypsum

Orthodontic bonding adhesives
➤ Orthodontic bonding adhesives are used for attaching brackets to the tooth surface.

➤ Biomechanical principles require a relatively inelastic interface between the bracket

base and tooth surface that would transfer the load applied to the bracket.

➤ Load is applied to the bracket by engaging the activated archwires to the bracket.

➤ Before the advent of direct bonding, the brackets were welded on to bands and the
prepared bands cemented to the tooth.

➤ The introduction of acid etching technique and composites has revolutionized direct
bonding of brackets.

Classification
Based on the polymerization initiation mechanism, orthodontic adhesives are classified
into:

1. Chemically-activated – (a) two-paste system, (b) single paste system

2. Light-cured

3. Dual-cured

4. Thermocured

Properties and manipulation

The properties and manipulation of various orthodontic bonding adhesives are
depicted in Table 17.4.

Table 17.4.
Bonding adhesives
ACCESSORY POINTS
➤ The first alloy to be used for orthodontic treatment is gold alloy (type 4).

➤ The only appliance that is still being formed with gold alloy is Crozat appliance.

➤ Corrosion resistance of stainless steel is due to passivating effect.

➤ Shape memory in nitinol is due to phase transformation from martensite to austenite.

➤ Superelasticity in Chinese NiTi is due to phase transformation from austenite to

martensite.

➤ Nitinol wire cannot be soldered and welded.

➤ Type 3 solvent type solder is used for orthodontic purpose.

➤ Portion of flame zone used for melting solder is tip of reducing flame.

➤ Frozen slab technique increases the setting time of cements.

➤ Most important fault of ceramic is its brittleness.

➤ Linear polymer of β-d-mannuronic acid is commonly called alginate.

➤ Wire which exhibits shape memory is nitinol.

➤ Joining of two parts of a metal without using a third metal is called welding.

➤ The temperature point at which first solid forms on cooling a molten metal is called
liquidus.

➤ The temperature point at which last liquid solidifies on cooling a molten metal is
called solidus.
➤ Brazing materials are not used for soldering in orthodontics because they have a very
high melting range between liquidus and solidus temperature.

➤ Stabilizing agent in stainless steel is titanium.

➤ Steel is an alloy of iron in which the carbon content is less than 1.2%.

➤ Currently the etching time for etching gels is approximately 15 s.

➤ The depth of enamel penetration or etch pit is approximately 10–20 microns.

➤ Soft solders have a melting range of approximately 260°C.

➤ Soldering techniques used are free-hand soldering and investment soldering.

➤ Martensite SS on heating changes to ferrite and carbide, this decreases hardness and
increases toughness. This is called tempering.

➤ Titanium is added six times that of carbon to reduce sensitization.

Advanced Learning
Sterilization and disinfection in orthodontics
Definitions
Sterilization is defined as the process by which an article, surface or medium is freed of
all microorganisms, either in the vegetative or spore state.
Disinfection denotes the destruction of all pathogenic microorganisms or organisms
capable of giving rise to infection.
The term antisepsis means prevention of infection, usually by inhibiting the growth of
bacteria.
Modes of transmission of infection
➤ From patient to practitioner

➤ From practitioner to patient

➤ From one patient to another (cross-infection)

Route of transmission
1. Inoculation: Accidental self-injury with a contaminated needle, sharp instruments.
The microorganisms transmitted includes HBV, HCV, HDV, HSV I, HSV II, HIV,
Neisseria gonorrhoeae, Treponema pallidum and Clostridium tetani.

2. Inhalation: Inhalation of microorganisms aerosolized from a patient’s blood or saliva

 occurs when using high speed or ultrasonic equipment. Examples are varicella zoster
virus, cytomegalovirus, mumps virus, rubella virus, Mycobacterium tuberculosis and
Candida albicans.

Protection of operators and patients

Barrier techniques

Gloves

Latex gloves must be worn for all patient procedures, and

changed between patients. If there is allergy to latex or
cornstarch, nylon glove linens are used.

Gloves must also be removed and replaced before handling

materials such as charts, study casts and radiographs.
Protective clothing

Long-sleeved, jewel-neck clinic jackets should be worn in the

laboratory and operatory.

These jackets should be replaced daily or when visibly soiled,

and worn only in the office. They should not be worn
outside work area.
Masks and protective eyewear

Masks and protective eyewear are required during bonding

and debonding procedures to protect against aerosols of
blood and saliva.

Face shields or side shields should be added to personal

eyeglasses. Masks and face shields are required whenever a
handpiece is used.

Patients should be provided eyewear during any procedure

 with a risk of eye injury from debris or chemical agents.
Limiting contamination

To avoid spatter, use high volume evacuations, proper patient

positioning and rubber dams.

Avoid contact with charts, telephones cabinets during

treatment.
Procedures before sterilization
1. Presoaking of instruments using phenol or glutaraldehyde is recommended. This
procedure keeps instruments wet, prevents drying of saliva and blood on the
instruments and facilitating easy cleaning.

2. Presterilization cleaning manually or by ultrasonic instruments.

Advantages of ultrasonic cleanser over manual cleaning

➤ Increased efficacy

➤ Reduced danger of aerosolization

➤ Reduced incidence of instrument injuries

➤ Increased tarnish removal and cleanliness

➤ Reduction in manual labour

Classification of instruments to be sterilized: The classifications of instruments

based on the need for sterilization with examples are given in Table 17.5.

Table 17.5.
Classification of instrument based on the need for sterilization

Classification Definition Examples

Critical Surgical and other instruments which penetrate soft tissue/bone should be Forceps, scalpels, bone chisels, scaling instruments, surgical
sterilized after each use burs
Semi-critical Instruments that do not penetrate soft tissue/bone but contact oral tissues Mirrors, plastic instruments, burs
Non-critical Items which do not come into contact with body fluids Light cure tips, glass slab, cement spatula, orthodontic pliers,
dappen dish

Sterilization of orthodontic materials: Sterilization procedures for various

orthodontic materials are enumerated in Table 17.6.
Table 17.6.
Various orthodontic materials and their methods of sterilization

Monitoring sterilization
There are three forms of monitoring namely physical monitoring, chemical monitoring
and biological monitoring.

1. Physical monitoring refers to periodical observation of displays or gauges on the

sterilizer during a cycle to ensure the sterilization process.

2. Chemical monitoring is of two types: Process indicators which consist of colour

changing material (liquid/paper) which changes colour upon exposure to appropriate
sterilization cycle and TST strips (TIME, STEAM, TEMPERATURE) which change
colour when all parameters have been adequately achieved in the sterilization cycle.

3. Biological monitoring involves using indicators that are heat-resistant bacterial spores
(Bacillus stearothermophilus, Bacillus subtilis). If the spores are killed, then less resistant
microbes are killed more readily and sterility is guaranteed.

Conclusion
Sterilization techniques are of utmost importance in preventing the spread of infectious
disease. This is of special significance in dentistry because more microorganisms are
found in the oral cavity than in any other part of the body. With the increasing number
of adult patients and diverse lifestyles, the orthodontist is more at risk than ever to
exposure to serious pathogens and must take precautions to guard against their
transfer.
Braided or twisted or coaxial wires
➤ Extremely small diameter stainless steel wires can be twisted or braided together to
form wires in clinical orthodontics.

➤ The separate strands may be as small as 0.178 mm (0.007 inch)

➤ The final intertwined wires may be either round or rectangular in shape.

➤ These braided wires are able to sustain large elastic deflections in bending.

➤ These wires also apply low forces for a given deflection when compared with the
similar sized solid stainless steel wire.

➤ Initial orthodontic levelling and alignment archwires require great working range to
accommodate the malalignment of bracket slots in the untreated malocclusion.
Coaxial/braided wires offer a good choice wire for the initial alignment and levelling.

Newer orthodontic wires/non-metallic wires

The following are the newer nonmetallic wires used in orthodontics:

1. Optiflex

• A transparent nonmetallic orthodontic archwire with a

silicon core, a silicon resin middle layer and a stain-resistant
outer layer.

• The brittle core layer prevents placement of sharp bends, but

the composite wire is highly resilient

• Optiflex was introduced by Talass MF.

2. Kusy RP and colleagues developed an archwire which contains ‘S2 glass fibres’
embedded in a polymeric matrix formed from Bisphenol A-Glycidyl Methacrylate
(Bis-GMA) and Tri-Ethylene Glycol Di-Methacrylate (TEGDMA). Benzoin Ethyl Ether
is present as ultraviolet photo initiator.
3. Kusy RP and colleagues developed a composite ligature wire consisting of ultra-high
molecular weight polyethylene fibres in poly (n-butyl methacrylic matrix)

4. Researchers at the University of Hokkaido have developed an archwire with

polymethyl methacrylate matrix reinforced by CaO-P2O5–SiO2–Al2O3 fibres which are
said to be biocompatible.

5. Watanabe M, Nakata S, Morishita T introduced a polyethylene tetraphthalate wire for

maxillary retainers.

6. Apart from all these wires, composite coated metallic wires for aesthetics are also
available.

Comparison of different metallic orthodontic wire alloys

The clinical efficacy and performance of the different metallic wire alloys are given in
Table 17.7.

Table 17.7.
Orthodontic wire alloys–comparison

Recent advances in orthodontic adhesives

The newer adhesives used for bonding are as follows:

1. Ormocers (organically modified ceramics)

They contain organic–inorganic copolymers in addition to the

inorganic silanated filler particles. Ormocers are synthesized
by sol–gel process from multifunctional urethane and
thioether acrylate alkoxysilanes. They are three-
dimensionally cross-linked copolymers.
Advantages: They are more biocompatible as they cure without
leaving residual monomer.

Coefficient of thermal expansion is close to enamel.

Disadvantage: They are highly viscous leading to poor

penetration of adhesives into bracket mesh.
2. Cyanoacrylates

It has the ability to polymerize as a thin film at room

temperature without a catalyst in moist environment.

Disadvantages:

• Polymerization process results in a rather short working

time of 5 s and might be considered disadvantageous in
direct bonding but is well suited for indirect bonding
purposes.

• Bond strength is significantly lower.

3. Chromatic adhesives

Photochromatic: Bonding adhesive, which is pink during

placement, turns clear on exposure to curing light.

Thermochromatic: This adhesive is dark blue in colour when

dispensed and turns into tooth colour above 32°C. The
colour reverts to blue colour below 32°C to facilitate
complete removal at debonding.
4. Adhesive-precoated brackets (APC)

To save chairside time, there are brackets with precoated

 adhesive. It also standardizes the amount of adhesive used
in each bracket and easier to clean up because of minimal
amount of flash.
Various light sources used for curing composite
The different light sources used for curing composite are given in Table 17.8.

Table 17.8.
Comparison of different light sources used for curing composites

Magnets in orthodontics
Magnets have been used for many years in dentistry, particularly for retention of
dentures and over dentures.
The magnets used initially were made of aluminium–nickel–cobalt (AlNiCo).
Because of their toxic nature, their usage was restricted.
The development of rare earth magnets has led to the application of magnetic forces
in orthodontics due to the biomechanical properties and possible biological effects of
the static magnetic fields on orthodontic tooth movement.
In orthodontics, they have been used both in research and clinical practice.
The rare earth magnets most often used in orthodontics today are samarium–cobalt
and neodymium–iron–boron types because they are small enough to be placed
intraorally and produce forces that can move teeth.
Advantages of magnets (darendeliler, 1993)
➤ They are able to produce measured force continuously over a prolonged period.

➤ They can be made to attract or repel, so push or pull type of force can be delivered.
➤ They can exert force through the bone and mucosa and there need not be direct
contact between them.

Clinical application of magnets in orthodontics

➤ Magnetic functional appliances and growth guidance

➤ Tooth intrusion

➤ Canine retraction

➤ Arch expansion

➤ Molar distalization

➤ Space control

➤ Deimpaction

➤ Correction of class II bimaxillary protrusion

➤ Orthodontic extrusion of fractured crown–root

➤ Retainer

Few clinical examples of use of magnet are given in Fig. 17.6.

FIG. 17.6. (A) Diagrammatic representation of a magnetic appliance, (B) functional magnetic
activator device and (C) force system for distal movement of canine.
SECTION VI
Orthodontic Appliances
OUTLINE

18. Removable appliances

19. Functional appliances

20. Orthopaedic appliances

21. Expansion appliances

22. Fixed appliances

CHAPTER 18
Removable appliances

CHAPTER OUTLINE
❖ Definition and classification of orthodontic appliances
❖ Ideal requirements of orthodontic appliances
❖ Advantages and limitations of removable orthodontic appliances
❖ Mechanical principles involved in designing of removable appliances
❖ Components/Various parts of removable appliances
❖ Designing of clasps used in orthodontics
❖ Classification of clasps used in orthodontic practice
❖ Free-ended clasps
❖ Circumferential clasps
❖ Triangular clasp
❖ Ball end clasps
❖ Duyzing’s clasp
❖ Lingual extension clasp
❖ Continuous clasp
❖ Jackson’s clasp
❖ Arrowhead clasp
❖ Southend clasp
❖ Adams’ clasp
❖ Delta clasp
❖ Various active components of removable appliance
❖ Springs used in removable appliance
❖ Canine retractors
❖ Labial bows
❖ Screws
❖ Elastics
❖ Orthodontic pliers
❖ Base plate
❖ Hawley appliance and retainer
❖ Insertion of removable appliance
❖ Failures of removable appliance/unsuccessful removable appliance therapy
❖ Accessory points
❖ Advanced learning
❖ Designing of removable orthodontic appliances
❖ Fabrication of removable appliance
❖ Treatment of various malocclusions by removable
mechanical appliances
Definition and classification of orthodontic
appliances
Definition
Orthodontic appliances are devices by means of which pressure may be applied to a
tooth or group of teeth to move them in a predetermined direction.

Classification of orthodontic appliances

There are different methods of classification.

I. Simple classification

Appliances

• Removable

• Mechanical

• Functional

• Fixed appliances

• Mechanical

• Functional

1. Removable appliances: Appliances that are designed to be

taken from the mouth by the patient.

2. Attached removable appliances maintain a fixed

relationship to the dentition through clasps or other
attachments.

3. Loose appliances fit imprecisely and alter the

 neuromuscular activity during function; also called
functional appliances.

4. Passive appliances are used to maintain the existing

occlusion (space maintainers and retention appliances)
and to disocclude the dentition (bite-blocks). Passive
appliances do not exert force.

5. Mechanical appliances exert force to tooth or group of

teeth through mechanical devices or active components.
II. Detailed classification

Appliances

1. Removable appliances

• Attached

• Active

1. Headgears

2. Facemask

3. Chin cups

4. Lip bumpers

5. Active plates

– Hawley appliance

– Space regainers
 – Schwarz expansion plates

– Anterior spring aligners (Barrer appliance)

– Crozat appliance

– Vacuum formed appliances (invisible appliances)

• Passive

1. Space maintainers

2. Bite planes

3. Retainers

4. Occlusal splints

5. Posterior bite-blocks

• Loose removable appliance/functional appliance

1. Activator

2. Bionator

3. Frankel

4. Twin block

2. Fixed appliances

• Mechanical

1. Edgewise
 2. Begg

3. PEA or preadjusted edgewise appliance

4. Lingual orthodontic appliances

• Functional

1. Herbst

2. Jasper Jumper

3. Forsus
Ideal requirements of orthodontic appliances
Ideal requirements of orthodontic appliances can be studied under the following
headings:

Mechanical aspects
➤ Appliance should deliver light continuous force.

➤ Appliance should have low load deflection rate.

➤ It should have high maximum elastic load.

➤ Should have control over centre of rotation.

➤ Appliance should have self-limiting force, i.e. if the patient misses appointment,
force delivery should not occur.

➤ Ease of fabrication is a requirement.

➤ Appliances should be able to withstand forces from mastication.

Biological aspects
➤ Should be able to produce tooth movement in the desired direction.

➤ Should not restrict normal growth.

➤ Function should not be interfered.

➤ Deleterious effects like root resorption, nonvitality should not be produced.

➤ Frontal resorption is desirable.

Oral hygienic aspects

➤ Appliance should be comfortable for the patient.

➤ Easily cleansable.

Aesthetic aspects
➤ With more number of adults seeking orthodontic treatment, the appliance should be
 acceptable aesthetically.

➤ Should be less visible.

Cost factor
➤ Appliance should be affordable for the patient.

➤ It should not be expensive.

Advantages and limitations of removable
orthodontic appliances
Advantages of removable appliances
➤ Malocclusions which require tipping can be efficiently treated by removable
appliance.

➤ It is used along with fixed appliances (e.g. posterior bite-block) to eliminate occlusal
interferences.

➤ Deep bite correction can be done satisfactorily by anterior bite plate.

➤ Fabrication of removable appliance is easier.

➤ Requires less chairside time.

➤ Does not require extensive training like fixed appliance.

➤ Can be removed by the patient for cleaning of teeth.

➤ Appliance can be cleaned by the patients.

➤ When the appliance is damaged, patients can easily remove the appliance before it
causes damage to the tissues.

➤ Aesthetically more pleasing when compared to fixed appliance.

➤ Economically cheaper when compared to fixed appliance.

➤ Used for space maintenance.

➤ Used as retention appliances.

Limitations of removable appliances

➤ Removable appliances produce only tipping movement. So cases which are already
tipped cannot be treated with removable appliance.

➤ Rotation correction cannot be achieved.

➤ Multiple tooth movements cannot be carried out.

➤ Not suitable for closure of extraction spaces by mesial movement of posterior teeth.
➤ Difficult to correct ectopic teeth.

➤ Difficult to obtain tight proximal contact between teeth with removable appliance.

➤ Patient tolerance is not good, more specifically in the mandibular appliances.

➤ Patients with complex problems cannot be treated.

➤ Patient co-operation is highly important.

➤ Appliances get damaged or broken, if they are not worn.

Mechanical principles involved in designing of
orthodontic appliances
Orthodontic archwires or springs can be considered as beams. They are supported
either on one side or both sides. Wires or appliances supported on one side act as
cantilever beams, e.g. springs projecting from the removable appliance.
Appliances supported on both sides include labial bows and archwire (Fig. 18.1).

FIG. 18.1. (A) Cantilever beam, and (B) supported beam.

When a force is applied to a beam, its response can be analysed with the diagram
(Fig. 18.2) and definitions.
 FIG. 18.2. Application of force. Relationship between stress, strain and resilience, formability.

Force: It is an act or load applied to an object which tends to change the position of
object.
Force delivered for a given deflection depends on
the wire length (L), radius (r ) and elastic modulus
(E)

➤ Increasing the size or diameter by 2 times increases the stiffness by 16 times.

➤ Increasing the length by 2 times reduces the stiffness by 8 times.

Stress: Force per unit area in a body which resists an external force.
Strain: Can be defined as the internal distortion produced by load or stress. Strain can
be elastic or plastic.
Elastic limit: It is defined as the greatest stress to which a material can be subjected
to, so that it will return to its original dimension when the forces are released.
Proportional limit: It is the point at which permanent deformation is first observed.
Yield strength: It is at the point at which 0.1% of deformation is observed.
Ultimate tensile strength: Maximum load a wire can sustain. This determines the
maximum force a spring can deliver (Fig. 18.3).
 FIG. 18.3. Force–deflection curve. Diagram shows the location of proportional limit, yield point
and failure point.

Springiness: This depends on the elastic or proportional limit. More horizontal the
slope, the more springiness.
Range: This is defined as the distance the wire will bend elastically before permanent
deformation occurs.
Resilience of the wire: It is the area under stress–strain curve up to proportional
limit. It represents the mechanical energy stored in the wire. It is a combination of
strength and springiness.
Formability: It is the amount of permanent deformation a wire can withstand before
it breaks.
Fatigue: This is the fracture of the wire due to repeated stress.
Effect of incorporating a coil: Introduction of a coil into a cantilever increases the
length of spring. Spring becomes more flexible.

Spring characteristics
Burstone enumerated three important features of the orthodontic appliance:

1. Moment to force ratio

2. Load deflection rate

3. Maximal elastic moment.

These three properties put together are found within the elastic range of an
orthodontic wire. These three properties are called spring characteristics.
1. Moment to force ratio: It determines the centre of rotation of tooth. Varying the
moment to force ratio produces different types of tooth movement.

2. Load deflection rate: It denotes the force produced per unit activation. Active
members of the appliance should have low load deflection rate which implies light
continuous force.

3. Maximum elastic moment: It is the greatest force or moment that can be applied to
the appliance without producing permanent deformation. This will prevent distortion
of the appliance during activation or accidental overloading during a chewing.
Components/various parts of removable
appliances
Components of the removable appliances:

Active component
1. Springs

2. Labial bows

3. Screws

4. Elastics

Fixation or retention
1. Clasps

2. Bows

Anchorage
1. Clasps

2. Contact of base plate with nonmoving part

3. Headgears

4. Intermaxillary elastic

Base plate
1. Forms the framework.
Designing of clasps used in orthodontics
Introduction
➤ Clasps are the retentive component of removable orthodontic appliance.

➤ Retention of appliance implies resistance to displacement of the appliance.

Importance
Good retention is essential for proper delivery and direction of force by the active
component.
If retention is inadequate:

➤ It leads to difficulty in appliance wear and poor patient cooperation.

➤ Active components will not work effectively, if there is poor retention.

➤ Chances of appliance breakage are more, if the retention is less.

Principles of clasp function

➤ Height of contour of a tooth is the line encircling the maximum bulge or
circumference of the crown

➤ Undercuts are portion of the tooth surface which is below the height of contour of
contours the area between height of contour and the anatomical neck of the crown.

➤ Clasps make use of these undercuts for retention purpose.

➤ There are differences between mesial, distal and labiolingual undercuts (Fig. 18.4).
The differences between mesial, distal and labiolingual undercuts are enumerated in
Table 18.1.

➤ Circumferential clasp engages one interdental undercut and buccal undercut.

➤ A line drawn from one side clasp to the other side should pass through the centre of
the appliance.
 FIG. 18.4. Undercuts: (A) buccal and lingual undercuts and (B) mesial and distal undercuts.

Table 18.1.
Undercuts, mesial and distal, and buccal and lingual–differences

Mesial and distal Buccal and lingual

Begins below the contact points Less extensive
Accessible immediately after eruption Not accessible till full eruption
Clasp using this undercut is most useful Less useful
More efficient, e.g. Adams’ clasp, triangular clasp Less efficient, e.g. Jackson’s clasp, circumferential clasp

This principle should be followed while designing an appliance.

Ideal requisites for a clasp

➤ Clasps should provide adequate resistance against displacement.

➤ Clasps should be passive. They should not produce unwanted tooth movement.

➤ Should be easy to fabricate.

➤ Adjustments should be easy.

➤ It should not get distorted easily due to frequent removal and insertion of the
appliance.

➤ Clasps should not interfere with occlusion.

➤ Clasps should be versatile, i.e. modification according to usage must be possible.

➤ Clasps should provide retention in partially erupted and deciduous tooth also.

➤ They should not irritate the soft tissues.

➤ Should function as anchorage part also, if required.

Types of clasps based on using the undercuts
Clasps
1. Clasps using mesial/distal undercuts:

• Adams’ clasp

• Triangular clasp

• Ball end clasps

• Arrowhead/Schwarz clasp

• Crozat clasp
2. Using buccal/lingual undercuts:

• Jackson’s clasp

• Southend clasp

• Duyzing’s clasp
3. Using both the proximal and buccal lingual undercuts:

• ‘C’ clasp
Classification of clasps used in orthodontic
practice
The various clasps used in removable orthodontic appliances can be classified under
two broad headings. They are:

1. Free-ended clasps (one end of the clasp embedded in acrylic)

• C clasp

• Triangular clasp

• Ball end clasp

• Duyzing’s clasp

• Crozat clasp

• Arrow pin clasp

• Wrought Roach clasp

• Visick’s clasp

• Lingual extension clasps

2. Continuous clasp (both ends of the clasp embedded in acrylic)

• Jackson’s clasp

• Arrowhead clasp

• Eyelet clasp

• Adams’ clasp
• Delta clasp

• Southend clasp
Free-ended clasps
Circumferential clasps
➤ Synonyms: ‘C’ clasps, three-quarter clasps.

➤ Wire used: 19 gauges or 0.9 mm hard stainless steel wire.

Clasp design (fig. 18.5)

➤ Palatal portion of the wire is embedded in acrylic.

➤ From the palatal, wire is bent in interdental undercut between second premolar and
first molar.

➤ Wire passes buccogingivally below the undercut towards the distal buccal
interdental undercut of first molar where it ends.

➤ Utilizes one proximal undercut and buccal undercut.

FIG. 18.5. Circumferential clasps extending into the distobuccal undercut.

Modifications (fig. 18.6)

➤ The ‘C’ clasp can be modified to engage the mesial proximal undercut.

FIG. 18.6. Modification in clasp design.

Advantages
➤ Kept out of occlusal control when compared to Adams’ clasp

➤ Simple design

➤ Easy to fabricate

➤ Adjustments are easier

➤ Resists distortion

Disadvantages
➤ Retentive ability is inferior when compared to Adams’ clasp.

➤ Can be used only for retainers and not active removable appliances.

➤ Cannot be used in partially erupted tooth.

➤ Modifications are not possible for different applications like Adams’ clasp.

Triangular clasp
➤ Wired used: 0.7 mm or 21 gauge hard stainless steel wire.

Clasp design (fig. 18.7)

➤ This is a triangular-shaped clasp with the open end of the triangle always placed
distal.

➤ It is actually a single arrow on a wire crossing the contact point.

➤ Apex of the triangle engages the proximal undercuts between two teeth.

➤ Usually placed between two premolars.

 FIG. 18.7. Triangular clasp.

Advantages
➤ This clasp provides excellent retention.

➤ No irritation to the gingival tissues.

➤ Easily fabricated.

➤ Preformed clasps are available.

➤ Triangles can be made in advance and adjusted according to the tooth.

➤ Can be used to engage elastics.

Disadvantages
➤ Not a versatile clasp like Adams’ clasp.

➤ Mainly used for additional retention.

Ball end clasps

➤ Synonym: Ball clasps

➤ Wire used: 0.7 mm or 21 gauge hard stainless steel wire

Clasp design (fig. 18.8)

➤ Clasp extends across the embrasure between adjacent teeth and engages interdental
undercut on the buccal surface.
➤ End of the clasp is fabricated in the form of a ball or knob.

➤ They are available as ready-made forms.

➤ Instead of the ready-made ball, the end of the wire can be recurved to make it fit into
the interdental undercut.

FIG. 18.8. Ball end clasps.

Advantages
➤ Easy to fabricate.

➤ Can be used for anterior teeth.

➤ Less conspicuous.

Disadvantages
➤ Relatively stiff because of short length.

➤ Provides only limited retention.

➤ Trauma to interdental papilla is possible.

Duyzing’s clasp
➤ Wire used: 0.7 mm or 21 gauge hard stainless steel wire.

Clasp design (fig. 18.9)

➤ This is made by two wires emerging from the acrylic plate, one crosses the mesial
and the other crosses the distal contact point.

➤ Each wire goes above the height of contour or greatest circumference till the middle
of the tooth.
➤ From there, it is curved back upon themselves so that the lower part lies below the
maximum contour in the undercut area.

FIG. 18.9. Duyzing’s clasp.

Advantages
➤ Possible to use only one-half of the clasp.

➤ One-half may be made to extend fully to the anterior or posterior part of the tooth.

➤ Does not irritate the gingiva.

Disadvantages
➤ Provides limited retention.

➤ Accumulation of food debris is more in this type of clasp.

Lingual extension clasp

➤ Wire used: 0.5 mm or 23 gauge wire.

Clasp design (fig. 18.10)

➤ Clasp starts from the lingual aspect of the acrylic plate.

➤ The clasp extends into the lingual embrasure between the teeth.

➤ Does not cross through the interdental contact area.

 FIG. 18.10. Lingual extension clasp. (A) Lingual extension clasp in place and (B) close-up
view of lingual extension clasp.

Advantages
➤ Does not interfere with occlusion.

➤ Used for retention appliances.

Disadvantages
➤ Adjustments are difficult.

➤ Prone to breakage.

➤ Causes tissue irritation.

➤ If active, can cause separation of teeth.

Continuous clasps
Jackson’s clasp
➤ This clasp was introduced by Jackson VH in 1906.

➤ Synonyms: Full clasp, U clasp, molar clasp.

➤ Wire used: 19 gauge wire or 0.9 mm hard stainless steel wire.

Clasp design (fig. 18.11)

➤ Palatal portion of the wire is embedded in acrylic.

➤ Wire is closely adapted along the buccocervical and proximal undercuts (both mesial
and distal).

➤ Placed usually for first molars.

➤ Crosses interdentally on both sides of first molar to end in acrylic plate.

FIG. 18.11. Jackson’s clasp. (A) Jackson’s clasp in place and (B) close-up view of Jackson’s
clasp.
Advantages
➤ Resists distortion.

➤ Simple design.

➤ Easy to fabricate.

Disadvantages
➤ Adjustments are not easy.

➤ Cannot be used in semierupted teeth.

➤ Modifications are not possible.

Arrowhead clasp
Introduced by AM Schwarz.

➤ Synonym: Schwarz clasp.

➤ Wire used: 0.7 mm or 21 gauge hard stainless steel wire.

Clasp design (fig. 18.12)

➤ This is the oldest clasp.

➤ The anterior arm of the clasp emerges from the acrylic plate and crosses through the
interdental area between premolar and molar.

➤ From here two or three arrows are formed. These arrows fit into the interproximal
area.

➤ Posterior arms extend up to the last fully erupted tooth.

➤ Crosses interdentally and inserted into the acrylic plate.

 FIG. 18.12. Arrowhead clasp. (A) Clasp in position and (B) close-up view.

Advantages
➤ Because of the vast length of the wire, clasp is more elastic.

➤ Adjustments can be done in the arrows individually.

➤ Conveniently used in combination with posterior bite-block.

➤ Facilitates further eruption of buccal teeth.

Disadvantages
➤ Needs great care in formation.

➤ Requires special pliers.

➤ Breakage chances are more.

➤ Occupies more space.

➤ Soft tissue injury is more.

➤ Tends to separate the teeth.

Pliers used for arrowhead clasp fabrication

➤ Arrowhead-forming pliers.

➤ Tischler’s pliers.

➤ Optical pliers.

Southend clasp
➤ Wire used: 0.7 mm or 21 gauge hard stainless steel wire.

Clasp design (fig. 18.13)

➤ Southend clasp extends to two adjacent margins of the teeth.

➤ A small U-loop engages the interdental undercut.

➤ Wire is adapted along the buccal cervical margins of the two teeth.

➤ Distal ends of the clasp crossover the occlusal embrasure and is embedded into the
acrylic plate.

FIG. 18.13. Southend clasp.

Advantages
➤ It is very useful for anterior retention.

➤ Clasp is unobtrusive.

➤ Retention is good.
➤ Adjustment is easier; adjusted by pushing the U-loop towards the palatal aspect.

Adams’ clasp
➤ Adams’ clasp was introduced by Philip Adams.

➤ It is a modification of Schwarz’s arrowhead clasp.

➤ Synonyms: Modified arrowhead clasp, liverpool clasp, universal clasp.

➤ Wire used: 0.7 mm or 21 gauge hard stainless steel wire, 0.6 mm is used for canines.

Clasp design (fig. 18.14)

➤ Adams’ clasp is the most versatile clasp. It engages the mesiobuccal and distobuccal
undercuts of posterior teeth.

➤ Adams’ clasp consists of three parts: Arrowhead, bridge and tag on retentive part.

1. Arrowhead

• The tip of the arrowhead should be placed below the

greatest circumference of the tooth mesially and distally.

• If the tooth is partially erupted, the plaster should be

trimmed in the gingival papilla region. This helps in correct
positioning of the arrowhead.

• Arrowheads slope to correspond with the contour of the

gingival margin into the interdental area.

• Arrowheads should be made parallel to each other.

2. Bridge

• Bridge connects the two arrowheads.

• It should be straight and not curved.

• The angulation between the bridge and the tooth surface
should be 45°.

• Bridge should be fitted against the buccal surface.

• There should be a gap of 1 or 2 mm between the bridge and

tooth surface.

• Bridge should be halfway between the cervical and occlusal

margins of the buccal surface.
3. Tags or retentive part

• Fit closely across the contact point.

• It should not create occlusal interferences.

• Therefore, it is best adapted interdentally.

• On the palatal end of the tag, there should be space between

the wire and plaster cast. This facilitates proper embedding
of the tags in the acrylic plate.

FIG. 18.14. Adams’ clasp.

Advantages of adams’ clasp

➤ It is the most versatile of all the clasps.

➤ It has got excellent retention.

➤ It does not tend to separate the teeth.

➤ Adams’ clasp can be used on partially erupted teeth.

➤ It can be used on all teeth.

➤ It can be used for deciduous teeth also.

➤ It is possible to form hooks in the clasp.

➤ Tubes can be soldered.

➤ It looks neat and unobtrusive.

➤ No specialized pliers are required to fabricate Adams’ clasp.

Disadvantages of adams’ clasp

➤ Fatigue fracture of clasp is more when compared to delta clasp.

➤ When used for prolonged duration in children, it might interfere with lateral growth
of the alveolar arch

Modifications of adams’ clasp

➤ Single arrowhead clasp – used in last teeth of the arch which are partially erupted
(Fig. 18.15A).

➤ Adams’ with additional arrowhead (Fig. 18.15B). The additional arrowhead is

soldered to the bridge of the main clasp.

➤ Adams’ with soldered headgear tube (Fig. 18.15C). Headgear tube is soldered to the
bridge in conditions which require extraoral anchorage or orthopaedic force.

➤ Adams’ with J hooks (Fig. 18.15D).

➤ Adams’ with helix (Fig. 18.15E).

➤ Incisor and canine Adams’ clasp (Fig. 18.15F).

➤ Adams’ with distal extension for engaging elastics (Fig. 18.15G).

 FIG. 18.15. (A) Single arrowhead clasp, (B) additional arrowhead clasp, (C) Adams’ clasp
with headgear tube soldered, (D) Adams’ clasp with J hook, (E) Adams’ clasp with helix, (F)
Adams’ clasp for anterior teeth, (G) Adams’ clasp with distal extension loop.

Adjustment (fig. 18.16)

Clasp is activated in two positions:

1. Position A: Adjustments of clasps by bending the retentive points inwards. This is

useful during initial placement of appliances.

2. Position B: Tightening of the clasps at the point of emergence from the base plate.
This is the usual place of adjustment after repeated insertion and removal.
 FIG. 18.16. Adjustment of Adams’ clasp.

Delta clasp
Delta clasp was designed by William Clark.

➤ Synonym: Circular arrowhead clasp.

➤ Wire used: 0.7 mm or 21 gauge hard stainless steel wire.

Clasp design (fig. 18.17)

Delta clasp is similar to Adams’ clasp and consists of (i) interdental tags, (ii) buccal
bridges and (iii) retentive loops.

FIG. 18.17. Delta clasp.

Retentive loops are shaped as closed triangles or circular loop in contrast to Adams’
clasp. Advantage of closed loop is that it does not open on repeated insertion and
removal. Buccal bridges are placed 1 mm away from tooth surface.

Advantages
➤ Improved retention.
➤ Metal fatigue is reduced.

➤ Need for adjustments is less.

➤ Can be used for deciduous tooth.

➤ Can be used for all permanent teeth.

Disadvantage
➤ Modifications are not possible.

Adjustment
➤ First method is by bending the clasp gingivally as it emerges from the acrylic plate.

➤ Second method is to hold the loop on the buccal aspect and twist the retentive loop
inwards towards the tooth surface.
Various active components of removable
appliance
The active components of removable appliances:

(i) Springs

(ii) Bows

(iii) Screws

(iv) Elastics
Springs used in removable appliance
Classification of springs
Springs are active components of removable appliances. There are two methods of
classification of springs.

1. Classification of springs based on their ability to withstand forces of distortion.

a. Self-supported springs:

i. Buccal canine retractor

ii. Helical loop canine retractor

iii. U-loop canine retractor

iv. Coffin springs

b. Guided springs:

i. Cantilever springs

ii. Finger springs

iii. Palatal canine retractor

iv. T-springs

c. Auxiliary springs:

i. Apron springs
2. Classification of springs based on their point of attachment:
 a. Free-ended springs:

i. Cantilever springs

ii. Canine retractors

iii. Finger springs

iv. T-springs

b. Springs attached at both ends:

i. Labial bows

ii. Coffin springs

c. Accessory springs attached to arches:

i. Apron springs

Ideal requirements of springs

➤ Springs should be simple to fabricate.

➤ Spring should be easily adjustable.

➤ Should be capable of being seated in the correct position when the plate is inserted.

➤ Springs should fit into the space available without any discomfort to the patient.

➤ Should be easily kept clean.

➤ Should be robust and stable, i.e. should not slip when applied to a sloping tooth
surface.

➤ Should deliver gentle forces.

➤ Should be able to apply forces of the required magnitude and direction for a given
amount of activation.
➤ Should not produce unwanted tooth movement.

➤ Should not irritate the mucosa.

Basic properties of spring

The parts of a spring (Fig. 18.18) are (a) active arm, (b) coil or helix and (c) tag. Springs
are generally variations of cantilever spring (Fig. 18.19). The force delivered by the
appliance is calculated using the formula

FIG. 18.18. Parts of spring: (A) active arm, (B) coil (or) helix and (C) tag on retentive arm.
 FIG. 18.19. Cantilever principle of spring and effect of incorporating coil. (A) Less deflection
and (B) more deflection with incorporation of coil.

Where
L = Wire length
r = Radius
E = Elastic modulus of the material.

➤ Doubling the diameter increases the force or stiffness by 16 times.

➤ Doubling its length reduces the force by 8 times.

➤ The deflection for a given load is proportional to the third power of the length of the
spring and inversely to the fourth power of its diameter.

➤ Incorporation of a coil increases the effective length of the spring and thereby
increases the deflection (Fig. 18.19).

Stability ratio of the spring: It is the stiffness in the direction of unwanted

displacement divided by the stiffness in the wanted direction. Ideally, it should be
higher and at least 1.

Coils
➤ The coil diameter should be 2.5 mm minimum.

➤ Incorporation of coil increases the effective length of the spring and reduces the
force.

➤ For maximum efficiency, coil should be made in such a way that it unwinds as it is
activated.
➤ Placement of coil: Coil is placed close to the attachment of the spring to the base plate.

This increases the range of the appliance.

Positioning of coil (fig. 18.20)

➤ The coil of the spring should be centred on the line through the midpoint of the tooth
and perpendicular to its intended path.

➤ Point of contact: The tooth will move in a direction perpendicular to the tangent at the
point of contact.

➤ Therefore, active arm should contact tooth surface at right angles to the desired
direction of tooth movement.

➤ If required, active arm has to be cranked to have such point of contact.

I. Self-supported springs

The following springs fall under the category of self-supported

spring.

• Canine retractors

• Buccal canine retractor

• Helical loop canine retractor

• U-loop canine retractor

• Coffin springs

• Self-supported springs are springs which can resist on their own

the distortion forces.

• They usually have a stability ratio of 1.

• They are made of 0.7 mm or 0.9 mm hard wire.

 1. Buccal canine retractor

Wire used: 0.7 mm or 21 gauge stainless steel wire.

Indication: Buccal canine retractor is used where a buccally

placed canine has to be moved both palatally and distally.

Spring design (Fig. 18.21):

• It is one of the few springs where the coil is closed for

activation.

• The end of the spring is bent at right angle to the canine to

be moved.

• Then it is shaped to the tooth.

• Coil is placed as high as possible without interfering with

the soft tissues.

• Tag should cross over the mesial contact point of second

premolar.

• Coil should be placed in between the present and future

position of canine (distal to long axis of canine)

• If thinner wires are used (0.6 mm), then they are sleeved to
prevent distortion.

Activation of buccal canine retractor (Fig. 18.22):

• The coil should be activated by only 1 mm.

• It is activated by closing the coil.

• Activation is done by using ‘hollow chop’ pliers like
Mathews or Andresen’s.

• Spring is activated by bending the anterior arm using these

pliers.

Modifications:

There are two modifications of buccal canine retractor. They

are:

• Supported or sleeved buccal canine retractor.

• Stabilized canine retractor.

Supported buccal canine retractor (Fig. 18.23):

• This is similar to buccal canine retractor.

• But it is made from 0.5 mm wire.

• The wire is supported in a tubing or sleeve.

• Tubing gives excellent vertical stability to the spring.

• It is flexible mesiodistally.

• Activation of 2 mm can be done.

 FIG. 18.20. Positioning of coil.

FIG. 18.21. Buccal canine retractor.

FIG. 18.22. Activation of buccal canine retractor using hollow chop plier.
 FIG. 18.23. Supported buccal canine retractor.

Stabilized buccal canine retractor (Fig. 18.24):

• The standard buccal canine retractor can be further

improved by addition of a stabilizer wire welded to the
bridge of the clasp on the back tooth.

• The effect of stabilizer is to restrict vertical movement

without affecting the anteroposterior flexibility of the
spring.

2. Reverse loop canine retractor (Fig. 18.25)

• Synonym: Helical loop canine retractor.

• Wire used: 0.7 mm or 21 gauge stainless steel wire.

Indications:

1. In patients with shallow sulcus depth for retraction of

canine

2. Mostly used in mandibular arch.

Spring design:

• Parts of the spring:

1. Helix/coil

2. Active arm

3. Retentive tag

• The active arm starts from the mesial cervical aspect of

canine. It can be made to encircle the mesiolingual aspect of
canine.

• The active arm proceeds backwards up to the distal of

second premolar.

• From there, a helix is made with a minimum diameter of 2.5

mm.

• The retentive part of the spring crosses the active arm in the
mesial aspect of second premolar.

• The height of the coil is made according to the depth of the

sulcus.

Drawbacks of helical loop canine retractor:

• It is stiff in the horizontal plane.

• Unstable vertically.

• Activation: There are two methods. In both the methods, it

should not be activated more than 1 mm.
• Method 1: Consists of cutting off 1 mm of wire from the free
end and reshaping it to engage the mesial surface of canine.

• Method 2: By opening the coil by 1 mm.

3. U-loop canine retractor

• Wire used: 0.7 mm or 21 gauge wire.

• Indications:

1. Indicated when only distal movement of canine is

required.

2. Minimal distal movement of canine is achieved with this

retractor.

Spring design (Fig. 18.26):

The parts of the springs are (i) active arm, (ii) U-loop and (iii)
retentive tag.

• The active arm engages the mesial surface of the canine at

the cervical level and proceeds posteriorly to form the U-
loop.

• The U-loop is made in a similar fashion like labial bow. The

mesial end of the U-loop starts at the premolar bent at right
angle, the width of the loop depends on the width of
premolar.

• It extends 2–3 mm below the cervical margin.

• Finally, curved around into the interdental area between the

 premolars.

Disadvantage:

This is the least efficient of all the canine retractors.

Advantages:

• Very easy to fabricate

• Simple in design

• Not bulky.

Activation:

It is activated by closing the loops by 1 mm.

FIG. 18.24. Stabilized canine retractor.

 FIG. 18.25. Reverse loop canine retractor.

FIG. 18.26. U-loop canine retractor.

4. Coffin springs

Coffin spring was introduced by Walter Coffin.

Wire used: 1.25 mm heavy stainless steel wire.

Indications:

1. Expansion of constricted maxillary arch

 2. Correction of crossbite

3. Conditions requiring differential expansion.

Spring design (Fig. 18.27):

• The spring consists of U- or omega-shaped loop positioned

in the midpalatal region. The distal ends of the U-loop are
limited to the distal of first permanent molar.

• Anteriorly, the loop gets constricted and recurved into the

base plate.

• It is a continuous type of spring where both ends are fixed to

the base plate.

• The wire should be placed 1 mm away from the mucosa.

Advantages:

• Cheaper when compared to expansion screws.

• Differential expansion of arch in the premolar or molar

region is possible.

• Less bulky.

Disadvantage:

• Coffin spring tends to be unstable, if it is not made precisely.

Activation:

• Marking pits are made on both sides of the plate by drilling.

 This allows the width of the appliance to be checked.

• Pliers should not be used for activation.

• Appliance is activated by expanding the appliance manually

by pulling the sides apart, first in the anterior region and
then in the posterior region.

• Adequate care should be taken to maintain the two sides of

the appliance in the same plane. If the plane changes,
appliance may not fit properly.

• An expansion of 2–3 mm is made during activation.

FIG. 18.27. Coffin springs.

II. Guided springs

• Various guided springs:

1. Cantilever springs – (a) single cantilever, (b) double

cantilever
 2. Finger springs

3. Palatal canine retractor

4. T spring

Guided springs are so-called because they cannot resist

distortion on their own. They are usually made of 0.5 mm
wires. To protect the wires from distortion, two methods are
employed:

a. Placing guide wires: These are incorporated in the spring

design (Fig. 18.28). These curves are made in such a way
that they lie above the active arm. Any distortion forces
will be directed to the guide wires first which bear the
brunt of the force.

b. Boxing of springs (Fig. 18.29):

• To prevent damage, the spring placed on the palatal aspect

can be boxed.

• When it is boxed, spring lies in the gap between the base

plate and the mucosa.

• When doing this, care should be taken so that the free

movement of active arm is not interfered with it.

• It should have a flat smooth surface.

1. Single cantilever spring

Wire used: 0.5 mm either with a guide wire or boxed in.

Indication: Labial movement of incisors.

Spring design (Fig. 18.30):

A single cantilever spring consists of three parts:

• Tag is embedded in the acrylic resin of the base plate.

• Coil is the active part of the spring. It is normally made so

that it tends to open on use or activation.

• Active arm which is in contact with the tooth to be moved.

The arm of the spring is placed at right angles to the required

path of tooth movement. Coil is placed as far away as
possible. If there is a crossbite, bite is raised by giving a
posterior bite-block.

FIG. 18.28. A guide wire placed for double cantilever spring.

 FIG. 18.29. Boxing of spring.

FIG. 18.30. Single cantilever spring.

Activation:

First visit: Activated by 1–2 mm.

Subsequent visits: Activated by 2–3 mm.

The spring is activated by opening the coil by two methods.

Method 1: Open the coil in the free arm of the spring as close
as to the coil.

Method 2: Tension can be given to cantilever spring by

squeezing the coil with the tip of the pliers (Fig. 18.31).

Modifications:

Cranked cantilever springs: Cantilever springs should be

cranked, if required to keep it clear of the other teeth.
Stability is better with cranked cantilever springs (Fig.
18.32).

2. Double cantilever springs

Synonym: ‘Z’ spring

Wire used: 0.5 mm or 23 gauge hard stainless steel wire.

Indications:

• Double cantilever springs are used when both labial and

lateral movement of the incisors are required.

• Minor rotation correction can be achieved.

• When two or more teeth have to be moved labially.

Spring design (Fig. 18.33):

Spring consists of two coils.

• It is placed perpendicular to the palatal surface of the tooth.

• The length of arm varies depending upon the number of
teeth to be moved labially.

• Double cantilever springs are supported either with guide

wire or boxed in.

FIG. 18.31. Method 2 of activating cantilever spring. (A) Before activation and (B) after
activation.

FIG. 18.32. Cranked cantilever spring.

 FIG. 18.33. Double cantilever or ‘Z’ spring.

Activation:

Spring is activated by opening the coil.

1. Lateral movement is produced by opening the right-

handed coil (Fig. 18.34A).

2. Forward or labial movement is produced by opening the

left-handed coil (Fig. 18.34B).

Modification (Fig. 18.35):

Crossed cantilever springs/paired cantilever springs (Fig. 18.35):

• When four incisors are to be moved labially, crossed

cantilever springs are used.

• Each spring moves the central and lateral incisor nearest to

the end of the springs.
 3. Finger springs (Fig. 18.36)

Wire used: 0.5 mm or 23 gauge stainless steel wire.

Indications:

• Mesiodistal movement of teeth.

• Closure of median diastema.

• Used for teeth in the line of arch only.

Spring design:

Parts of the springs: (i) active arm (ii) coil and (iii) retention tag
(Fig. 18.36).

• Active arm contacts tooth surface at right angles to the

desired tooth movement.

• Coil should be placed as far away possible to have a good

range of action. It is centred on the line through the
midpoint of the tooth and perpendicular to its intended
path. In simple terms, coil should be positioned between the
present and future position of the tooth to be moved. Coil
size should be 2.5–3 mm.

• For maximum efficiency, coil should be placed on the

opposite side of the tooth movement.

• For distal movement, coil is placed on the mesial aspect of

the tooth. For mesial movement, coil is placed on the distal
aspect of the tooth.
• The active arm, coil and retentive tag lie in the same line.

• Finger springs are either given with a guide wire or boxed

in.

Activation:

• Method 1: Spring is activated by opening the coil by 2–3

mm.

• Pull the free arm of the spring slightly away from the point
of emergence from coil.

• Method 2: Tension can be given to finger spring by

squeezing the coil with the tip of the pliers (Fig. 18.36).

FIG. 18.34. Activation of double cantilever spring. (A) Activation of right-handed coil and (B)
activation of left-handed coil.
 FIG. 18.35. Crossed cantilever springs.

FIG. 18.36. Finger spring.

4. Palatal canine retractors

This is similar to finger springs.

Wire used: 0.5 mm or 23 gauge hard stainless steel wire.

Uses:
 1. Distalization of palatally placed canine.

2. Distal movement of premolar.

Design (Fig. 18.37):

Palatal canine retractor consists of three parts: (i) active arm,

(ii) coil and (iii) retentive tag.

1. Active arm contacts tooth surface at right angles to the

desired tooth movement.

2. Coil should be placed as far away as possible to have a

good range of action. It is centred on the line through the
midpoint of the tooth and perpendicular to its intended
path. Coil size should be 2.5–3 mm. For maximum
efficiency, coil should be placed on the opposite side of
the tooth movement. For distal movement, coil is placed
on the mesial aspect of the tooth. For mesial movement,
coil is placed on the distal aspect of the tooth. The active
arm, coil and retentive tag lie in the same line.

3. Retentive tag gets embedded in the acrylic plate.

Activation:

• Method 1: Spring is activated by opening the coil by 2–3

mm.

• Pull the free arm of the spring slightly away from the point
of emergence from coil.

• Method 2: Tension can be given to the spring by squeezing

the coil with the tip of the pliers (Fig. 18.36).
 5. T-springs

Wire used: 0.5 mm or 23 gauge hard stainless steel wire.

Indication: Used for buccal movement of premolars and

molars.

Spring design (Fig. 18.38):

• Spring is made up of T-shaped arm.

• The retentive arm is embedded in base plate.

• T-springs have got both vertical and horizontal force

component. If the contact surface is vertical (e.g. premolar),
the intrusive component is less.

• If the contact surface is sloping (e.g. canine), tooth intrusion

might take place.

• Adjustment loops are incorporated to allow the spring to be

lengthened.

Activation:

Spring is activated by pulling it away from the base plate

towards buccal direction.
III. Auxiliary springs

Synonym: Apron springs

Wire used: 0.35–0.40 mm stainless steel wire

Indications:

• Used in extreme proclination of incisors for lingual

movement.

• Used to correct single tooth proclination.

Spring design (Fig. 18.39):

• Apron springs are used with high labial bow.

• Apron springs constitute the active component.

• Apron springs are attached to the base arch by winding a

few turns in vertical arms and then 2 or 3 turns in the
horizontal arm.

• Apron springs are bent into shape according to the number

of teeth to be moved lingually.

Advantages:

• Highly flexible.

• Delivers very light force.

• Individual tooth correction is possible.

Disadvantages:

• Difficulty in fabrication.

• Breakages are more and rewinding a new apron spring is

tedious.
• Irritates the soft tissues.

Activation:

• Activated by bending the upright arms of the apron springs.

Modification:

• To retract individual tooth (Fig. 18.40A).

• To retract groups of teeth (Fig. 18.40B).

FIG. 18.37. Palatal canine retractor.

 FIG. 18.38. T-springs.

FIG. 18.39. Auxiliary springs.

FIG. 18.40. (A) Apron spring to retract individual tooth and (B) apron spring to retract group of
teeth individually.
Canine retractors
Canine retractors are used for distal movement of canine.

Types of canine retractors

1. Bucally placed: (a) Buccal canine retractor, (b) helical loop canine retractor and (c) U-
loop canine retractor

2. Palatally placed: (a) Palatal canine retractor.

Labial bows
Labial bows are active component of the removable orthodontic appliances. They are
used for the lingual or palatal movements of incisors.

Types of labial bows

a. Labial bows with U-loop

1. Short labial bow

2. Long labial bow

3. Split labial bow

4. Reverse labial bow

5. Fitted labial bow

b. Labial bows without U-loop

1. Roberts’ retractor

2. Mills retractor

3. High labial bow with apron spring

1. Short labial bows

Wire used: 0.7 mm or 21 gauge hard stainless steel wire

Indications:

• Closure of spaces mesial to canines

• Minor overjet reduction

• A component of retention appliance

• Minor incisor alignment

• Incorporated with other springs for retention.

Design (Fig. 18.41):

• Labial bows are fixed at both ends.

• Parts of labial bow: (i) two U-loops, (ii) bow connecting the
loops and (iii) retention tag.

• 0.7 mm wire is adapted to the palatal tissue and carried over

the embrasure between the canine and first premolar.

• Well-defined bend is made gingivally to start the fabrication

of vertical loop. Loop should be 10–12 mm long. It should
not contact the gingival tissue. Loop should not be very long
to injure the mucosa and muscle attachments. Width of the
loop should be 5 mm approximately.

• Mesial arm of the loop should make a horizontal bend just in

front of the canine lateral incisor embrasure and it should be
in the canine region.

• From here, the horizontal portion traverses the incisor

segment in the middle third of the incisor crowns.

• Wire should not be adapted to individual tooth

irregularities.

• It touches only the most prominent labial surfaces, which

means a relatively unbent labial wire.
• At the opposite side, the procedure is repeated and the
spring ends in the palatal mucosa in between canine and
first premolar.

Activation:

Activated by closing the U-loops by 1 mm.

Disadvantages:

• Active part is very rigid.

• Range of action is minimal.

• Labial bow exerts high pressure over a small range.

• Buccal drift of canines happen sometimes.

2. Long labial bow (Fig. 18.42)

Wire used: 0.7 mm or 21 gauge stainless steel wire.

Indications:

• To close the space distal to canine

• To guide the canine into proper position

• Component of retention appliance

• Minor incisor alignment

• Minor overjet reduction

• For retention purpose

Clasp design:

• Similar to short labial bow.

• The difference is the crossover wire which passes between

first premolar and second premolar.

Activation:

• Labial bow is activated by closing the loops by 1 mm.

FIG. 18.41. Short labial bow.

FIG. 18.42. Long labial bow.

3. Split labial bow

Wire used: 0.7 mm or 21 gauge stainless steel wire.

There are two types of split labial below: (i) Used for retraction
of incisors and (ii) Used for closure of median diastema.

(i) Split labial bow used for retraction (Fig. 18.43)

• One of the main drawbacks of labial bow is its rigidity.

• The flexibility of the labial bow can be increased by dividing

the labial bow so that there are two buccal arms.

• Split labial bows are effective for retraction of incisors.

Drawbacks: Rotation or minor irregularities are difficult to

control with split labial bow.

Activation: Activated by closure of the loop by 1 mm.

(ii) Split labial bow used for median diastema closure (Fig. 18.44)

• In this type, the free ends of the labial bow crossover each
other.

• The arms should be parallel to each other.

• The free end of one bow crosses the opposite central incisors
and hooked on to the distal aspect of central incisor.

• In the same way, opposite side bow is fabricated.

Drawbacks:

• This is useful only for closure of median diastema.

• Not effective in overjet correction.

Activation:

• Activated by closure of the loop by 1 mm.

FIG. 18.43. Split labial bow for retraction of incisors.

FIG. 18.44. Split labial bow for diastema closure

4. Labial bow with reverse loops

Synonym: Reverse labial bow.

Indications:

• For minor retraction of overjet.

• For minor crowding correction.

• As retention appliance.

Design (Fig. 18.45):

• The design is similar to short labial bow, except that the

loops are reversed.

• The distal ends of the loop go up to the interdental area

between first and second premolars.

• Here a vertical bend is given which does not contact the

mucosa.

• The loop is completed and the crossover wire passes above

the horizontal part of labial bow between canine and first
premolar.

Drawbacks:

• It is very rigid.

• Stability ratio is poor.

Activation:

It is done in two stages (Fig. 18.46).

Stage A:

• Open the vertical loop by compressing with pliers.

• Bow is lowered in the incisor region because of this opening.

Stage B:
Consists of placing compensating bends at the base of the
loop.
5. Fitted labial bow

Wire used: 0.7 mm or 21 gauge stainless steel wire.

Indication:

Used as retention appliance after active orthodontic

treatment.

Design (Fig. 18.47):

• The bow is adapted to the contours of the labial surface of

individual teeth.

• Labial bow is placed in the middle third.

• The appliance should be passive.

Activation

• Used only for retention purpose.

• Loops are not to be activated.

• Adjustments can be made for proper fit of the appliance.

 FIG. 18.45. Reverse labial bow.

FIG. 18.46. Two-stage activation of reverse labial bow.

FIG. 18.47. Fitted labial bow.

6. Roberts retractor

Designed by GH Roberts.

Wire used: 0.5 mm or 23 gauge hard stainless steel wire.

Indications:

• Retraction of four incisors

• Highly flexible, so used in cases where more than 4 mm

overjet is present.

• Excellent retraction bow.

Design (Fig. 18.48):

• Roberts retractor consists of two-sleeved canine retractors

joined to form an apron spring.

• The arch should lie way up the crowns of the teeth and
extends only up to two-thirds of the width of the lateral
incisors.

• Coils are placed at the point of emergence of the wire from

the sleeves.

• Coil diameter should be minimum 3 mm.

Disadvantages:

• Breakages and damage are common.

• Difficult to repair.
Activation:

It is adjusted in the vertical limb below the coil by bending it

palatally.
7. Mills retractor

Synonym: Extended labial bow.

Wire used: 0.7 mm or 21 gauge hard stainless steel wire.

Indications:

Highly flexible and so used for reduction of large overjets;

alignment of irregular incisors.

Design (Fig. 18.49):

This labial bow incorporates extensive loops and thereby

flexibility is increased.

Disadvantages:

• Less comfortable for the patient.

• Difficult to fabricate.

Activation:

• Activated by compressing the extended loop and bending

the bow palatally.

• Care should be taken to avoid trauma to the mucosa during

adjustment.
8. High labial bow with apron springs

• High labial bow with apron springs consists of two

components: (i) heavy base archwire and (ii) apron spring.

a. Heavy base arch wire

Wire used: 0.9 mm or 19 gauge hard stainless steel wire.

Design (Fig. 18.50)

• A high labial arch with vertical arms incorporated and

relieved in the areas of labial and buccal frenum provides
the base arch.

• High labial arch should not contact the mucosa and should
not extend deep into the full depth of the sulcus.

b. Apron springs

• Apron springs are used with high labial bow.

• Apron springs constitute the active component.

• Apron springs are attached to the base arch by winding a

few turns in vertical arms and then two or three turns in the
horizontal arm.

• Apron springs are bent into shape according to the number

of teeth to be moved lingually.
 FIG. 18.48. Roberts retractor.

FIG. 18.49. Mills retractor or extended labial bow.

FIG. 18.50. High labial bow with apron springs.

Screws
➤ Screws are active component of removable orthodontic appliances (Fig. 18.51).

➤ An orthodontic screw has its two ends threaded in opposite direction.

➤ When they are opened, the metal ends move apart.

➤ The screw is activated by opening the screw.

➤ For each activation, one quarter turn of screw is given.

➤ One-quarter turn (¼) of the screw will separate the base plate by 0.2 mm.

➤ This is equal to the width of the periodontal ligament.

➤ The screw is activated by quarter turn each week.

FIG. 18.51. Orthodontic expansion screw.

Types of screws used in removable appliance

1. Badcock screw

2. Glenross screw

3. Sprung Glenross screw

4. Nord screw
5. Double screw

Uses of screws
➤ Screws are used for anteroposterior expansion.

➤ Screws are used for lateral expansion.

➤ Screws can be used for contraction of expanded maxillary arch.

➤ Labial movement of teeth.

➤ Mesial or distal movement of teeth.

Note
➤ Expansion screws are mainly used in the maxillary arch.

➤ Expansion screws have been tried in mandibular but with only little or no result.

➤ Appliances which incorporate screws are called Schwarz appliance or plate.

Elastics
➤ Elastics are active components of orthodontic appliances.

➤ Elastics are either made of rubber or latex.

➤ Elastics are available in various sizes.

➤ They can be broadly classified into two types: (i) Intraoral elastics and (ii) extraoral
elastics.

➤ Intraoral elastics are rarely used with removable appliances. Sometimes used with
hook for retraction of incisors.

➤ Elastic usage is not advisable with removable appliances.

Uses (refer chapter 22 for use of elastics with fixed appliances)

➤ Used with extraoral traction.

➤ Provides intermaxillary traction.

Disadvantages
➤ Slipping of elastic takes place and results in gingival damage.

➤ Using elastics directly to the tooth causes extrusion of the tooth because the elastics
tend to slip apically and can even lead to loss of tooth.
Orthodontic pliers
The different types of pliers used in fabrication of removable appliances:

1. Universal pliers

2. Adams’ pliers

3. Loop-forming pliers

4. Hollow chop pliers

5. Arrowhead-forming pliers.

1. Universal pliers (Fig. 18.52)

Universal pliers are used for all types of wire bending. The
beaks of the pliers are parallel when a wire is gripped.
2. Adams’ pliers/Adams’ universal pliers (Fig. 18.53)

The dimensions of the Adams’ pliers are given in Fig. 18.53.

• The distance between the hinge pin and tip of the beak is
less.

• Sides of the beak are flat.

• The edges of the grasping surfaces are sharp.

• The grasping surfaces should be textured.

• When the beaks are closed, tips are in contact but there is a
gap at the hinge which is about 0.6 mm.
3. Loop-forming pliers (Fig. 18.54)

• Loop-forming pliers have round and tapered beaks.

• They are used for making loops or coils of different sizes.
4. Hollow chop pliers (Fig. 18.54)

• These pliers are used for making bends in the wire which are
fixed to the acrylic plates.

• One beak of the plier is round and the other hollowed.

• Used for activation of buccal canine retractor.

5. Arrowhead-forming pliers

• This plier was designed by AM Schwarz.

• It is used to make arrowhead clasps.

FIG. 18.52. Universal pliers.

FIG. 18.53. Adams’ universal pliers.

FIG. 18.54. Hollow chop pliers.
Base plate
➤ Base plate serves to hold the components of the removable appliances.

➤ Base plate forms the framework of the appliance.

➤ It is usually made of either cold-cured or heat-cured resins.

Functions
1. As a base of operation

i. Supports the wire or screw components

ii. Transmits forces from the active components

iii. Protects the palatal springs

iv. Facilitates movement, e.g. posterior bite-blocks

2. As anchorage

i. Prevents unwanted movement of teeth

ii. Contacts with teeth and palate (contributes to anchorage)

3. As an active component

i. Split plate

ii. Anterior bite plane

iii. Upper anterior inclined plane.

Materials used
➤ Base plates are made either from cold-cured or heat-cured acrylic.
➤ Cold-cured acrylic is commonly used because it is simple to process and chances for
thermal distortion are less.

➤ But heat-cured acrylic is stronger.

➤ Clear acrylic resin is preferred because any pressure spots can be visualized by the
presence of blanching with the appliance.

Requirements for choice of material

➤ It should be easily cleansable by the patient.

➤ It should be rigid and strong.

➤ Resistance to abrasion is required.

➤ Any pressure point should be visualized with the appliance.

➤ Biocompatible.

➤ It should not degrade in oral environment.

➤ Any deposits should be easily discernible.

Dimensions of base plate

Maxillary plate
➤ Size: 1.5–2 mm thick.

➤ Extension: Extended up to distal of first permanent molar.

Mandibular plate
➤ 1.5–2 mm thick.

➤ Extends up to distal of first permanent molar.

➤ Base plates should not be made unduly thick. Single thickness of wax shall be used
and the base plate thickened over the wire tags only.

Anterior bite planes (fig. 18.55)

➤ Anterior bite planes are used to reduce deep bite.

➤ They are also used for relieving occlusal interference.

➤ In cases with anterior bite plane, labial bow should not be activated.

➤ With the opening of bite, bite plates are trimmed and then labial bow is activated for
lingual movement of teeth.

FIG. 18.55. Flat anterior bite plane.

Posterior bite planes/molar capping (fig. 18.56)

Posterior bite plane is used to get occlusal clearance to tooth movement during
correction of anterior crossbite. The thickness should be just enough to clear the
occlusion.

FIG. 18.56. Posterior bite plane.

Hawley appliance and retainer
➤ Hawley appliance is the most basic type of removable appliance.

➤ Hawley type appliance is the most useful removable appliance used by dental
surgeons. It is used for preventive, interceptive and limited corrective orthodontics.

➤ Hawley appliance is called dental crutch.

Indications
➤ It is useful for closing of spaces in the anterior region.

➤ It is used to retract minor proclination.

➤ It is used as retainer appliance. It is called Hawley retainer.

➤ Hawley appliance with bite plane is used for deep bite correction.

➤ Used in TMJ problem.

➤ It is used as a habit breaking appliance.

➤ Hawley appliance with bite plate removes the restraining effect in mandible and
allows further growth.

Design (fig. 18.57)

The basic appliance consists of three parts: (i) Labial bow, (ii) base plate and (iii) clasps
on molars for retention.
 FIG. 18.57. Hawley retainer.

Differences between Hawley appliance and retainer are depicted in Table 18.2.

Table 18.2.
Hawley appliance and Hawley retainer: Differences

S.
Hawley appliance Hawley retainer
no.
1. This is an active appliance This is a passive appliance
2. It is used to correct spacing and retraction of minor proclination It is used as a retention appliance
3. The acrylic plate behind the incisor is trimmed to facilitate palatal The acrylic plate extends up to the palatal surfaces in the form of collars
movement of incisor extending interdentally also
4. Labial bow is activated Labial bow should not be activated

Most of the other removable appliances are modifications of Hawley appliance.

Construction
➤ Fabrication of labial bow

➤ Fabrication of clasp

➤ Base plate fabrication

➤ Trimming and polishing

➤ These are the steps involved in the constructions of the Hawley appliance.
Insertion of removable appliance
Insertion of removable appliance involves several steps: (i) Before the patient’s arrival,
(ii) with the patient and (iii) follow-up visit.

1. Before the arrival of patient

• Check that the appliance has no sharp projections.

• Check for the fit of the appliances in the model.

• Make sure the wire components are positioned correctly.

• Check for the free movement of active components.

• There should not be undue delay in insertion of appliance.

Large time delay between fabrication and insertion can lead
to warpage.

• Make sure that the appliance does not get interchanged.

2. With the patient/instructions to patient

• Fit of the appliance should be checked in patient’s mouth.

• Adjust the extension of base plate, if required.

• Adjust the active components.

• Measure the position of tooth; this helps to monitor the

treatment progress.

Patient instructions:

• Demonstrate the appliance insertion and removal to the

 patient.

• Instruct the patient to remove and insert the appliance

without help.

• Instruction about duration of wear to be given. Most of the

appliances are worn full time.

• Inform patient of the initial difficulties in getting used to the

appliance, e.g. difficulty in eating and speaking.

• Cleaning of the appliances should be taught.

• Importance of maintenance of oral hygiene should be

stressed upon.

• Careful storage of appliance should be stressed to prevent

distortion.

• Give subsequent appointment. Usually, subsequent

appointment will be after 4 weeks.

• Patient is instructed to report immediately, if there are any

problems because of the appliance or if there is any damage
to the appliance.
3. Follow-up visit

• Ask for any difficulties encountered.

• Repeat the measurement to assess treatment progress.

• Adjustment of the retentive component.

• Activation of the active components.

• Inform the patient about the improvements noted.

• Check for patient cooperation.

• Check for oral hygiene status.

• Check for trauma by the appliance resulting in gingival

enlargement.
Failures of removable appliance/unsuccessful
removable appliance therapy
Failure of removable appliance is due to three important reasons: (i) Poor patient
cooperation, (ii) iatrogenic factors and (iii) intrinsic factors.

1. Poor patient cooperation

Most important cause for unsuccessful treatment with

removable appliance is lack of patient cooperation in
wearing the appliance.

Signs of poor patient cooperation:

• Little or no tooth movement.

• No outline of the shape of base plate in the palatal mucosa.

• Persisting speech difficulty.

• Patient’s inability to remove and insert the appliance.

• Appliance looks new.

• Improper fit due to warpage of the appliance.

• Patient sometimes will admit.

• Patient misses out the appointments.

2. Iatrogenic factors

• Treatment with wrong choice of appliance.

• Treatment with wrong choice of extraction.

• Improper designing of appliance.

• Inadequate anchorage control.

• Improper fabrication of the appliance.

• Improper activation.

• Ineffective retention.

• Appliance causing trauma to the mucosa.

• Patient given wrong instructions.

• Improper trimming of base plate, e.g. failure to give relief in

areas where tooth movement is required.

• Failure to correct the underlying aetiology.

3. Intrinsic factors

• Ankylosed tooth

• Dilacerated root

• Narrowing of bones

• Skeletal problems
In the above mentioned intrinsic conditions, in spite of a correctly designed,
constructed, adjusted and worn appliance, teeth fail to move in the desired direction
and period.
ACCESSORY POINTS
➤ The earliest removable appliances had their bases made of vulcanite.
➤ Removable appliance generates intermittent force.

➤ Labial bow was designed by Charles A Hawley.

➤ Arrowhead clasp was designed by Schwarz.

➤ The most versatile of all clasps is modified arrowhead clasp or Adams’ clasp.

➤ The most important step in the fabrication of Adams’ clasp is establishing the bridge
length.

➤ The angulation of the arrowhead to the bridge in Adams’ is 45°.

➤ Mandibular removable expansion device was devised by Schwarz.

➤ Simultaneous anterior and posterior expansion can be achieved by Y-plate.

➤ In bite plate therapy, the labial bow is used to prevent flaring of incisors.

➤ Crossed cantilever spring is used in labial movement of four incisors.

➤ Split labial bow was designed by Bass NM and Robinson SN.

➤ Clear acrylic is preferred to coloured acrylic as base plate material because areas of
irritation can be detected.

➤ Canine retractor is an example for open-end spring.

➤ Helix or coil is incorporated in a spring to increase the flexibility and range of action.

➤ Modulus of elasticity refers to rigidity or stiffness of the wire.

➤ Posterior bite plane is used to aid in the correction of anterior crossbite.

➤ Catlans appliance is used to correct anterior crossbite.

➤ Repeatedly flexing a spring below its elastic limit leads to fatigue of the wire.

➤ Robert’s retractor is a type of labial bow.

Recommended wire thickness for clasps

S. no. Component Wire diameter
1. Adams’ clasp for molars 0.7 mm/21 gauge
2. Adams’ clasp for premolars 0.7 mm/21 gauge
3. Adams’ clasp for deciduous canines and molars 0.6 mm/22 gauge
4. Double Adams’ for anterior teeth 0.7 mm/21 gauge
5. Southend clasp 0.7 mm/21 gauge
6. C clasp 0.9 mm/19 gauge
7. Triangular clasp 0.7 mm/21 gauge
8. Jackson’s clasp 0.9 mm/19 gauge
9. Delta clasp 0.7 mm/21 gauge
Recommended wire thickness for active component
S. no. Component Wire diameter
1. Labial bow 0.7 mm
2. Reverse labial bow 0.7 mm
3. Roberts retractor 0.5 mm in 0.5 mm internal diameter tubing
4. Mills retractor 0.7 mm
5. Apron springs 0.3–0.4 mm
6. High labial bow 0.9 mm
7. Buccal canine retractor 0.7 mm
8. Helical loop canine retractor 0.7 mm
9. U-loop canine retractor 0.7 mm
10. Cantilever springs 0.5 mm
11. Finger springs 0.5 mm
12. Palatal canine retractor 0.5 mm
13. T-springs 0.5 mm
14. Coffin springs 1.25 mm

Advanced Learning
Designing of removable orthodontic appliances
Designing of removable appliances can be studied under six stages:
Stages of designing ( fig. 18.58)
Stage 1: Identification of movable portion

Path of movement

FIG. 18.58. Removable appliances: Designing.

Sequence of movement

Multiple movements
➤ The tooth to be moved must be clearly identified together with the desired path of
movement.

➤ This will govern the design of activation system.

➤ Should multiple movements be required, the sequence and methods of these

movements must be assessed.

➤ For example, some patients may require single tooth crossbite correction with
proclination correction.

➤ In such cases correct crossbite first, followed by proclination correction.

Stage 2: Identification of stable portion

Appliance minus the movable portion is the stable portion

Contains both retention and anchorage systems

➤ Once the movable or active portion has been established, the remainder of the
appliance will be the stable portion of the appliance.

➤ Stable portion includes two portions: Retention and anchorage.

➤ This distinction helps to check whether stable anchorage is maintained during

movement of teeth.

➤ Too often while designing appliances, concern is directed towards moving the teeth,
without analysing from where and how these movements are possible.

➤ The broad expanse of palate permits the tissue-borne appliances to distribute the
stresses created and provide adequate retention at the same time.

➤ Reinforce the anchorage wherever required.

Stage 3: Designing of activation system

Springs

Labial bows

Screws

Elastics

Base plate
Stage 4: Direction of movement
Labial and buccal movement

Lingual movement

Mesiodistal movement

The different springs used to achieve tooth movements in various directions:

Labial and buccal movements
➤ Cantilever springs

➤ Expansion screws

➤ Inclined plane

➤ T-springs

➤ Coffin springs
Lingual movement
➤ Labial bows

➤ Lingual movement of premolars

Mesiodistal movement
➤ Finger springs

➤ Canine retractors

➤ Split labial bows

➤ Expansion screws

➤ Headgears
Stage
The 5: Analysis
correct of displacing
spring forces
for the patient hasand methods
to be selectedtoaccording
prevent displacement
to the need. of
appliance

Force of displacement

Effective retention with clasps

Anchorage

Stabilization of reactionary parts

➤ When a force of a spring or active component is applied to the curved surface of

teeth, the force of reaction have two components: (i) Force of reaction and (ii) force of
displacement.

➤ Force of reaction is directed distally opposite to the line of force.

➤ Force of displacement is directed downwards and backwards (Fig. 18.59).

➤ Compensation is made in the design of appliance to prevent the appliance from

getting dislodged from the mouth.

➤ Clasps are effective in counteracting these reactionary forces.

➤ If required, additional clasps should be given.

➤ Rule of thumb in placing second clasp is that it should be located close to the area of
displacement.

➤ In case of retraction of anterior teeth, second clasp is placed in premolar area.

➤ In case of protraction, clasp is placed anteriorly.

 FIG. 18.59. Analysis of displacing forces.

Stage 6: Planning for extra attachments

Extra attachments

Headgears, elastics

➤ The last step in designing of removable appliances is planning for extra attachments.

➤ Extra attachments are added for the purpose of tooth movement or reinforcement of
anchorage.

➤ These include elastics, headgears.

Fabrication of removable appliance
➤ Removable appliances are processed using acrylic.

➤ Clear acrylic is preferred over pink acrylic since pressure spots are easily made out
with clear acrylic.

➤ Processing of appliance is done in two ways: (i) Using heat-cured acrylic or (ii) using
cold-cured acrylic by either sprinkle on method or bulk method.

1. Heat-activated resins or heat-cured resins

Benzoyl peroxide when heated to 60°C liberates free radicals. Free radicals in turn
will initiate polymerization.
Processing:
Processing of removable appliance with heat-cured acrylic is done using compression
moulding technique.
Master cast and completely waxed up appliance with the wire components is flasked
with dental stone.
2. Cold-cured resins or chemically activated resins

Dimethyl-p-toluidine reacts with benzoyl peroxide to release

free radicals. Free radicals initiate the polymerization
reaction.

Processing
Sprinkle-on technique/pepper salt technique
• Soak the working model in water for 15 min. This prevents
the absorption of liquid monomer by dry cast.

• Divide the palatal portion of the upper model into four

parts. Lower model also can be divided into three segments
(Fig. 18.60).

• Coat the palatal surface with a thin layer of separating media

using a brush.

• With a plastic applicator bottle, liquid monomer is added to

the polymer powder in the first section of the palate.
Polymer powder is added to a thickness of 1.5–2 mm.

• Procedure is done in all the segments. If anterior bite plane is

required, a flat area is built in segment 2.

• Curing is done in a bowl of warm water or pressure pot for

approximately 20 min.

• Appliance is removed after 30 min, trimmed and polished.

Bulk technique

• Bulk technique involves mixing powder and liquid

monomer separately in a mixing jar. The prepared mix is
placed over the wet model and contoured or adapted to the
required level after applying separating media.
Appliance trimming

Trimmed appliance should look like the one given in Fig. 18.61.

• Appliance should be bevelled from the tissue level to the

area of contact.
• An area of tissue relief is incorporated to prevent tissue
impingement.

• The trimmed appliance is polished and kept ready for

insertion.

FIG. 18.60. Division of the maxillary cast into four parts.

FIG. 18.61. Orthodontic appliance trimming.
Treatment of various malocclusions by
removable mechanical appliances
Table 18.3 depicts treatment of various types of malocclusion by removable mechanical
appliances.

➤ All the appliances will have clasps in first permanent molar.

➤ Adams’ clasp is the most preferred type of clasp.

➤ Circumferential clasps are also used widely.

➤ Wherever required additional retention is given.

Table 18.3.
Malocclusions and methods of treatment

S. no. Condition Methods of treatment

1. Anterior crossbite 1. Hawley appliance with posterior bite plane and ‘Z’ spring to correct the tooth in crossbite
2. Upper anterior expansion (Schwarz appliance) with posterior bite plane
3. Inclined plane, if the bite is deep
2. Posterior crossbite 1. Schwarz type lateral expansion with posterior bite plane for occlusal clearance
2. Hawley appliance with posterior bite plane and T-springs or ‘Z’ springs to correct the tooth in crossbite
3. Median diastema 1. Upper Hawley appliance with two finger springs to move both the central incisors mesially
2. Upper plate with split type labial bow
3. Simple Hawley appliance, if the median diastema is due to proclination
4. Mild proclination 1. Hawley appliance
2. Hawley appliance with long labial bow, if there is space distal to canine
5. Moderate proclination 1. Roberts’ retractor
2. High labial bow with apron spring
6. Generalized anterior spacing 1. Hawley appliance with the base plate trimmed on the palatal aspect
7. Buccally placed canine 1. Buccal canine retractor when palatal and distal movements are required
2. Helical loop canine retractor when the sulcus depth is shallow
8. Palatally placed canine 1. Hawley appliance with ‘Z’ spring and posterior bite plane when only buccal movement is required
2. Palatal canine retractor with posterior bite plane when both distal and buccal movements of canine are required
9. Buccally placed premolar 1. Spring for palatal movement of premolars
10. Deep over bite 2. Upper Hawley appliance with flat anterior bite plane
11. Anterior open bite 1. Upper Hawley appliance with tongue spikes, if it is due to habits
2. Posterior bite planes to intrude molar
CHAPTER 19
Functional appliances

CHAPTER OUTLINE
❖ Definition and classification of functional appliances
❖ History of maxillofacial orthopaedics
❖ Principles of functional appliance therapy
❖ Mechanism of action of functional appliances
❖ Craniofacial response or effects produced by functional appliances
❖ Ideal requirements of functional appliances
❖ Clinical visualized treatment objective
❖ Guidelines for case selection for functional appliances
❖ Advantages and limitations of functional appliances
❖ Bite planes used in orthodontics
❖ Vestibular/oral screens
❖ Lip bumper
❖ Activator
❖ Modifications of activator
❖ Bionator
❖ Functional regulators and their types
❖ Indications of functional regulator
❖ Mechanism of action of Frankel appliance
❖ Functional regulator I
❖ Functional regulator III
❖ Clinical management of functional regulators
❖ Differences between activator and functional regulator
❖ Twin block
❖ Accessory points
❖ Advanced learning
❖ Fixed functional appliances
❖ Action of functional appliances through theories of
growth
Definition and classification of functional
appliances
There are various definitions of functional appliances.

1. Definition (Proffit WR): Functional appliances are appliances which alter the posture
of the mandible, holding it open or open and forward or backward.

2. Moyer’s definition: Functional appliances are loose removable appliance designed to

alter the neuromuscular environment of the orofacial region to improve occlusal
development and/or craniofacial skeletal growth.

3. Functional appliances are appliances which act by either harnessing the muscular
forces or by preventing aberrant muscular forces from acting on the dentition.

Functional appliances are also called functional jaw orthopaedic appliances.

Classification of functional appliances

There are various methods of classification of functional appliances:

i. Functional appliances

• Tooth-borne passive (Proffitt, 1993): No intrinsic force

generating capacity, e.g. bionator, twin block, Herbst,
activator.

• Tooth-borne active: Includes springs or screws in functional

appliances, e.g. activator modifications.

• Tissue-borne

• Frankel appliances
ii. Group 1: Transmits muscle force directly to the teeth, e.g. inclined plane, oral screen.

• Group 2: Transmits force to teeth as well as other structures,

e.g. activator.
• Group 3: Operates from vestibule, e.g. Frankel appliance.
iii. Myotonic appliances (Houston WJB, Stephens CD and Tulley WJ 1993: Rely on
muscle mass for action, e.g. activator, bionator.

• Myodynamic appliances: Rely on muscle movements or

dynamic properties, e.g. Bimler. Frankel appliance does not
fit into any of these two groups.
iv. Removable functional appliances

• Activator, twin block, bionator, Frankel

Fixed functional appliances

• Herbst, Jasper Jumper, Forsus

v. Acts by force application: Majority of functional appliances act by force application,
force elimination – vestibular shields, Frankel.
History of maxillofacial orthopaedics
The development of functional appliances can be correlated with the work of various
persons who had contributed to functional appliances concept (Table 19.1).

Table 19.1.
Evolution of functional appliances

S.
Name of person Contribution
no.
1. Norman Kingsley (1879) The earliest reference to orthopaedic appliance is Kingsley’s ‘jumping the bite’ appliance to reposition the mandible
2. P Robin (1902) Robin combined the repositioned mandible with bimaxillary expansion into a single appliance called monobloc
3. Andresen and Haupl Andresen’s appliance or activator was introduced. The original name of the appliance is biomechanical working retainer
(1920)
4. Harvold (1960) Vertical activator with increased vertical opening
5. Stock fish (1966) Developed kinetor
6. W Balters (1960’s) Developed bionator – a skeletonized activator
7. Rolf Frankel (1966) Introduced Frankel appliance or functional regulator as exercise device. Appliances operated from vestibule
8. Hans Pancherz (1979) Popularized Herbst appliance, a fixed functional appliance
9. William Clark (1982) Introduced twin block, which overcame the main drawback of functional appliance. Appliance could be worn while eating,
during speech
10. Graber and Vardimon Magnetic functional appliance therapy
(1989)
Principles of functional appliance therapy
➤ The most important principle underlying the functional appliance therapy is the
adaptation between form and function. Functional appliances induce change either in
form or function.

➤ Neuromuscular adaptation allows the form and function to get adjusted.

➤ Functional appliances work by two principles: (i) Force application and (ii) force
elimination (Fig. 19.1).

FIG. 19.1. (A) Force elimination and (B) force application.

Force application
Appliance worn by the patients produces the following effects:

➤ Force applied to dentition and underlying basal bone induces change in the form or
shape.

➤ Secondary adaptation of function to the form takes place.

➤ Most of the removable appliances and fixed appliances work by this principle.

➤ Subsequent to change in form, the neuromuscular response brings about adaptation

 in function to the new form.

Force elimination
Appliance worn by the patient induces the following changes:

➤ Abnormal and restrictive muscular forces are prevented from acting on the
developing dentition and jaws.

➤ Function is rehabilitated or changed.

➤ This is followed by secondary adaptation in form according to the new rehabilitated

function.

➤ Vestibular shields, Frankel appliances act by this principle.

Neuromuscular response
➤ The success of functional appliance treatment depends on the neuromuscular
response.

➤ Functional appliance treatment induces change in either form or function.

➤ Secondary adaptation of form to function or adaptation of function to form occurs

due to the neuromuscular response.
Mechanism of action of functional appliances
The various mechanisms of action of functional appliances:

➤ Re-education of musculature

➤ Lateral pterygoid muscle stimulation

➤ Decreased biochemical feedback

➤ Unloading of mandibular condyle

➤ Transduction of viscoelastic forces

➤ Differential eruption of teeth

1. Re-education of musculature

• Continuously holding the mandible forward in class II cases,

muscles will be obliged to learn a new functional pattern.

• Muscular adaptation takes place subsequent to functional

appliance therapy.
2. Lateral pterygoid muscle stimulation (Fig. 19.2)

• Increased activity of the superior head of lateral pterygoid

muscle is associated with functional appliance wear.

• Skeletal adaptation proceeds until muscle activity is

restored. The sequence of the effects produced by functional
appliance is as follows:
3. Decreased biochemical feedback

• Zone of functional chondroblasts in condyle secretes a

substance that retards mitotic activity of stems cells – a sort
of negative feedback.

• Stimulation of lateral pterygoid subsequent to functional

appliance wear causes quick maturation of chondroblasts,
consequently secreting less ‘negative feedback’ material.

• Removal of this biochemical brake causes acceleration of

condylar growth.
4. Unloading of condyle (Fig. 19.3)

• Condyle is normally subjected to pressure.

• When the functional appliance is used, condyle is distracted

from fossa, thereby facilitating an increased growth.

• Adaptation to the new position occurs through condylar

 growth as shown by the arrow in Fig. 19.3.
5. Transduction of viscoelastic force

Functional appliances harness the passive tension arising from

the inherent elasticity in muscle, skin and tendinous tissue
and transmit to the dentition.
6. Differential eruption of teeth

Eruption pattern is modified as per the need by placing molar

stops, and by providing acrylic guide planes.

FIG. 19.2. Parts of lateral pterygoid muscle and retrodiscal pad. Stimulation of lateral
pterygoid and retrodiscal pad takes place with the functional appliance wear.
FIG. 19.3. Unloading of condyle. Arrow indicates posterosuperior elongation of mandibular
condyle and adaptation to new position.
Craniofacial response or effects produced by
functional appliances
Functional appliance therapy is directed at the cause of malocclusion. The changes
produced by functional appliances can be studied under the following headings: (i)
Dentoalveolar changes, (ii) skeletal changes, (iii) neuromuscular adaptation and (iv)
muscular changes.

1. Dentoalveolar changes

The reduction of overjet and overbite occurs rapidly with

functional appliances in class II malocclusion. Following
reasons are attributed to reduction in overjet and overbite.

• Proclination of lower anteriors

• Retraction of upper anteriors

• Differential eruption of teeth

• Relative intrusion where the lower incisors are prevented

from supraerupting and molars are allowed to erupt. This
causes opening of the bite or deep bite correction.
2. Skeletal changes

Skeletal changes are seen in both maxilla and mandible.

In class II

i. Midface restriction

a. Restriction of forward maxillary growth is observed

(Weislander L, 1993).
 ii. Mandibular growth induction

a. Growth acceleration of mandible takes place (Dermaut LR

and Aelbers CMF, 1996).

b. Change in condylar position.

c. Glenoid fossa remodelling (James A McNamara, 1973).

d. Redirection of condylar growth (Mills JRE, 1991).

In class III

i. Stimulation of maxillary growth.

ii. Restriction of mandibular growth.

3. Changes in neuromuscular anatomy and function

• Neural excitation is produced by all functional appliances.

• Functional appliances register a new sensory engram for

mandibular position.

• Correct neural stimulation of temporomandibular joints

(TMJ), muscles, periodontium and mucosa produces good
stomatognathic equilibrium.
4. Muscular changes during functional appliances

• Elongation of muscle fibres.

• Migration of muscle attachment along bony surfaces.

• Changes in muscle dimension are observed.

Ideal requirements of functional appliances
Following are the ideal requirements of functional appliances:

➤ They should be comfortable and acceptable for the patients.

➤ They should promote better compliance.

➤ They should offer good range of mandibular movements.

➤ They should be simple and inexpensive.

➤ They should be easy to fit.

➤ They should be adaptable to both class II and class III malocclusions.

➤ When used with fixed appliances, they should not cause breakage of fixed appliance
components.

➤ They should be usable in both mixed and permanent dentitions.

➤ They should provide good results with minimal patient cooperation.

Clinical visualized treatment objective
Clinical visualized treatment objective (VTO) helps in analysing whether functional
appliances will be beneficial for the patient. It also helps in patient motivation.
An improvement in profile means positive VTO and functional appliances are
indicated.

Class II visualized treatment objective

➤ Clinical VTO was advocated by Thomas D Creekmore as an aid to decide about the
type of appliance in skeletal class II malocclusion.

➤ Procedure consists of asking the patient to bring the mandible to an edge-to-edge bite
relationship.

➤ Change in the appearance of the patient is noted at two levels: (i) One at edge-to-
edge position and (ii) the other at a position midway between the existing occlusion
and edge-to-edge position.

➤ If the profile worsens at edge-to-edge position, it means the fault lies in maxilla. It is
a case of maxillary prognathism and appliances like maxillary intrusion splint or
headgears are advised.

➤ If the profile improves at edge-to-edge position, it means the fault lies in the
mandible. It is a case of mandibular retrognathism. Functional appliances to stimulate
mandibular growth are indicated.

➤ If the profile improves midway, it is a case of combination of maxillary prognathism

and mandibular retrognathism. Appliances like activator headgear, twin block with
headgears are indicated.

Visualized treatment objective for class III

➤ In cases of patients with class III malocclusion, rolls of cotton are kept in the upper
labial vestibules.

➤ In cases with maxillary retrusion, the profile improves with the cotton roll.

➤ In class III due to prognathic mandible, the profile worsens.

Guidelines for case selection for functional
appliances
In general, functional appliances are used in the treatment of class II division 1
malocclusion. The criteria for case selection are as follows:

1. Skeletal criteria

• A decreased lower facial height based on profile assessment

(low angle case).

• Proportionate facial balance between upper and middle face.

• Mild to moderate class II facial pattern.

• Positive VTO.
2. Dental criteria

• No crowding in the maxillary or mandibular dental arches.

• A good mandibular arch with no rotations or displacement

of teeth.

• Relatively flat mandibular occlusal plane.

• No labial tipping or flaring of the mandibular incisors.

• Moderate deep overbite.

• Anteroposterior molar class II relationship.

• Preferably no midline asymmetry.

3. Soft tissue criteria
• Competent or potentially competent lips where the lower lip
will be able to stabilize the upper teeth after correction.

• Muscular pattern that does not exhibit undue tightness.

4. Emotional criteria

• Keen patient interest and desire from both parent and

patient.

• Patient’s potential cooperation is highly essential.

5. Respiratory criteria

• No nasal obstructions or chronic respiratory disorders.

6. Age/growth criteria

• Functional jaw orthopaedics is primarily indicated in

patients who have still growth left in them.
The ideal age for commencement for appliance is late mixed dentition stage, i.e. by 9
years of age.

Class III cases

➤ Functional appliances are used in the management of class III due to retrognathic
maxilla in a growing child.

➤ Remember: Functional appliances are used to correct deficiency states only.

• Correction of mandibular deficiency

• Correction of maxillary deficiency

Advantages and limitations of functional
appliances
Advantages
➤ Functional appliances are effective in cases where dysfunction is the cause for
malocclusion.

➤ They are most effective in the correction of class II malocclusion in children in the
mixed dentition period.

➤ They can be used to correct open bite and deep bite cases.

➤ Maintenance of oral hygiene is easier with functional appliances.

➤ Requires less chairside time.

➤ Restores muscular balance.

➤ Since treatment is initiated in mixed dentition stage, the possibility of psychological

trauma to the child because of malocclusion is reduced.

➤ Functional appliances try to correct the skeletal problems.

Limitations
➤ Most of the functional appliances are bulky and, therefore, inconvenient for the
patients.

➤ Patient cooperation is not good.

➤ A good degree of expertise is required in the management of functional appliance.

➤ Not suitable for adults with skeletal problems.

➤ Individual tooth problems cannot be corrected.

➤ Not suitable for high angle cases.

➤ Cannot be used in cases with crowding. Minor crowding, if present, has to be

corrected prior to functional appliance treatment.

➤ Second phase of treatment with fixed appliance is usually required to obtain detailed
 finishing of occlusion.

➤ Not suitable for nongrowing patients.

Bite planes used in orthodontics
Bite planes are extension of the base plate which serves different functions apart from
forming the framework of the appliance.
Bite plane is the simplest form of functional appliance. Kingsley is supposed to be the
originator of bite plane.
Bite planes are classified in the following ways:

1. Bite planes parallel to occlusal plane (horizontal)

a. Upper anterior flat bite plane

b. Posterior bite planes

2. Bite planes inclined at an angle to the occlusal plane (inclined)

a. Upper anterior inclined planes

b. Lower inclined planes: (i) Cemented inclined plane

(Catlan’s appliance) and (ii) removable inclined plane
1. Horizontal bite planes

Horizontal bite planes are designed to produce axial stresses

on the teeth. They are mainly used for two reasons: (i)
adjustments of vertical relationship of teeth, (ii) prop or
open the bite to facilitate tooth movement, e.g. correction of
anterior crossbite.

a. Upper anterior flat bite plane (Fig. 19.4)

This consists of acrylic platform made parallel to the occlusal

plane which is present behind the upper incisor teeth on
which the lower incisor bites.

Mechanism of action:
• Bite planes cause differential eruption of posterior teeth.

• Anterior bite planes are most successful, if they are used in

patients who have large interocclusal clearance.

• Bite opening by anterior bite plane should not interfere with

normal free way space.

• When the appliance is worn, the posterior teeth are freed

from mastication and occlusion. So, the posterior teeth
supraerupt and cause reduction of deep overbite. This effect
is known as ‘opening the bite’.

• Bite planes also cause relative intrusion.

• The posterior teeth should be maintained at 2–3 mm

separation.

Bite plane with labial bow:

• The important side effect of anterior bite plane is the labial

proclination of the upper anterior teeth (Fig. 19.5).

• This can be minimized by placing a labial bow. The idea of

placing a labial bow in upper anterior bite plane is to
prevent labial proclination of upper incisors.

• The labial bows should not be activated for retraction with

bite planes.

• After the overbite has been reduced, the bite plane is

trimmed and then the upper incisors are retracted.

Sved bite plane (Fig. 19.6A):

• Another method to prevent labial proclination of upper
incisor with bite plane is by using Sved bite plane.

• Sved, Alexander in the year 1944, modified the bite plane by

extending the acrylic plate to cover the incisal edges of the
upper anterior teeth.

• This eliminates the forward component of force which

causes proclination.

• Sved bite plane is a highly satisfactory method of supporting

the bite while allowing the posterior teeth to erupt.

• Sved bite planes should be worn while eating.

• Sved bite planes are a form of reinforced anchorage.

Uses of anterior bite planes:

• Used to reduce the overbite.

• Used to correct TMJ problems.

• Correction of bruxism.

• Correction of occlusal prematurities.

• Used as a periodontal splint.

• Eliminates functional retrusion effects.

• Promotes increase in mandibular intercanine width since the

restricting influence of the maxillary arch is removed.
• Used as a dental crutch.

b. Posterior bite plane (Fig. 19.6B)

Posterior bite planes are used to disocclude the teeth to

facilitate tooth movements. Posterior bite-blocks are also
used in vertical activators where they cause intrusion of
posteriors.
2. Inclined planes

Inclined planes are designed to produce stresses lateral to the

long axis of the teeth. They cause movement of the teeth in
labial direction.

a. Upper anterior inclined plane (Fig. 19.7)

The appliance looks like a flat anterior bite plane.

• The difference is the incorporation of an anterior inclined

plane to engage the lower incisors and cause the mandible
to slide anteriorly.

• Normally, the guide plane has angulations of approximately

45° with a seating groove for the lower incisors to reduce the
labial tipping of lower anteriors.

• The upper anterior inclined plane is also used as retention

appliance after functional appliance therapy like twin block.

b. Lower inclined planes – Catlan’s appliance/design and

construction of an appliance for correction of anterior
crossbite
Introduction:

• Lower inclined plane is an appliance used for the correction

of anterior crossbite when one or more upper teeth are in
lingual relation to lower incisors.

• This appliance was introduced by Catlan 150 years ago.

• Appliance should not be worn for more than 3 weeks.

Indications:

• The lower inclined plane is indicated during the eruptive

stages of incisors when there is a good degree of overbite.

• All inclined planes cause opening of the bite by allowing

posterior teeth to erupt.

Contraindication: Inclined planes are contraindicated in cases

without sufficient overbite.

Advantages of inclined plane:

• Easy to fabricate.

• Correction of crossbite is very fast because functional forces

are used.

• Trauma to tooth is minimal.

• Minimal or no relapse.

Disadvantages of inclined plane:

• Difficulty in eating with the appliance.

• Speech problems.

• If the appliance is worn for a long time, it leads to anterior

open bite.

• Appliance has to be removed to check the correction

achieved.

• Precise alignment of the teeth is not achieved.

• Overeruption of posterior teeth leads to anterior open bite.

FIG. 19.4. Upper anterior flat bite plane. Lower incisor occludes with the flat anterior bite
plane.
FIG. 19.5. (A) Labial thrust of bite plate appliance and (B) labial bow counteracts the labial
thrust.
 FIG. 19.6. (A) Sved bite plane. The labial or forward thrust of the bite plate appliance is
counteracted by the acrylic plate which covers the incisal edges, (B) posterior bite plane.

FIG. 19.7. Upper anterior inclined plane.

Appliances
Removable lower inclined plane (fig. 19.8)
➤ Removable lower inclined plane is a frequently used appliance.

➤ It produces satisfactory result.

➤ It is fabricated by merely adding an inclined plane to a removable mandibular

 Hawley-type appliance, at an angle of 45° to the occlusal plane.

➤ Clasps are used for retention purpose.

➤ One important advantage of removable inclined plane is that the labial bow can be
used to retract the lower incisors, if they are labially placed.

FIG. 19.8. Removable lower inclined plane. This causes labial movement of upper incisors.

Removable inclined plane with bite rail (bruckl’s appliance)

➤ In conditions where the bite is shallow, removable inclined plane with bite rail is
used (Fig. 19.9).

➤ It also produces lingual movement of lower incisors.

➤ The lateral bite rails which covers like the posterior bite-block, prevents
supraeruption of posterior teeth, and thereby prevents bite opening.
 FIG. 19.9. Removable inclined plane with bite rail.

Cemented inclined planes

Cemented inclined planes are the most suitable in correcting crossbite with deep
overbite cases (Fig. 19.10). Cemented inclined planes are fabricated as follows:

➤ Working models are prepared.

➤ Draw the design of inclined plane in the model. Inclined plane should include a
tooth and half on both sides of the crossbite area.

➤ Inclined plane is waxed up.

➤ Inclined plane should be at an angle of approximately 45° to the occlusal plane.

➤ Posteriorly extend sufficiently to prevent the patient from biting into retruded
position.

➤ Waxed-up inclined plane is acrylized.

➤ During insertion, the bite should not be opened more than 4 or 5 mm.

➤ Extreme opening causes muscle fatigue.

➤ The finished appliance is cemented with thin mix of luting cement (zinc
oxyphosphate).

➤ Recall appointment after 1 week.

➤ Correction is achieved in 2 week’s time.

 FIG. 19.10. Cemented inclined planes.

Cast crown or banded inclined planes (fig. 19.11)

➤ Cast crown and banded inclined planes are alternative methods to correct anterior
crossbite.

➤ Mechanism of action is similar to cemented inclined plane.

➤ Angulations of inclined plane are 45° to occlusal plane.

➤ This is used primarily to eliminate functional prematurities.

➤ The cast crown or banded inclined planes are placed in maxillary incisors.

FIG. 19.11. Banded inclined planes use either stainless steel crown or cast metal crown.

Instructions to the patient

➤ Appliance should be worn full time.
➤ Patients are instructed to cut up foods and adopt a soft diet till the appliance is
removed.

➤ Lower inclined planes are not worn more than 3 weeks.

Vestibular screens/oral screens
➤ Oral screen is a sheet of acrylic resin which is worn inside the lips and outside the
teeth.

➤ Oral screen/vestibular screen is a functional appliance because it has no active

elements designed to produce force. It produces its effect by redirecting the pressure
of the muscles and soft tissues like lips and cheek.

➤ Vestibular screens were introduced by Newell in the year 1912.

➤ Krauss F differentiates between oral screen and vestibular screen.

1. Oral screen

• Used to control abnormal habits namely mouth breathing

and tongue dysfunction.

• Teeth contact is present with acrylic.

2. Vestibular screen

• Extended into the vestibule, in contact with the alveolar

process.

• No teeth contact.

• But the terms oral screens and vestibular screens are used as
synonyms by many of the authors.

• Vestibular screens are also called lip moulder.

Mechanism of action (fig. 19.12)

➤ The screen prevents the pressures from cheeks from acting on the dentition. Because
of this, tongue is free to exert its force. This causes passive expansion of the arches
(Fig. 19.13).
➤ The pressure from the lips is directed to the incisors. This causes lingual movement
of the labially proclined teeth.

➤ Lower jaw is moved forward.

➤ Hypotonic lips are activated. Tonicity of the lips is improved.

➤ Retroclination of maxillary incisors.

➤ Possible intrusion of maxillary incisors.

➤ Passive expansion of apical base.

➤ Differential eruption of molars.

➤ Mandibular advancement when protrusive bite is taken.

FIG. 19.12. Vestibular screen: mechanism of action. The screen prevents forces of buccinator
mechanism from acting on the dentition.
 FIG. 19.13. Oral screen in position. Other effects of oral screen. 1, produces mandibular
advancement; 2, improves the tonicity of upper and lower lips; 3, pressure from lip is
transmitted to incisors which causes retraction of maxillary incisors; 4, might cause intrusion of
maxillary incisors; 5, screen prevents muscle force from acting on dentition; this causes
passive expansion of apical base; 6, differential eruption of molars and opening of bite.

Other actions
➤ Stimulation of proper nasal breathing.

➤ Cessation of habits like finger and thumb sucking, lip biting.

Construction of the appliance (fig. 19.14)

➤ Appliances are preferably made in clear acrylic.

➤ Working models placed in normal occlusion or protrusive bite is taken for class II
division 1 malocclusion.

➤ Wax-up of the appliance is done.

➤ Anterior segment is influenced directly by the appliance. So, incisal third of anterior
teeth is not covered with wax.

➤ Posterior segment is not influenced by the appliance directly. It acts by keeping away
the appliance. To effect this change, buccal surface of teeth and alveolar process are
 covered with two layers of wax up to distal aspect of first permanent molar in
permanent dentition. It extends to the vestibular depth.

➤ Extension: In deciduous dentition extends up to distal of second deciduous molar.

➤ Correct curve is provided between the upper and lower incisors and lower labial
sulcus to accept the lower lip.

➤ Edges are made less thick than the buccal vestibular sulcus depth.

➤ Allowances are made for labial and buccal frena.

➤ Appliance is processed with either heat-cure or self-cure acrylic.

➤ Trimmed and polished.

FIG. 19.14. Construction of oral screen.

Adjustment of the appliance

➤ Appliance should be worn by the patient every night and also during day time when
possible.

➤ Lip seal exercises should be done for about 30–45 min/day.

➤ Breathing holes should be gradually reduced in size.

➤ Padding with quick setting self-cure acrylic is done in areas where tooth contact is
present. Padding is done with pink acrylic.
Uses
➤ Used as both active and passive appliances.

➤ Used for the correction of tongue thrusting, thumb sucking and lip biting habits.

➤ Correction of mouth breathing when the airway is patent.

➤ Correction of mild distocclusion.

➤ Correction of flaccid hypotonic orofacial musculature.

➤ Counteract deficiencies in lip posture and function.

➤ Correction of mild proclination of incisors.

Advantages
➤ Simple and versatile appliance in early interceptive treatment.

➤ Oral screen establishes a better muscle balance between the tongue on the inside and
buccinator mechanism on the outside.

➤ Corrects the faulty relationships of upper and lower lips to each other and near
normal lip seal becomes possible.

➤ They contribute to the development of a proper functioning occlusion.

➤ Effective mechanism for reducing or eliminating hyperactive mentalis activity.

➤ Best suited to work with abnormal lip and tongue activity.

Disadvantages
➤ It is not a complete mechanotherapy.

➤ It is only an initial assault or phase 1 correction of orthodontic problem.

Modifications
1. Hotz modification

2. Screen with breathing holes

3. Double oral screen

4. Oral screen used in open bite cases

5. Rehak’s modification

Hotz modification (fig. 19.15)

➤ Addition of a wire loop to the anterior aspect of the screen. Patient pulls the
appliance forward by grasping the loop while simultaneously resisting the
displacement of the oral screen with tightly held lips. This is Hotz modification.

FIG. 19.15. Hotz modification.

Oral screen with breathing holes (fig. 19.16)

➤ Place breathing holes in the labial aspect of the oral screen.

➤ A button with a string attached is placed on the lingual aspect.

➤ Patient is instructed to perform exercises by pulling the string through the breathing
hole.

➤ Holes may be gradually reduced in size as nasal breathing takes over.

 FIG. 19.16. Oral screen with breathing holes.

Double oral screen by krauss (fig. 19.17)

➤ Useful in patients with abnormal tongue posture, tongue thrust.

➤ A lingual screen is attached to vestibular screen with two 0.9 mm wires that run
through the bite in lateral incisor area.

FIG. 19.17. Double oral screen.

Oral screen used in open bite cases (fig. 19.18)

➤ The tongue is kept away from the dentition by an acrylic projection.
 FIG. 19.18. Oral screen used in open bite conditions.

Modification of rehak (fig. 19.19)

➤ In this, a nipple is combined with the screen which projects out. The nipple has to be
retained by the lips. Therefore, the natural sucking movements are used to increase
the effects of oral screen.

FIG. 19.19. Rehak’s modification.

Lip bumper
The lip bumper (or lip plumper) is a functional component that is used along with a
lower or upper fixed appliance. It is a combined fixed removable appliance or
component of fixed appliance (Fig. 19.20).

FIG. 19.20. Lip bumper: Maxillary and mandibular lip bumpers.

Types
I. Lip bumper based on the ability to be removed:

1. Combined fixed removable – in this, the lip bumper

portion can be removed from the fixed part which is a
molar tube.

2. Component of fixed appliance – lip bumper is also

soldered to the molar band where it cannot be removed
separately.
II. Lip bumper based on the arch used:

1. Maxillary lip bumper (Denholtz appliance)

2. Mandibular lip bumper.

Mechanism of action (fig. 19.21)

➤ Lip bumpers are used when there is problem in the upper or lower lip.
➤ Appliance prevents the hyperactivity of the mentalis muscles in the same way as lip
shields or vestibular screen.

➤ Lip bumper prevents the abnormal force from acting on the incisors.

➤ The other effects of lip bumper are that it causes proclination of the incisors and
distalization of molars.

FIG. 19.21. Mechanism of action of lip bumper. Arrows denote proclination of incisors and
distalization of molars.

Design of lip bumper (fig. 19.20)

➤ Typically, it is a vestibular arch carrying an acrylic pad engaged to lower molar
bands.

➤ The pad stands 2–3 mm away from the teeth and gingiva.

➤ It lies about 4 mm below the cervical margins of the lower incisors.

➤ The lower lip is thus held forwards.

➤ The diameter of the wire used is about 0.93 mm.

➤ The wire can be either soldered or inserted into the molar tube with a U-bend or with
coil springs.

Uses of lip bumper

➤ Used in the correction or elimination of lip trap.
➤ Eliminates hyperactive mentalis activity.

➤ Lip bumpers are used to upright molars.

➤ They can be used as space regainers when there is mesial drift of first molar.

➤ Lip bumpers are used as anchorage saver.

➤ Molar distalization can be achieved. It is the only appliance which is used for
distalization of lower molars.

➤ Reduction of overjet by proclination of lower incisors.

Activator
Synonym: Monobloc

Andresen and Haupl appliance

Andresen’s appliance

Norwegian appliance

History (table 19.2)

➤ Activator is a tooth-borne passive type of functional appliance (Fig. 19.22).

➤ Kingsley introduced the bite plate in 1879 to correct the sagittal malrelation.

➤ Hotz R modified the Kingsley’s plate to ‘Vorbissplate’ and used it for correction of
deep bite and retrognathism.

➤ Pierre Robin created monobloc to position the mandible forward to prevent

occluding of airway due to glossoptosis.

➤ Vigo Andresen in 1908 developed a loose-fitting appliance for his daughter to be

worn as a retainer. He called it biomechanical working retainer.

➤ Andresen shifted to Norway and joined with Haupl to develop the activator
appliance in the year 1920.

➤ Activator is so-called because the wearing of this loose-fitting appliance activates the
muscles.

➤ Introduction of activator paved way for a series of modifications and numerous

functional appliances.

Table 19.2.
Activator–history
 FIG. 19.22. Activator.

Indications
➤ Class I malocclusion with deep bite.

➤ Class I malocclusion with open bite.

➤ Class II division 1 malocclusion.

➤ Class II division 2 malocclusion after aligning the incisors.

➤ Class III malocclusion (appliance is called reverse activator).

➤ For crossbite correction (trimming modified to move maxillary molars laterally –

screws can be incorporated).

➤ Phase I treatment before fixed appliance treatment.

➤ As habit breaking appliance.

➤ As retention appliance.
➤ Serves as space maintainer in mixed dentition, where acrylic is extended into the
space of missing tooth.

➤ Used for treating patients who snore during sleep.

➤ Used in obstructive sleep apnoea.

Contraindications
Activator is not used in the following conditions:

➤ Crowded arch

➤ Increased lower facial height

➤ Extreme vertical mandibular growth

➤ Severely proclined lower incisors

➤ Subjects with nasal stenosis

➤ Nongrowing patients

➤ Retroclined upper incisors

➤ Crossbite tendency

➤ Gross intra-arch irregularities

Advantages and disadvantages

Advantages and disadvantages of activator are given in Table 19.3.

Table 19.3.
Activator–advantages and disadvantages

Advantages Disadvantages
Treatment in deciduous and mixed dentition is possible Fully relies on patient co-operation
Appointments can be delayed over 2 months Little value in cases with crowding
Tissues are not injured Force on individual tooth cannot be controlled
Appliance worn at night time only Little or no response in older patients
Helps to eliminate abnormal habits It is bulky and uncomfortable
Oral hygiene maintained
Economical

Selection criteria
Selection criteria are the same as mentioned in criteria for case selection for functional
appliances.
Mode of action of activator
There are different views and mechanism by which activator works.

a. First view

• Muscles of mastication particularly lateral pterygoid play

important role in this adaptation.
b. Second view: Stresses on viscoelastic properties

This mechanism is for vertical activators where potential

energy is utilized in extreme opening of mandible (>10 mm).
c. Combination of kinetic and potential energy: Vertical opening is 4–6 mm.

d. Differential eruption of teeth: Selective grinding leads to differential eruption of

teeth.

Effects of activator treatment (table 19.4)

The changes produced by the activator are enumerated in Table 19.4.

Table 19.4.
Activator treatment–effects
Site Treatment effects
Maxilla 1. Slight intermolar expansion
2. Slight intercanine expansion
3. Retraction of upper incisors
4. Increase in the vertical height in posterior teeth
5. Restraining effect on the maxillary arch as a unit
Mandible 1. No change in intercanine width
2. Proclination of lower incisors
3. Increase in the vertical height of posterior teeth
4. Reduction in deep bite
5. Increase in downward and forward translation of the mandible and the teeth as unit
Soft tissue 1. Changes in lip posture where potentially competent lips become sufficiently competent

Construction of activator
The steps in the fabrication of activator:

1. Preparation of models–working and study models

2. Registration of construction bite–horizontal or vertical bites

3. Articulation of models

4. Wax up and wire bending

5. Processing of appliance

6. Trimming of activator

Registration of construction bite

The maximum amount of sagittal advancement and vertical opening should be 10

mm in construction bite for activators.

Guidelines for bite registration (fig. 19.23)

Early mixed dentition: The mandible should be moved forward until the upper
primary canine relates directly above the interproximal between the lower primary
canine and the first primary molars. On an average, it will be 4–5 mm.

Late mixed dentition: The mandible should be moved forward until the upper canine
 relates directly above the interproximal between the lower cuspid and first bicuspid.
On an average, it will be 6–8 mm.

Anterior midline: When the bite registration is taken, the upper and lower midlines
should coincide. If there is skeletal midline deviation, bite registration is done with
midlines coinciding. If there is dental midline shift, no attempt should be made to
correct the midlines.

FIG. 19.23. Typical construction bite for class II malocclusion.

Articulation
➤ Reverse articulation. This helps in providing good access during acrylization of the
appliance.
Labial bow
➤ Wire bending – 0.9 mm wire is used to make a passive labial bow. The ends of the
bow cross between canine and first premolar or deciduous first molar through the
centre of interocclusal wax.

➤ The labial bow should contact the middle third of the labial surface of the upper
anterior teeth.

➤ Labial bow should not be adjusted to exert any mechanical pressure on the upper
anterior teeth.

➤ It acts as a passive medium for the transmission of muscular forces to the maxillary
teeth and arch.

Processing of appliance: This is done using either heat cure or cold cure. Appliance
consists of (i) maxillary part – gingival, dental, (ii) interocclusal part and (iii)
mandibular part – dental, gingival (Fig. 19.24).

FIG. 19.24. Acrylic parts of activator.

Appliance construction–sequence
 Trimming of activator: After processing of the appliance, an interocclusal block of
acrylic is present between the upper and lower posterior teeth. Guiding grooves are
placed in the interocclusal block to facilitate tooth movement. Appropriate flame-
shaped burs are used to create guiding grooves.
Trimming for vertical movement: Two movements occur in vertical plane with
activator treatment–intrusion and extrusion.

1. Intrusion of the incisors teeth can be achieved by loading the incisal edges of teeth.
Intrusion is recommended in deep bite cases (Fig. 19.25A).

Intrusion of molars can be achieved by loading the cusps alone

of the molars. The acrylic is ground from fossae and fissures.
Molar intrusion is indicated in open bite cases (Fig. 19.25B).
2. Extrusion of the incisor teeth can be achieved by loading the lingual surfaces above the
area of greatest convexity. Extrusion of incisors can be enhanced by placing the labial
bow also above the area of convexity. This is indicated in open bite cases (Fig. 19.25C).

• Extrusion of molars is achieved by loading the lingual surfaces

above the area of greatest convexity in maxilla and below in
mandible.

• Molar extrusion is indicated in deep bite cases (Fig. 19.25D).

• During supraeruption of molars, selective trimming is done.
In this, either upper or lower molars are allowed to erupt
individually or both together (Fig. 19.25E).
FIG. 19.25. (A) Intrusion of incisors, (B) intrusion of molars, (C) extrusion of incisors, (D)
extrusion of molars, (E) selective eruption of molars.
Trimming for anteroposterior or sagittal movements
The following movements can be achieved in the anteroposterior plane.

➤ Protrusion of incisors can be produced by loading the entire lingual surface of the
incisors with acrylic (Fig. 19.26).

FIG. 19.26. Protrusion of incisors.

Protrusion can be achieved with accessory elements like:

➤ Protrusion springs

➤ Wooden pegs

➤ Gutta-percha

Retrusion of incisors is achieved by trimming away the acrylic from behind the incisors
and alveolar process. If the labial bow touches the teeth, it also causes tipping of incisors
and they are called ‘active bows’ (Fig. 19.27).
 FIG. 19.27. Retrusion of incisors.

Distal movement of molars

➤ For distalizing movements, the guide planes load the molars on the mesiolingual
surfaces (Fig. 19.28).

➤ The guide plane extends to the area of greatest convexity.

➤ Distal movement of upper molars is indicated in class II malocclusion.

➤ Distal movement of lower molars is indicated in class III malocclusion.

➤ Distal movement can also be achieved by active springs.

 FIG. 19.28. (A) Loaded areas and (B) guide planes. Arrow indicates distal movement of
molars.

Mesial movement of molars

➤ Mesial movement is achieved by the guide planes contacting the teeth on the
distolingual surfaces (Fig. 19.29A).

➤ Guide planes extend to the greatest lingual circumference in the mesiodistal plane
(Fig. 19.29B).

➤ Mesial movement of posterior teeth in upper arch is indicated in class III

malocclusion.
 FIG. 19.29. (A) Loaded areas and (B) guide planes. Arrow indicates mesial movement of
molars.

Transverse movements with activator

➤ If the construction bite is shifted to one side, asymmetric action is created in the
transverse plane.

➤ Activator may also be trimmed to achieve lateral movements. But this is not highly
effective. For lateral movements, the lingual acrylic surfaces opposite the molar teeth
should be in contact (Fig. 19.30).

➤ More effective expansion can be achieved by incorporating jackscrews.

 FIG. 19.30. (A) Loaded areas and (B) guide planes. Arrows indicate transverse movement
with activator.

Guidelines for clinical control

➤ It is important to ensure during treatment that the grooves maintain their contact.

➤ Grinding of grooves should be done to facilitate mesial and vertical eruption of lower
teeth.

➤ Proper monitoring of deep bite should be done.

➤ Reshaping of grooves and padding with fast setting self-cure acrylic in contact areas
should be carried out.

➤ Wearing time of the appliance should be monitored. Appliance is worn for 2–3 h
during the first 2 weeks. Then increased to full night time wear.

➤ Any trauma or sore spots should be grinded.

Retention period
➤ Retention period begins when the bicuspid exchange has been completed and an
adult class I occlusion has been established.
➤ Average length of retention period is 6–8 months following active treatment.

➤ Following 6–8 months of retention period, wearing of the appliance is gradually

tapered off over a period of 2–3 months.
Modifications of activator
There are various modifications of activator proposed by different authors.

Classification
Based on the bulk and rigidity of activator
(a) Rigid one-piece appliance; (b) flexible two-piece appliance. The differences between
rigid and flexible appliances are given in Table 19.5.

Table 19.5.
Differences between rigid and flexible activators

Rigid one-piece appliance Flexible two-piece appliance

• Bulky – wear time reduced
• Isometric contractions develop as rigid activator do not permit muscle
contraction (more effective)
• Long-lasting tonic – stretch reflex contraction can be elicited
• Example–elastic open activator bionator
• Not bulky – patient can increase the wear time with relative comfort
• Isotonic contractions develop as the flexible activator permits muscle
shortening (less effective)
• The momentary stretch in these flexible construction produces a transient
phase reflex contraction
• Example: Schwarz double plate

Various modifications of activator

Herren shaye activator
Herren states that mandible along with the activator will not retain its position during
sleep. A slight unconscious lowering of the mandible will detach the incisor from the
maxillary parts and lessens the effectiveness.
Since the correct posture of the mandible during sleep is essential for the success of
activator therapy, following modifications are done:

a. Sagittal positioning is overcompensated in the construction bite advancing the

mandible forward 3–4 mm beyond the neutral relationship.

b. Triangular arrowhead clasps are used to firmly seat the appliance on maxillary
dentition. Jackson clasp or Duyzing’s clasp may be used as well.

c. Long lingual flanges are constructed to hold the appliance in position during sleep.

d. In this modification, lower incisors bite on the acrylic plane, impeding eruption of
incisors and allowing the posterior teeth to erupt occlusally thus levelling the curve of
Spee.

Bow activator of AM schwarz

This is a flexible activator in which the upper and lower halves of the activator are
connected by a simple elastic bow (0.9 mm).
In the anterior area between the halves, a layer of rubber is attached to act as a shock
absorber and to open the incisors in front.
The advantages of this appliance are:

➤ Stepwise sagittal advancement is possible by periodic adjustment of the bow.

➤ Transverse mobility was thought by Schwarz to provide an additional stimulus.

➤ Can also be used in subdivision cases by activating only the bow on the side of
unilateral distoclusion.

➤ Maxillary and mandibular expansions can independently be attempted by activating

the screws incorporated in the particular half of the appliance.

The reduced activator or cybernator of schmuth

The acrylic part of the activator is reduced similar to the bionator and labial bow is
used. Lower incisors are covered by acrylic to hold them in a stable position. The lower
acrylic structure is split to permit expansion which prevents the frequent breakage in
this region.
A coffin spring in the palatal portion is judiciously used to keep the parts of the
appliance in contact with the lateral teeth without pressure. This will have a widening
effect, especially when inserted during or soon after the eruption of the lower incisors.
Spurs may be used to prevent the mesial drift of upper first molars. When the
appliance is not split, the appliance is stabilized and made more resistant by a lower
labial bow.

Karwetzky modification
This is similar to Schwarz bow activator. It consists of both upper and lower active
plates united by a ‘U’ bow in the region of first permanent molar. The ‘U’ bow has one
shorter leg embedded in the upper appliance and a long leg embedded in lower plate.
By constricting the bow, i.e. narrowing the U-bend, mandibular horizontal movements
are created.
The advantages of this modification are:

➤ It exerts a delicate influence on the dentition and TMJ.

➤ Mobility of the parts allows various mandibular movements.

➤ Allows sequential forward positioning.

➤ This appliance may also be used to supplement the treatment of certain types of jaw
fractures.

➤ Appliance can also be used in certain types of orthognathic surgeries like

 corticotomies and subapical resection.

Wunderer modification for class III malocclusion

Appliance is split horizontally with the upper and lower portions connected by a screw
(designed by Weisse) that is embedded in an acrylic extension of the mandibular
portion behind the maxillary incisors.
As the screw is opened, the maxillary portion moves anteriorly with a reciprocal
posterior thrust on the mandibular dentition. Occlusal surfaces of the posterior teeth are
covered with acrylic to enhance retention.

Cut out or palate-free activator

Metzelder K attempted to combine the advantages of the bionator to the original
Andresen–Haupl activator. This is a modified activator wherein the maxillary acrylic
portion covers only the palatal or lingual aspects of the buccal teeth and small part of
the adjoining gingival, while the palate remains free.
It has a small screw incorporated in the narrow anterior portion of the appliance, and
has a labial bow made out of 0.9 mm diameter stainless steel wire.
There is no coffin spring in the palate. Stabilization is provided by carrying the acrylic
over occlusal surface over some of the buccal teeth. Protrusion springs may be added
for lingually tipped upper incisors in class II division 2 cases. The mandibular portion is
same as regular activator.

Elastic open activator

This modified appliance is reduced in the anterior palatal region and is called open
activator. Their goal is to restore exteroceptive contact between the tongue and palate.
The standard appliance consists of bilateral acrylic parts, an upper and lower labial
wire, a palatal arch and guiding wires for the upper and lower incisors. These wires will
have different designs, depending on the treatment objectives.
The acrylic parts extend from canine posteriorly to the point just behind the first or
the second permanent molar. The acrylic is thin in order to have larger possible space
for the tongue.
Stabilization of the acrylic portion is accomplished by means of contact with the
lingual surface of the maxillary and mandibular canines.

Elastic activator for treatment of open bite

The rigid intermaxillary acrylic of lateral occlusal zones is replaced by elastic rubber
tubes. By stimulating the orofacial muscular system by orthopaedic gymnastics
(chewing gum effect), activators intrude upper and lower posterior teeth. Cribs can also
be incorporated to eliminate habits.

Combined labial bow – eschler (1952)

Eschler developed modification of the labial bow with intermaxillary effectiveness. It
consists of an active part which moves the teeth and a passive part holding the soft
tissue of the lower lip away and thus enhancing the tooth movement as desired.

The propulsor
This is designed by Muhlemann HR and refined by Rudolf P Hotz, it is a hybrid
appliance, with features of both monobloc and oral screen.
A definite advantage of propulsor over other activator-like appliances is in its
coverage and its ability to effect changes in the alveolar process. This appliance does not
carry any wire components. It is commonly used in maxillary dentoalveolar protrusion.

Hamilton’s expansion activator

Appliance has a palatal expansion screw and is bonded to the maxillary arch. The
lingual flanges guide the mandible into its correct anterior construction bite via
proprioception.

Petrik’s modification
The activator modified by Leopold Petrik has simple stiff sections of wire mesial to the
permanent first molars for stabilizing the sagittal and vertical position of the activator
(support bars).
In addition, it also has other stiff wire constructions that deliver forces, during
occlusion, to specific teeth to promote their movement.

Akkerman’s fixed appliance activator

Akkerman constructed an activator which can be used as a retainer after fixed appliance
treatment as well as in a modified form during the treatment.

Teuscher activator
This is an example of an activator with headgear. The appliance has headgear tubes
placed in bite-blocks in deciduous molar region and four torquing springs in the
anterior region.

Van beek activator

It is another example of headgear–activator combination. The short and strong outer
bow is placed in the acrylic of activator between central and lateral incisors.
The lower incisors are covered by acrylic labially and lingual surface is let free. The
upper incisors are also covered by acrylic. Position of the mandible is achieved by
lingual flanges.

Magnetic activator device

This magnetically active functional appliance was developed by Dellinger EL (1993).
Other modifications of activator are kinetor, bionator and LSU activator.
The types of magnetic activator devices are as follows:
➤ MAD – I: Correction of lateral mandibular displacement;

➤ MAD– II: Correction of class II malocclusion;

➤ MAD – III: Correction of class III malocclusion;

➤ MAD – IV: Correction of open bite.

Bionator
Introduction
➤ Bionator is an activator-derived device (Fig. 19.31).

➤ Bionator was introduced by Professor Wilhelm Balters of Germany.

➤ Balters’ bionator is referred to as skeletonized activator.

➤ It is less bulky and elastic when compared to conventional activator.

➤ It permits day and night wear except during eating.

FIG. 19.31. Bionator – parts.

Philosophy of bionator
➤ According to Balters, the equilibrium between the tongue and circumoral muscles is
responsible for shape of the dental arches and intercuspation (Fig. 19.32).

➤ Balters says that the position of the tongue is responsible for certain type of
malocclusion.

➤ Posterior displacement of tongue leads to class II malocclusion.

➤ Anterior displacement of tongue leads to class III malocclusion.

➤ The role of the tongue is considered decisive.

➤ The principle of treatment with bionator is not to activate the muscles but to
modulate muscle activity. This enhances normal development.

➤ Bite registration is done only with sagittal advancement with minimal vertical
opening.

FIG. 19.32. Position of teeth is influenced by muscle and occlusal forces.

Objectives
Following are the objectives of treatment with bionator:

➤ Elimination of lip trap and abnormal relationship between the lips and incisor teeth.

➤ Elimination of mucosal damage due to traumatic deep bite.

➤ Correction of tongue malposition and associated mandibular retrusion.

➤ Attainment of correct occlusal plane.

Case selection criteria

➤ Children in late or early mixed dentition period.

➤ Mildly retrognathic mandible.

➤ Well-aligned dental arches.

➤ No labial proclination of lower incisors.

Indications and contraindications (table 19.6)

Table 19.6.
Bionator – indications and contraindications

Indications Contraindications
1. Used to treat class II division 1 malocclusion due to retrognathic mandible 1. Class II due to prognathic maxilla
2. Open bite due to functional causes 2. In vertically growing patient
3. Class III malocclusion due to deficient maxilla 3. Labial flaring of lower incisors
4. TMJ problems in adults 4. Anterior crowding

Types of bionator
There are three types of bionator:

1. Standard appliance – used to correct class II division 1 malocclusion.

2. Screening appliance – used for the elimination of abnormal tongue activity in open
bite cases.

3. Reverse appliance – used for treatment of class III malocclusion.

Standard appliance
Standard appliance (Eirew HL, 1981) consists of (i) acrylic component and (ii) wire
components.
Construction bite: This is taken in edge-to-edge incisor contact, if possible. In severe
overjet, phased or incremental advancement is advised.

Acrylic component
➤ Acrylic block is of minimal extent and thickness so as not to encroach in the tongue
space.

➤ Acrylic starts from the distal of the upper canine to 2–3 mm behind the first molars.

➤ It covers only 2–3 mm of mucosa above the gingival margins of upper and lower
cheek teeth.

➤ The upper and lower parts are joined by the interocclusal acrylic block. This extends
over half of the occlusal surface of the teeth.

Wire components
1. Palatal arch (Fig. 19.33)

• Palatal arch is made rigidly of 1.2 mm wire.

• This originates near the maxillary canine/first premolar

embrasure.

• From there, it rises vertically to the vault of the palate.

• Roughly on a line joining the centres of first premolars or

first deciduous molars, it turns distally to form the palatal
loop.

• It extends up to the line joining the distal aspects of first

permanent molar.

• The loop is egg-shaped, horizontal and 1 mm clear of the

mucosa.

• It is adapted to follow the contours of the palate.

• Purpose of palatal arch is to (i) stabilize the appliance and

(ii) to encourage the tongue and mandible to adapt a more
anterior posture.

• Palatal arch should not be activated.

2. Vestibular arch (Fig. 19.34)

• Vestibular arch is made of 0.9 mm wire.

• Labial portion of vestibular arch is ideally shaped.

• It should not touch the incisor teeth surface.

• At the distal of lateral incisor, the wire bends downwards
and distally to form the buccinator loop.

• Buccinator loop runs along the middle of the crowns of

posterior teeth standing 3 mm away from the tooth surface.

• Purpose of buccinator loop is to prevent the cheek pressures

from acting on the buccal segments, which cause passive
expansion of the arch.

• Buccinator loop extends as far as the embrasure between

deciduous second molar and first permanent molar of the
maxillary arch.

• From here, it makes a 90° rounded bend and runs along the
crowns up to the embrasure between canine and deciduous
first molar or premolar. It is anchored to the acrylic there.

FIG. 19.33. Palatal arch.

 FIG. 19.34. Vestibular arch. Buccinator loop and labial portion.

Clinical management
➤ Bionator must be worn day and night except while eating.

➤ Time interval between successive appointments is about 3–5 weeks.

➤ Trimming of facets is done as required.

Functional regulators and their types
➤ Functional regulators (FRs) are functional appliances introduced by Dr Rolf Frankel
of Germany.

➤ As the name implies, treatment with this appliance is not directed towards the teeth
or skeletal tissues, but to the functional disorders responsible for dentoskeletal
malformation.

➤ Accordingly, the primary aim is to identify a faulty postural performance of the

orofacial musculature and correct it by functional appliance.

➤ FR is also called by the following names:

• Functional corrector

• Vestibular appliances

• Frankel appliance

• Exercise device

• Oral gymnastics

• Orofacial orthopaedic appliance

➤ FRs are tissue-borne type of functional appliance.

The types of FRs are as follows (Frankel, 1980):

FR I:

This is used for correction of class I and class II division 1 malocclusion.

FR Ia:

• Used in class I malocclusion with minor crowding.

• Used in delayed development of the basal bone and dental

 structure.
FR Ib:

• Used in class II division 1 malocclusion with deep bite and

overjet less than 7 mm.
FR Ic:

• Used in severe class II division 1 with overjet more than 7

mm.
FR II:

This is used for correction of class II division 1 and division 2 malocclusion.

FR III:

This is used for treatment of class III due to maxillary deficiency.

FR IV:

This is used for treatment of open bite and bimaxillary protrusion.

FR V:

Functional appliances that incorporate headgear. FR V is used in high angle cases.

Indications of functional regulator
The indications of FR can be studied under each type.

Indications of FR I
Class I
Early treatment: Discrepancy between tooth size and arch size in patients with normal
overbite.
Late treatment: Mild crowding in the presence of adequate apical base.

Class II division 1
Early treatment: Mandibular retrusion with normal overbite.
Late treatment:

1. Mandibular retrusion with normal overbite, overjet more than 7 mm.

2. Mandibular retrusion with crowding. In this prefunctional fixed appliance, treatment

is done to correct crowding.

3. Mandibular retrusion with open bite.

Indications of FR II
Class I
Early treatment: Deep bite associated with arch size deficiency.
Late treatment: Deep bite without irregularities.

Class II division 1 and 2

Early treatment: Mandibular retrusion with deep bite and excessive overjet. Pretreatment
mechanotherapy to correct the upper incisors is required.
Late treatment:

1. Mandibular retrusion with deep bite and excessive overjet without arch irregularities;
pretreatment mechanotherapy to correct incisors is required.

2. Mandibular retrusion with arch irregularities; pretreatment fixed appliance

mechanotherapy to correct crowding by extraction is required.

Indications of FR III
Class III
➤ Early and late treatment of maxillary retrusion.

➤ Open bite: Open bite associated with class III.

Indication of FR IV
➤ FR IV is used in early treatment of skeletal open bite and bimaxillary protrusion.

Indications of FR V
➤ High angle cases.

➤ Vertical growth pattern.

Indications of FR as retainer
➤ FR type used as the last appliance should be worn as retainer.

➤ After fixed appliance mechanotherapy.

➤ After oral surgery, FR is used as exercise device to prevent relapse.

Mechanism of action of frankel appliance
A thorough understanding of the concepts pertaining to the mechanism of action of FRs
can be made under the following headings.

Vestibular area of operation

➤ The major part of Frankel appliance is confined to the oral vestibule.

➤ The buccal shields and lip pads hold the labial and buccal musculature, the
buccinator mechanism from acting on the dentition.

➤ According to Frankel, malocclusion is a result of faulty muscle posture and muscle

imbalance.

➤ The buccal and lip shields prevent the aberrant muscular force from acting on the
teeth.

➤ The removal of the restraining influence enables outward development of the arches.

➤ Re-establishment of adequate space condition in the lower part of the oral

functioning space is the primary aim of FR.

➤ FR acts as oral gymnastics device which helps in the correction of faulty muscle
posture.

➤ Table 19.7 depicts the faulty muscle function responsible for producing malocclusion.

Table 19.7.
Malocclusion – faulty muscle function

Malocclusion condition Faulty muscle function

Class II malocclusion with deficient
mandible
Class III with maxillary deficiency
Open bite
Postural imbalance between the retractor and protractor muscles
Restricting effect of aberrant posture within the upper lip muscle groups
Poor postural performance of the muscles forming the external soft tissue capsule and those suspending the
mandible

Exercise device
➤ Frankel appliance apart from restricting the faulty muscle posture also acts as
exercise device. That is, it stimulates normal function while eliminating aberrant
muscle activity.

➤ Hence, full time wear of the appliance is recommended along with functional
 exercises.

Tongue function
➤ Though Frankel appliance gives more importance to buccinator mechanism, tongue
also plays a significant role in moulding the arches.

➤ Because of the restricting effect of the shield, tongue force causes passive expansion
of the arches.

Anteroposterior correction
➤ Increased activity of the superior head of lateral pterygoid muscle is associated with
functional appliance wear. Skeletal adaptation proceeds until muscle activity is
restored (Fig.19.2 and the explanation given here in the form of flow chart).

Frankel appliance

Maxillary restraining effect

➤ Frankel appliances have a restraining effect on the maxillary teeth and arch
(Weislander, 1993).

Decrowding during eruption

➤ Decrowding during eruption is a feature of all the Frankel appliances.

➤ The vestibular screens are deliberately extended into the vestibular sulcus so that
 tension is created in the soft tissues.

➤ This causes outward bending of the thin buccal plate, thereby facilitating outward
drift of the teeth.

Differential eruption
➤ Frankel appliances prevent maxillary molars from downward and forward
movement.

➤ The differential eruption of lower molars contributes to establishment of correct

sagittal relationship by 1–2 mm.

Periosteal matrix stimulation

➤ Buccal shields and lip pads are extended into the vestibule, causing tension.

➤ This tension elicits periosteal pull and causes bone deposition.

➤ Maxillary arch expansion and mandibular anterior extension occur due to periosteal
matrix stimulation.
Functional regulator (FR) I
The FR I is composed of two buccal shields, two labial pads, one lingual pad and wire
parts.
Appliance consists of acrylic parts and wire components (Fig. 19.35). The features of
FR Ib are described and the differences between other types, namely FR Ia, Ic and FR II,
are given at the end.

FIG. 19.35. Functional regulator I b.

Acrylic parts
Buccal shields
Extend deep into the sulci in the apical region of maxillary first premolar and tuberosity
region.

➤ Areas where expansion of dental arch and alveolar process is required, the shields
stand away from the lateral aspects of teeth and alveolus.

➤ In maxillary teeth and alveolus, the gap between shield and teeth surface is double
wax thickness.

➤ In mandible, only single layer of wax is added.

➤ The thickness of the buccal shield should be 2.5 mm.

Functions
1. Physiotherapy: Buccal shields expand the circumoral capsule in transverse direction
causing the soft tissues to adapt to new form.

2. Forced training of the muscles of cheeks to adapt to functional performance.

3. Correction of spatial disorder: Stimulation of periosteal matrices corrects spatial

disorder.

Labial pads/pelots
➤ Lip pads are rhomboid-shaped and fit the labial surface of mandibular frontal
alveolar process.

➤ It is teardrop-shaped in cross-section. This permits free seating of the lip pads in the
vestibule.

➤ There should be 5 mm distance from the upper edges of the lip pad to the gingival
margin.

➤ Distal edge of lip pad should not overlap the canine root protuberance.

Functions
1. Physiotherapy: Supports the lower lip, smoothens the mentolabial sulcus and improves
lip posture (Fig. 19.36). Along with buccal shields, overcome the structural imbalance
between the superior part of the buccinator and orbicularis oris of the lower lip and that
formed by the inferior part of the buccinator and the orbicularis oris of the upper lip.

2. Forced training: Main function of lip pads is to prevent the hyperactive mentalis from
raising the lower lip.
 FIG. 19.36. Lip pad: Supports the lower lip and improves lip posture.

Lingual shield
➤ Lingual shied is situated or placed below the gingival margin of the mandibular
teeth.

➤ This extends up to the distal of the second premolar.

➤ It is positioned by the two connecting wires to the buccal shield.

Functions
Forced training

➤ In mandibular retrusion cases, the mandible is kept in the advanced position by the
supporting action of lingual and labial shields.

➤ Whenever mandible tries to slide back to its original position, the lingual shield
elicits a pressure sensation on the lingual aspect of the alveolar process (Fig. 19.37).

➤ This sensory input activates the proprioceptors in the gingiva and periosteum to
stimulate the protractors of mandible.
 FIG. 19.37. Lingual shield: Mechanism of action stimulates the protractor muscles by
activating proprioceptors.

Wire components
Vestibular wires
➤ Lower labial wires or vestibular wires are the connecting wires between the labial
pad and buccal shield.

➤ It is made from 0.9 mm wire and serves as the skeleton for the lower lip pads.

Maxillary labial bow

➤ Maxillary labial bow is made from 0.9 mm and usually lies in the middle of the labial
surfaces of the maxillary incisors.

➤ Runs gingivally at right angles between lateral incisor and canine.

➤ Forms a gentle curve distally at the height of middle of canine root and re-embedded
in buccal shield.

Palatal bow (pabo)

➤ Crosses the palate with a slight curve in a distal direction and runs interdentally
between the maxillary first molar and second premolar or deciduous second molar.

➤ Makes a loop into the buccal shield and emerges to form an occlusal rest in molar.

➤ Provides maxillary anchorage and stabilizing action.

Canine loop
➤ Starts with its tags in buccal shield.

➤ Runs palatally to the lingual surface of the canine for a distance of about 1 mm.

➤ Then crosses the interproximal contact between canine and lateral incisor.

➤ Keeps the perioral activity away from canine and provides passive expansion in
canine area.

Lower lingual springs

➤ These recurved springs, two in number, pass above the cingulum of the lower
incisors.

➤ Prevent supraeruption of lower incisors.

➤ They also cause bite opening by relative intrusion.

Crossover wires
➤ Connect the lingual shield with buccal shields.

➤ They run between the mandibular first and second premolars.

Construction bite for class II correction: Frankel advocates minimal sagittal or

forward advancement. Mandible is advanced by 2.5–3 mm only.
Vertical opening also should be very minimal, just enough for the crossover wires to
pass through.

Differences between FR IA and IC and FR II

FR Ia There is lower lingual wire loops instead of lingual shield.
FR Ic Buccal shields are split horizontally and vertically into two parts for incremental advance.
FR II
1. Addition of upper palatal protrusion bow behind upper incisors.

2. Modified canine loop.

Functional regulator III
Indications
➤ FR III is used in early and late treatment of maxillary retrusion.

➤ Open bite: Open bite associated with class III malocclusion, can also be treated with
FR III.

Parts of functional regulator III

Acrylic parts
Buccal shields (Fig. 19.38)

• Buccal shields stand away from the upper dentoalveolar

process by 2.5–3 mm.

• The lower part lies against the buccal aspect of dentoalveolar

process to restrict mandibular development.
Lip pads

• Lip pads are placed in maxillary anterior region.

• They should be parallel to and standing away from the

alveolar by 2.5 mm.

• Purpose of lip pads and buccal shields is to expand the

orofacial capsule and correct the postural imbalance by
direct influence (Fig. 19.39).
Wire parts

• Palatal bow: This connects the two buccal shields.

• Upper lingual wire: This is a tooth moving element. It is
used for proclining maxillary incisors.

• Lower labial bow: This should be in tight contact with

mandibular incisors and canines.

• Placed at lower level at the height of papilla.

• Restricts the anterior growth of mandible.

• Occlusal rests: On the last, mandibular molars are used to

prop the bite.

FIG. 19.38. Functional regulator III. (A) Maxillary lip pad, (B) lower labial bow, (C) protrusion
bow, (D) buccal shield and (E) palatal bow.
 FIG. 19.39. (A) Without the appliance and (B) profile with the appliance. Postural imbalance
between the muscles is corrected.

Mode of action of FR III (fig. 19.40)

➤ The maxillary lip pads eliminate the restrictive pressures of the upper lip on the
underdeveloped maxilla.

➤ The stretch of lip pads causes tension and periosteal pull in the maxillary sulcus. This
causes stimulation of bone growth.

➤ The upper lip force is transmitted to the mandible as a restraining force through the
lower labial bow.

FIG. 19.40. Mechanism of action of FR III.

 Construction bite for FR III: A retrusive bite with mandible in edge-to-edge
relationship is taken. The vertical opening should be minimum.
Clinical management of functional regulators
The treatment with FR can be classified into three stages or phases: (i) Initial treatment
phase, (ii) active treatment phase and (iii) retention phase.

1. Initial treatment phase

This phase is for the patients to get used to the appliance and
handle it as an orthopaedic exercise device combined with
lip seal training. The initial phase consists of:

a. Delivery of the appliance

• All margins are checked for smoothness.

• Check for the proper shape of the lip pads.

• Check the fit of the appliance in maxilla and mandible,

separately.

• Peripheral portions of shields contact without producing

blanching.

• Instruct the patient, the method of appliance wear.

• Palpate the face on the outside to make sure there are no

sharp edges.

• After insertion, ask the patient to speak. During speaking,

the vestibular shields loosen up the tight musculature which
helps in adapting to the appliance.

b. Wearing of the appliance

• The objective of the appliance should be well understood.

• In traditional orthodontics, we change the form with a

spontaneous adaptation of the neuromuscular pattern.

• In contrast with functional approach, the faulty postural

function is overcome first which results in spontaneous
adaptation of form to altered normal function.

• Worn during day time also.

• Initial wear for 2–3 h for the first 2 weeks.

• Lip together exercises to be performed by the patient.

• Check-up after 2 weeks – presence of tissue redness and also

speech improvement is a sign of cooperation.

• Next 3 weeks 4–6 h day time wear.

• Normally 3–4 months for initial phase.

2. Active treatment phase

Before advising night-time wear, check for improvement in

facial muscle balance.

• There must be some change in overcoming the hyperactivity

of the muscle. Then night-time wear is advised.

• Appliance adjustments like bending of canine loops

occlusally, molar rests, labial bows are carried out, if
required.
• Progress is recorded. After 3 months of full time wear,
expansion of dental arches will be evident.

• In 6–8 months, correction from class II to class I takes place.

• Patient will have difficulty in positioning the lower jaw

posteriorly.
3. Retention treatment phase

A chance for relapse is less with functional appliances; there is

spontaneous adaptation of form to altered function.

• Therefore, the action of retention phase is to stabilize the

restraining effect of the exercise device ac3ieved during
active treatment.

• The last appliance itself is used as retention appliance.

• Wearing time: 2 hours in the afternoon and 6 hours in the

night for 6 months. Then during night only for another 12
months.
Differences between activator and functional
regulator
Differentiating features of activator and FR are depicted in Table 19.8.

Table 19.8.
Activator and functional regulator – differences

Activator Functional regulator

Activator is a tooth-borne appliance Frankel is a tissue-borne appliance
This is a loose-fitting appliance Firm maxillary anchorage
Activates the muscles and harnesses the muscle force; hence called activator Prevents the aberrant muscle force from acting on the dentition and arches
Does not act as an exercise device Acts as an exercise device
Bulk of the appliance is placed within the teeth Bulk of appliance is placed outside the teeth in vestibule
Only one wire component Many wire components
Activator is one single acrylic block Three acrylic parts joined by wire components
Mandibular advancement by 6–7 mm Minimum advancement by 2.5–3 mm
Vertical opening is more Minimal vertical opening; just for the wire to pass
Worn during night-time Worn day and night
Speech is not possible with appliance in mouth Speech is possible with the appliance
Twin block
I. Introduction

• Twin block was introduced by William Clark, a Scottish

orthodontist.

• This is a highly successful and most popular functional

appliance (Chadwick SM, Banks P, Wright JL, 1998).

• Twin blocks are simple bite blocks that modify the occlusal
inclined plane efficiently (Fig. 19.41).

• Twin blocks differ from other functional appliances in that

they are:

• Two separate pieces of appliances

• All functional movements are possible with the appliance.

• Eating and speaking are possible with the appliance.

• Twin blocks are designed for full time wear.

• They correct the maxillomandibular relationship through

functional displacement.

• Twin blocks produce rapid functional correction of

malocclusion by guiding the mandible forward into correct
occlusion.

• Forces of occlusion are used to correct the malocclusion.

II. Appliance design
The parts of the appliance are (i) acrylic part which consists of
base plate and occlusal inclined plane, (ii) wire components
which include labial bow, delta clasp and ball end clasp.

1. Acrylic part

• Twin blocks are two separate appliances (Fig. 19.42).

• The upper and lower occlusal inclined planes interlock at an

angle of 70° to occlusal plane.

a. Lower block

• The inclined plane must be clear of mesial surface contact

with lower molar.

• The lower molar must be free to erupt.

• The inclined plane on the lower bite-block is angled from the

mesial surface of the upper second premolar or deciduous
molar at 70° to the occlusal plane.

• Buccolingually, the lower block covers the occlusal surface

of the lower premolars or deciduous molars.

b. Upper block

• Upper inclined plane is angled from the mesial surface of

lower first molar.

• The flat portion passes distally over the remaining upper

posterior teeth in a wedge shape.

• Upper blocks cover only the lingual cusps of the posterior

 teeth.

Angulations of the inclined planes: Inclined planes are

angled at 70° to the occlusal plane.

2. Wire components

a. Clasps used

• Initially, Adams clasps were used.

• Now delta clasps are used in lower premolar and upper first
molar (see Fig. 18.22).

• In the lower anterior region, ball end clasps are used.

b. Labial bow

• Use of labial bow is optional.

• Used for retention purposes.

• Used when there is severe proclination and if they have to be

uprighted.

c. Construction bite

• Horizontal bite is usually taken in edge-to-edge.

• If the overjet is severe, 70% of the total protrusive path is

taken.

• Total protrusive path is the maximum sagittal advancement

that is possible in a patient.
• The vertical opening should be such that there is 2 mm
interincisor clearance.

• In the premolar area, there should be 5 mm clearance.

Optional attachments to twin block:

1. Expansion screws: If the maxillary arch is constricted or if

the horizontal mandibular advancement causes posterior
crossbite, then expansion screws are indicated.

2. Headgears: Headgears are used when maxilla has to be

intruded or retruded.

3. Concorde face bow: Used for combined intermaxillary

and extraoral traction.
III. Clinical management

Treatment consists of three stages:

1. Active phase – treatment with twin block (6–9 months).

2. Supportive phase – upper anterior inclined planes are

given after twin block (3–6 months).

3. Retention phase – regular retention appliance (9 months).

IV. Types of twin block appliances

1. Standard twin block

2. Sagittal twin block

3. Reverse twin block for class III correction

 4. Magnetic twin block
V. Uses or indications of twin block

Twin block is used in the following conditions:

• Class II division 1

• Class II division 2

• Class I open bites

• Class I closed bites

• Class III

• Lateral arch constriction

• TMJ problems

FIG. 19.41. Twin block.

 FIG. 19.42. Upper and lower occlusal blocks with inclined plane.

ACCESSORY POINTS
➤ The term functional jaw orthopaedics was coined by Andresen and Haupl.

➤ The term dental orthopaedics was coined by Norman Bennet.

➤ The term dentofacial orthopaedics was coined by BF Dewel.

➤ Original name of Herbst appliance: Scharnier or joint.

➤ Biomechanical orthodontics or biomechanical working retainer is the original name

of activator.

➤ Original angulations advised by Clark for occlusal inclined plane is 45°.

➤ Functional appliance used for correction of asymmetry is called as hybrid appliance.

➤ Disadvantage of the activator is that it cannot be used for correction of maxillary

prognathism.

➤ FR V was introduced by Albert H Owen.

➤ Pterygoid response is the rapid adaptive clinical response seen shortly after wearing
functional appliance. Patient experiences pain when asked to retract the mandible.

➤ Herbst appliance was reintroduced into use by Pancherz.

➤ Differentiating feature between activator and bionator is that bionator’s acrylic is

reduced to promote tongue force against palate.

➤ Twin block appliance is a modification of Schwarz double plate mechanism.

➤ Functional appliance used to achieve molar distalization is lip bumper.

➤ Type of activator used in patients with vertical growth pattern with open bite: V
activator.

➤ In the construction bite of Frankel, the forward mandibular positioning is 2.5–3 mm.

➤ Frankel type used in open bite cases is FR IV.

➤ Herbst appliance was introduced by Emil Herbst.

➤ Herbst appliance is an example for rigid fixed functional appliance.

➤ Sved bite plane has a bite plane covering the incisal edges of maxillary anterior teeth.

➤ Sunday bite is the bite achieved by the patient bringing his mandible forward in class
II division 1 malocclusion.

➤ Denholtz appliance is the other name for maxillary lip bumper.

➤ An example for tissue-borne functional appliance is FR.

➤ Stockli’s activator is a type of functional appliance which uses torquing spring.

➤ Functional appliances are not indicated in maxillary prognathism and mandibular

prognathism.

➤ Vertical opening should be just sufficient enough for crossover wire in FR.

➤ Noncompliance class II correctors are the other name for fixed functional appliances.

➤ Vestibular/oral screen was introduced by Newel in the year 1972.

➤ Rule of Ten’s: The maximum amount of sagittal advancement and vertical opening
should be 10 mm in construction bite for activators.

Advanced Learning
Fixed functional appliances
➤ The concept of fixed functional appliances was introduced by Emil Herbst.

➤ Then it was popularized by Hans Pancherz in 1979.

➤ Subsequently, numerous varieties of fixed functional appliances have come into use.

➤ Fixed functional appliances are normally known as noncompliance class II correctors.

Advantages of fixed functional appliances

➤ They are designed to be used 24 h a day.

➤ Because of 24-h wear, there is continuous stimulus for mandibular growth.

➤ They are smaller in size.

➤ Better adapted to functions such as mastication, swallowing, speech and breathing.

➤ Reduce the need for patient cooperation.

➤ Overall treatment time is reduced.

➤ Treatment of malocclusion is possible with minimal effort.

➤ Allow greater control by the orthodontist since the appliance cannot be removed by
the patient.

Classification of fixed functional appliances

Fixed functional appliances are classified as: (i) Flexible fixed functional appliances
(FFFA) and (ii) rigid fixed functional appliances (RFFA).

I. Flexible fixed functional appliances

• FFFA can be described as intermaxillary torsion coils or

fixed springs (Fig. 19.43).

FIG. 19.43. Flexible fixed functional appliance.

• Elasticity and flexibility are the important features of this
group of fixed functional appliances.

• These appliances allow greater movement of the mandible.

• Lateral movements can be carried out.

Disadvantages:

• Fractures of the appliances.

• Tendency of the patient to chew the appliance.

• Not aesthetically pleasing.

• Springs can cause mucosal ulcerations or irritation.

Uses:

• Used in class II division 1

• Used in class II division 2

• Used in class III

Examples:

• Jasper Jumper – first FFFA.

• Amoric torsion coils

• Adjustable bite corrector

• Scandee tubular jumper

• Klapper superspring

• Bite fixer

• Churro jumper
II. Rigid fixed functional appliances

Most important advantages of RFFA:

• After fixing, appliances do not permit the patient to close in

centric relation. This creates a 24-h stimulus for mandibular
growth.

• They do not fracture easily.

These appliances work on telescopic mechanism (Fig. 19.44).

FIG. 19.44. Rigid fixed functional appliance.

Examples:

• Herbst appliance
• Cantilevered bite jumper

• MALU Herbst appliance (mandibular advancement locking

unit – Herbst)

• Flip lock Herbst appliance

• Ventral telescope

• Magnetic telescopic device

• Mandibular protraction appliance

• Universal bite jumper

• Mandibular anterior repositioning device

• Biopedic appliance

• Ritto appliance

• Calibrate force module

• Eureka spring

• FORSUS – Fatigue-resistant device

Action of functional appliances through theories of growth

The action of functional appliances can be explained using functional matrix theory
and servo system.
Functional appliances and functional matrix theory ( fig. 19.45)
➤ Functional appliance wear stimulates both the periosteal matrix and capsular matrix.
 FIG. 19.45. Functional matrix theory and functional appliances–interaction.

Periosteal matrix
➤ Local periosteal matrices, like muscle, teeth and periosteum, are stimulated. For
example, the vestibular screen through lip pads and buccal shields stimulate the
periosteal matrices and growth of microskeletal units take place.

➤ Passive expansion of the arches, increase in intercanine arch width also occurs due to
periosteal matrix stimulation.

➤ Stimulation of lateral pterygoid causes posterior superior deposition of bone in

condyle which causes supplemental lengthening of mandible.

Capsular matrix
➤ When the mandible is advanced, the whole mandible is brought forward. This causes
the volumetric expansion of orofacial capsule.

➤ Volumetric expansion of orofacial capsule causes translation of the mandible.

Macroskeletal unit is altered.

Functional appliances and servo system theory

The direction and magnitude of growth of condyle due to functional appliances are due
to the altered sensory engram for the position of mandible.
The sequence of events taking place with functional appliance wear and interaction
can be explained by means of servo system theory (Fig. 19.46).
FIG. 19.46. Interaction between servo system theory and functional appliances.
CHAPTER 20
Orthopaedic appliances

CHAPTER OUTLINE
❖ Headgear strap/anchorage source
❖ Reverse-pull headgears or facemask
❖ Chin cup
❖ Accessory points
Headgears strap/anchorage source
Introduction
➤ Headgear is an extraoral orthopaedic appliance used to restrain the downward and
forward growth of maxilla.

➤ Orthopaedics may be defined as any manipulation that alters the skeletal system and
associated motor organs (Robert M. Ricketts).

History of extraoral appliances

1822: Report of the earliest use of headgear by Gunnel for occipital anchorage.
1892: The use of headgear for retracting the incisor teeth was described and popularized by Kingsley 1890s: Angle used headgear both for orthodontic
and orthopaedic purposes.
1900s: Calvin Case used headgear for extraoral anchorage. Headgear prescription reduced considerably in the early 1900s.
1930s: After the death of Angle, Oppenheim revived the use of headgear in orthodontic practice.
1940s: Kloehn introduced and popularized cervical headgear.

Components of headgear
The following are the basic components of headgear (Graber TM, 1977).

1. Face bow (Fig. 20.1)

Face bow is the handle through which the force of headgear is

transmitted to the jaws/dentition. It is the force delivery unit
and is made of heavy gauge stainless steel wire. A face bow
consists of two parts, namely outer bow and inner bow.

Outer bow

The outer bow is made of heavy stainless steel wire of gauge

0.059 inch or 1.5 mm. It is contoured to fit around the face in
the cheek area in the form of a broad ‘U’. The outer bow can
be:

• Short: Length of the outer bow is less than that of the inner
bow.
• Medium: Length of the outer bow equals the inner bow’s
length.

• Long: Length of the outer bow is longer than the inner bow’s
length.

The length of the outer bow is not equal on both sides in an

asymmetric headgear. The outer bow is about 5–10 mm
away from the cheek tissue to avoid impingement and
discomfort to the patient. The ends of the outer bow are bent
into a loop to facilitate engagement of force element.

Inner bow

The inner bow is also made of stainless steel wire of heavier

gauge of the size 0.045 inch or 0.050 inch (1.12 to 1.25 mm).
The inner bow is contoured to fit around the dental arch of
the patient.

Inner bow is in contact with the maxillary first molar buccal

tubes. At no point should the bow be in contact with the
teeth. The bow should be about 3–4 mm away from all the
teeth around the arch.

A U-loop is bent in the inner bow just in front of the mesial

aspect of the molar tube to be used as a stop.

Junction: The inner and outer bows are soldered anteriorly.

The junction is usually in the midline but in asymmetric
headgear, the position of the joint can be shifted to either
side.

Position of the bow: The position of the inner and outer bows
 when engaged should be between the two lips and be
passive. It should not lift the lips.

Purpose of using a face bow:

• Face bow helps in transmitting the forces of the headgear to

the dentition and maxillary complex.

• It acts as a splint to hold the teeth and jaw together.

• It can be used to effect expansion of the posterior segment, if

a crossbite is seen.

Other modes of force application:

• Acrylic splints covering the palate and occlusal surface of

maxillary teeth can be used instead of the face bow.

• Headgear can be directly engaged to loops on the archwire

of the fixed appliances. This is called J-hook headgear.
2. Anchorage source or headgear strap

Headgear or headcap is wrapped around the occipital region,

neck or junction of the parietal and occipital region. The
strap forms the base for deriving anchorage from the bones.
The selection depends on the type of headgear used.
3. Force element

Earlier, elastic bands, straps, etc. were used to apply stretch

force. Spring mechanism with safety release to prevent
injury to the child is currently used.
 FIG. 20.1. Face bow–parts.

Types/classification
Headgear is classified into three types according to the site from which anchorage is
gained. They are: (1) High-pull – distal and upward force, (2) medium-pull – distal and
slight upward force and (3) low-pull – distal/extrusive force on first molars.

1. High-pull or occipital headgear: The headcap is attached to the back of the head in
the occipital region or junction of parietal and occipital region (Fig. 20.2). It is used in
high mandibular angle cases. It exerts a superior and distal force to the maxilla and
maxillary dentition. Effects on maxillary molars are distal and intrusive.

2. Combination-pull/straight headgear/medium-pull (Fig. 20.3): The combination-pull

headgear has both the occipital and cervical straps. It is used in normal/average
mandible angle cases. The force value can be changed by asymmetric application of
force from one of the straps. If the force levels of both the straps are equal, then there is
a distal and slight upward force on maxilla and the teeth.

3. Cervical- or low-pull headgear: The cervical-pull headcap derives its anchorage from
the nape of the neck (Fig. 20.4). In addition to the distal force, it also exerts an extrusive
component of force to the maxillary molars. It is recommended in cases with low
mandibular Angle class II cases in which along with a distal force, an extrusion of
molars to open the bite is recommended, e.g. class II division 2 malocclusion.

Effects of cervical-pull headgear:

• To erupt the entire upper molars

• Tends to move the upper jaw distally

• Steepen the occlusal plane

• Expansion of the upper arch.

Cervical-pull headgear is also called Kloehn headgear.

FIG. 20.2. High-pull headgear.

FIG. 20.3. Combination-pull headgear.

 FIG. 20.4. Low-pull headgear.

Biomechanics
The effect of the headgear depends on the direction of application of force. The
following effects are observed.

Force applied to maxillary molar

Centre of resistance (Fig. 20.5):

➤ The centre of resistance of the maxillary first molars is in the mid-root region
between the roots slightly apical to the furcation (Fig. 20.5).
➤ Centre of resistance of maxilla: The centre of resistance of maxilla is between and
above the apices of the upper premolar teeth and between the lower margin of
orbitale and the distal apex of the first molar vertically in the sagittal plane.

➤ Length of the face bow and the direction of the outer bow determine the force vector.

FIG. 20.5. Centre of resistance.

Maxillary molars
➤ The force vector through the centre of resistance of molars causes bodily movement
of the tooth.

➤ The force vector below or above the centre of resistance tips the crown or root
respectively distally.

Maxilla
➤ Translation of maxilla upwards and backwards would result when the force vector
 passes through the centre of resistance of maxilla.

➤ A force vector above the centre of resistance would rotate the maxillary anterior end
up counterclockwise and force vector below the centre of resistance would rotate
maxilla clockwise.

Force parameters
Force values

Force value applied to sutures need to be heavier than normal to elicit an orthopaedic
response, because force seems to dissipate over the greater surface of the craniofacial
sutures. Minimum value of force to impede the forward movement of maxilla
appears to be 250 g/side. Force value differs for different uses of the headgear.

Duration

The type of force produced by headgear is heavy intermittent. Lighter forces elicit an
orthodontic tooth movement that is undesirable and heavy orthopaedic forces cannot
be applied continuously, hence intermittent force is applied.

Duration of wear is usually 12–16 h/day. At the start of the treatment, the patient is
asked to wear the appliance for 10 h/day and it is gradually increased.

Patients are asked to wear the headgear during the evening hours when the growth
hormone release is at maximum. Duration of orthopaedic treatment with headgear is
usually 12–18 months.

Uses of headgear
➤ Orthopaedic: In pre-adolescent patients with skeletal class II base due to prognathic
maxilla, headgear can be used to hold the maxilla from downward and forward
growth. Mandibular growth expresses itself and class II correction is normally
achieved in 12–18 months. Force value is 350–450 g/side but should not exceed 1000 g
in total duration of wearing for 10–12 h/day (Bowden DEJ, 1978).

➤ Anchorage: Headgear can be used in the adults for reinforcement of anchorage

during fixed appliance treatment. Force value is about 250–350 g/side for 10–12 h/day.

➤ Distalization of maxillary first molar: In growing patients with class II molar

relation, headgear appears to be the most effective and straightforward method of
distalizing the maxillary first molar to correct the molar relation. Straight-pull or
high-pull headgear is used. Pure translation of molar can be attained, if the force is
applied through the centre of resistance of the maxillary molar. Force applied is about
300 g/side for 10–12 h/day. Treatment period is usually 12–18 months. If the class II
 molar relation is unilateral, then asymmetric headgear is used.

➤ Retention: Headgear is used for the retention of molar correction achieved through
other techniques.

➤ Space maintenance and regaining: Space regaining after space loss can be
accomplished through the use of asymmetric headgear. Headgear can also be used
for space maintenance after premature loss of deciduous teeth. Face bows can be used
to control all three dimensions–vertical, sagittal and transverse; both dental and
skeletal.

➤ Overjet reduction: Asher’s face bow is used to retract upper and lower anteriors
simultaneously

➤ Intrusion of molars and incisors using high-pull headgear: Intrusion can be

attained by using maxillary intrusion splint.

➤ Expansion or contraction of the arch: By adjusting the inner bow of the face bow,
expansion or contraction can be achieved.

➤ Uprighting of molars: Mesially tipped molars can be uprighted using headgear.

Patient instructions
➤ Patient compliance: Regular wear of the appliance should be reinforced because the
force applied is intermittent, patient’s initial acceptance of the appliance is difficult to
achieve. Proper counselling should be given.

➤ Appliance should be worn during the evening hours.

➤ Patients should be advised on the safety aspects of the appliance. Headgear should
not be used as a play toy. Pulling the face bow and sudden release would result in
serious eye injury. Use of safety release module prevents such injury.

Disadvantages of headgear therapy

➤ Accidental disengagement when the child is playing with the headgear.

➤ Incorrect handling by the child during the fitting or removal of the headgear.

➤ Deliberate disengagement of the headgear caused by another child.

➤ Unintentional disengagement or detachment of the headgear during sleep.

➤ Prone for injuries (Samuel RHA and Jones ML, 1994).

➤ Allergy to nickel.
Reverse-pull headgears or facemask
Introduction
Facemask is an extraoral traction appliance used to correct skeletal class III
malocclusion. According to Moyers, extraoral traction devices are those that utilize
anchorage outside the oral cavity for efficient application of force in direction not
otherwise possible. Facemask is a method by which anterior directed forces to the teeth
or skeletal structures are delivered from an extraoral source.

History
➤ Early 1970s: Hickham was the first to use the reverse-pull headgear to correct the
class III malocclusion.

➤ 1972: Jean Delaire improvised the design of facemask.

➤ 1980s: Henri Petit modified Delaire’s facemask and a simplified design of the
appliance comfortable for the patient was introduced. The facemask used currently is
a modification of the Petit’s facemask.

Indications
➤ Facemask is primarily used to correct class III skeletal malocclusion due to maxillary
retrognathism in young children (Nanda).

➤ In pseudo-class III malocclusion, facemask can correct centric relation–centric

occlusion discrepancy.

➤ After surgical correction of the skeletal class III malocclusion, facemask is indicated
as a retaining device.

Components of a facemask
Facemask regardless of the type has the following components (Fig. 20.6):

➤ Chin cup

➤ Forehead cap/support

➤ Metal framework

➤ Intraoral splint/device
➤ Elastics

1. Chin cup

Chin cup covers the chin and derives anchorage from the same
so that protraction force delivered to the maxilla delivers
reciprocal force to the chin to push it backwards.

Action

Chin cup restrains the forward growth of the mandible by

changing the direction of growth from forward and
downward to backward and downward.
2. Forehead support

• This portion rests against the forehead and delivers

anchorage to the appliance from the frontal bone. This also
provides a reciprocal force to the forehead with a
protraction force on maxilla.

• The framework is anchored around the head by means of

elastic band attached to forehead support.
3. Metal framework

• Various types of facemask differ in the design of the metal

framework used.
Purpose of use of framework

• The framework supports and connects all the parts of the

facemask.

• It also gives attachment to the rods to which elastics are

 attached from the intraoral device.
Types of facemask

a. Hickham: Hickham’s reverse-pull headgear consists of a

chin cup and forehead support. The framework has metal
rods running parallel to the mandible and at the angle of
the mandible the rods turn up to run parallel to the lateral
border of the face. Two arms are included to engage the
elastics.

b. Delaire: Delaire of France designed a facemask with the

framework very similar in design to Hickham’s, but away
from the face without touching it. The hexagonal
framework has a horizontal rod at the lower third of the
face parallel to lip line for the engagement of elastics.

c. Petit: Henri Petit, also of France, modified Delaire’s

facemask to make it much simpler. Petit’s facemask just
has a central midline rod with the horizontal adjustable
rods for the engagement of elastic. The horizontal rod can
be raised or lowered according to the needs of the
practitioner. The midline rod is curved to the contours of
the face and extends from the chin cup to the forehead
support.

d. Turbinger: Turbinger’s design of the metal frame is

similar to Petit’s but with two rods instead of the midline
rod. The rods run parallel form the chin cup and in the
region of the base of the nose they turn medially to
accommodate the nose. The rods then run parallel till the
forehead support. The horizontal rod is present at the lip
level for the engagement of elastic.
4. Intraoral device

In facemask, other variable feature is the intraoral device (Fig.

20.7). Intraoral device can be full-banded fixed appliances,
in which case elastic is engaged from the molars. McNamara
advocates the use of a banded rapid maxillary expansion
(RME) or bonded RME with hooks at the premolar region
for the engagement of elastics. A modified protraction
headgear is also used in which elastics are engaged from
outer bow of the headgear to the rods.

Purpose of using RME

The purpose of using RME in skeletal class III is that the RME
helps in relieving the posterior crossbite often associated
with class III malocclusion. It also helps in the disruption of
the suture system to facilitate protraction.
5. Elastics
 FIG. 20.6. Facemask–components.

FIG. 20.7. Bonded palatal expansion appliance with hooks for engaging elastics.

Heavier orthopaedic elastics are used to give traction force to the maxilla.

Effects of facemask
➤ Forward movement of maxilla

➤ Forward movement of maxillary teeth

➤ Proclination of maxillary incisors

➤ Correction of anterior and posterior crossbite

➤ Downward and backward rotation of the mandible

Biomechanics
Elastic traction pulls the maxilla forward.

Force parameters
➤ Force value: Initial force of 300 g/side; 2 weeks later, 450–500 g/side.

➤ Force direction: Force applied 20° downwards to the occlusal plane produces
translation of maxilla forwards. Elastic parallel to the occlusal plane produces an
 upward rotation along with forward movement of maxilla.

➤ Duration: Time of wear is 20 h/day, but after 6 months it is reduced to night-time

wear for retention. Active treatment takes about 4–6 months.

➤ Timing of treatment: Early mixed dentition is the ideal age for starting the treatment
but till 10 years of age response is good. After 10 years, the response reduces. Verdon
P (1989) recommends forward posturing of mandible before 8 years of age.

➤ RME: RME is activated once in a day usually before bedtime for a period of 2 weeks
or till the desired expansion is achieved.

➤ Treatment completion: The following are indications of treatment completion.

• Attainment of positive overjet.

• Improvement from the concave profile.

Advantages
➤ Facemask is the only extraoral traction device for correction of maxillary deficiency
with rapid improvement and early results.

➤ Patient confidence is gained early due to rapid treatment progress and patient
compliance is improved.
Chin cup
Introduction
Chin cup is an extraoral appliance designed to exert an upward and backward force on the
mandible by applying pressure to the chin, thereby preventing forward growth.

Indications
➤ Skeletal class III malocclusion due to mandibular prognathism.

➤ Anterior open bite cases.

➤ It can be used in patients with increased anterior facial height.

Parts
The chin cup consists of (i) chin cup, covering the chin, (ii) headgear and (iii) elastic to
generate orthopaedic force.

Types
1. Occipital-pull chin cup

Occipital-pull chin cup is used in cases of skeletal class III due

to mild to moderate mandibular prognathism with
horizontal growth pattern. The headgear is around the
occipital and the parietal bone just like high-pull headgear.
Force can be directed in two ways: (i) through the condyle of
the mandible and restricts the downward and forward
growth of mandible and (ii) below the condyle, producing a
downward and backward rotation of the mandible.
2. Vertical-pull chin cup

Vertical-pull chin cup is used to correct anterior open bite

conditions. In this chin cup, headgear is near the coronal
suture and there is a horizontal strap to the back of the head.
 The vertical force reduces the anterior facial height by
rotating the mandible up. Elastic strap is attached to the
hook on the chin cup.

Biomechanics (fig. 20.8)

➤ At the start of the treatment 150–300 g/side of force is applied.

➤ Two months later, force is increased to 450–700 g/side.

➤ Less force is enough, if the line of force is below the condyle.

➤ Patient is instructed to wear the appliance for 14 h/day with a range of 10–16 h.

FIG. 20.8. Chin cup–used in mandibular prognathism.

Age of treatment
➤ Less than 8 years in the mixed dentition.
➤ Treatment completion is indicated by the correction of anterior crossbite.

Fabrication
➤ Custom-made chin cups are made according to individual patient’s size.
Measurements of the chin are recorded and chin cup is fabricated using cold-cure
acrylic resins.

➤ Ready-made chin cups are available commercially in different sizes. The best suitable
size is selected and given for the patient.

Side effects
➤ Lingual tipping of lower incisors and crowding.

➤ If temporomandibular joint (TMJ) symptoms develop, treatment should be

discontinued immediately.

Other uses
Chin cup is a good retention appliance after class III correction through other methods,
e.g. facemask, surgical class III correction.
ACCESSORY POINTS
➤ Kloehn face bow is used in class II malocclusion.

➤ The maximum extent of forward displacement of maxilla in maxillary deficiency

with extraoral traction is 3 mm.

➤ Rule of thumb in headgear therapy: If more than half of extraction space is required
to align teeth and achieve class I canine relationship, then extraoral anchorage will be
required.

➤ Force applied with chin cup is 450–700 g/side.

➤ In a growing patient with class III due to deficient maxilla and mild excess mandible,
the choice of treatment is facemask therapy.

➤ Delaire facemask is used for treatment of maxillary deficiency.

➤ Disadvantage of using cervical headgear is extrusion of maxillary molars and increase in

facial height.

➤ Forces employed to correct or change the direction of growth are known as

orthopaedic force.
➤ Elastic force of the value 450–500 g/side is applied at a direction 20° to the occlusal plane
with facemask.

➤ Minimum value of force to impede the forward movement of maxilla appears to be

250 g/side.

➤ Headgears: Force usually is in the range of 350–450 g/side but never exceeds 1000 g
total. Force applied is heavy intermittent and the patient wears the appliance for 12–
16 h/day.
CHAPTER 21
Expansion appliances

CHAPTER OUTLINE
❖ Types of expansion
❖ Classification of expansion appliances
❖ Rapid maxillary expansion (RME)/rapid palatal expansion (RPE)
❖ Classification of slow expansion appliances
❖ Removable slow expansion appliances
❖ Fixed slow expansion appliances
❖ Differences between RME and slow expansion
❖ Accessory points
Types of expansion
Expansion can be divided into three categories.

Orthodontic expansion
➤ This is produced by conventional fixed appliances and different types of removable
appliances.

➤ In orthodontic expansion, there is lateral movement of the buccal segments which

results in mainly dentoalveolar expansion.

➤ There is buccal tipping of the crowns and lingual tipping of the roots.

➤ Aberrant soft tissue pressure from cheeks can cause relapse of the achieved
expansion.

Passive expansion
➤ Results from the intrinsic forces exerted by the tongue.

➤ With the use of buccal shields (e.g. Frankel), the forces from the labial and buccal
musculature are prevented from acting on the dentition.

➤ This results in the widening of the arches, because the forces from tongue exert
expansible forces on the arches. The tongue force is not counteracted by buccinator
mechanism.

➤ Passive expansion is not achieved by mechanical appliances but by the vestibular or

lip shields.

Orthopaedic expansion
➤ In this type of expansion, changes are produced mainly in the skeletal structures.

➤ There is less amount of dentoalveolar expansion.

➤ Rapid maxillary expansion (RME) appliances are classical examples for true
orthopaedic expansion.

➤ RME causes separation of midpalatal suture.

➤ RME also affects circumzygomatic and circummaxillary sutures.

➤ After expansion, new bone is deposited in the midpalatal suture.
Classification of expansion appliances
Expansion appliances are one of the oldest appliances which are still being used in
orthodontics. Expansion appliances can be broadly classified into maxillary and
mandibular expansion appliances.

Maxillary expansion appliances

Slow
Removable Fixed
1. Active plate with screws 1. W arch
2. Coffin spring 2. Quad helix
3. Active plate with Z springs 3. Expansion screws
4. With fixed appliance

Rapid
Banded RME Bonded RME
1. Haas 1. Acrylic splints
2. Isaacson 2. Cast metal splints
3. Hyrax
4. Derichsweiller

Mandibular expansion appliance

Lower schwarz plate
Surgically assisted rapid palatal expansion (SARPE): In this, the resistance of the lateral
buttresses of maxilla is reduced by osteotomy cuts. Expansion appliance used is a jack
screw.
Rapid maxillary expansion (RME)/rapid palatal
expansion (RPE)
History of expansion appliances
➤ Expansion appliances have been used from olden days, e.g. Bandelette by Pierre
Fauchard, E arch by Angle EH.

➤ These appliances were slow expansion appliances.

➤ Emerson C Angell (1860) is the pioneer of RME.

➤ Angell had to face stiff opposition from people who were against expansion mode of
treatment.

➤ Goddard CL, Martin Dewey and Charles Hawley supported Angell EC.

➤ Angell’s concept was supported by ENT surgeons also.

➤ Walter Coffin also introduced a slow expansion appliance which is called coffin
spring during this period.

➤ RME now plays an important form of the orthopaedic therapy.

Indications of rapid maxillary expansion

Indications of RME can be studied under two headings:

Orthodontic indications
➤ RME is used in unilateral or bilateral posterior skeletal crossbite.

➤ Narrow maxilla in certain class II cases can be treated using RME.

➤ Used in class III malocclusion.

➤ Treatment in collapsed maxillary arch due to cleft palate.

➤ Treatment along with reverse-pull headgear to loosen the sutures.

➤ RME is used in anterior crossbite to gain space.

➤ Bonded RME can be used in high-angle cases.

Medical indications (gray LP and brogan WF)
➤ Poor nasal airway

➤ Septal deformity

➤ Recurrent ear, nasal or sinus infections

➤ Allergic rhinitis

➤ Asthma

➤ Before septoplasty

Principle of RME

Rapid expansion appliance–classification

1. Removable RME

2. Fixed RME

a. Bonded or banded type

b. Tooth-borne or tooth and tissue-borne type

• Removable appliances are not effective for RME because

 they are not rigid enough to produce skeletal expansion.

• Fixed RME: They can be bonded or banded or tooth-borne,

tooth and tissue-borne.

Banded RME appliance

Basic step (fig. 21.1)
First premolars (deciduous molar) and first permanent molars are banded. They are
joined labially and palatally by soldering with heavier gauge wire. The basic RME
appliance is the screw which is placed in the midline. The difference in appliance design
is based on the various types of screws and mode of attachment. The different types of
banded RMEs are as follows:

1. Derichsweiller type: In this, the screw is connected to the bands by means of tags
that are welded and soldered to the palatal aspect of band on one side and embedded in
acrylic on the palatal aspects of all nonbanded teeth except the incisors. Acrylic adapts
to the palate and is in two halves to permit activation of screw.

2. Haas type: Heavy stainless steel wire (0.045 inch/1.15 mm) is welded and soldered
along the palatal aspects of the band. The free ends are turned back to be embedded in
acrylic. Both Derichsweiller and Haas type use similar kind of screws.

3. Isaacson type: The drawback of expansion screw is the build-up of pressure, which is
hazardous to tissue. To overcome this, and to make the force application smooth and
constant, Minne-Expander was introduced. This is also flexible. Minne-Expander uses a
special spring-loaded screw. This is adapted and soldered directly to the bands. Acrylic
plates are not used in this.

4. Biedermann type: Biedermann type uses HYRAX (hygienic rapid expansion) screw.
It has heavy wires which are adapted, welded and soldered to the palatal aspect of the
bands.
 FIG. 21.1. Banded RME appliance.

Bonded RME appliance

In bonded RME, instead of bands, metallic cap splints or acrylic covering is used.

Cast metal cap splints

➤ Cast cap splint to all the teeth are prepared to which the screw is soldered.

➤ The entire assembly is cemented/bonded.

Acrylic splints
➤ Thick gauge stainless steel wire is closely adapted around the posterior teeth from
premolars to molars both buccally and palatally.

➤ Screw is soldered to the wire.

➤ Acrylic is covered over the occlusal, buccal and palatal occlusal third of all the
posterior teeth.

➤ The assembly is cemented/bonded.

Advantages of bonded RME

➤ Bonded appliances are useful in high-angle cases.

➤ The occlusal acrylic covering prevents the increase in mandibular angle by acting as
 a splint.

Appliance management
➤ Before 15 years

Activated twice in a day

90o activation each time

Total 180o activation every day

0.5 mm/day

Review: After 1 week

➤ 15–20 years

Activated 4 times/day

45° activation

Total 180° activation

0.5 mm/day

Review: After 1 week

➤ Above 20 years

Activated 2 times/day

First activation 90°

Then 45° activation

Total 90°

Review: After 3–4 days

➤ Pain is felt in patients who are in late adolescences (above 15 years) and adults due to
build-up of force.

➤ Slight discomfort may be felt during expansion.

➤ Persistent pain is noticed in patients whose suture is fused. In such cases, activation
should be stopped.

➤ In young patients, parents should be taught to turn the screw and the schedule of
activation.

SARPE (surgically assisted rapid palatal expansion)

➤ In adults, palatal osteotomies lateral to midpalatal suture is done to assist rapid
expansion.

➤ In lateral maxillary osteotomy, cuts are also made in certain areas to curtail the
strong buttressing effect of the circummaxillary sutures and bones.

Clinical implications of expansion

➤ Midpalatal suture does not open evenly but opens in a ‘V’ fashion.

➤ The broad end of V is in anterior region and apex of V is at the posterior region.

➤ There will be appearance of median diastema.

➤ Occlusal and frontal cephalometric radiograph will reveal the suture opening.

➤ Usual treatment period is 2 weeks.

➤ Relapse is higher after RME, hence overcorrection is advised.

➤ Force recorded during rapid expansion is in the range of 10–20 pounds.

Tissue changes observed with RME

Tissue changes can be divided into: (i) Bone changes, (ii) sutural changes and (iii) dental
changes.

Bone changes
➤ Maxilla moves laterally due to expansion.

➤ Maxilla also rotates with the fulcrum at frontonasal suture.

➤ Increase in nasal airway, reduction in airway resistance.

➤ Downward and backward rotation of mandible.

➤ Increase in mandibular angle.

Sutural changes
➤ Space created by sutural opening is filled with tissue fluid and haemorrhage.

➤ After initial hyperaemia, area is invaded by osteoblasts.

➤ New bone is deposited at the edges of palatal process.

➤ Gradual bone filling in the space.

Dental changes
➤ Initially, teeth move labially by translation.

➤ Subsequently, there is increased buccal inclination of the posterior teeth.

➤ Slight extrusion of the posterior teeth.

➤ Appearance of median diastema.

➤ Later, median diastema closes due to the pull of transseptal fibre.

Tissue reaction after expansion

➤ At the end of active expansion treatment, 80% skeletal and 20% dental expansion
occur.

➤ When relapse occurs after active treatment, there is more skeletal relapse, dental
correction is retained.

➤ After 4 months, 50% skeletal and 50% dental changes are observed.

➤ Relapse is highest during the first 6 weeks after expansion.

➤ Disappearance of median diastema due to pull of transseptal fibres occurs.

Retention schedule after RME
The objective of retention is to hold the expansion while the forces generated have
decayed.

➤ The same fixed RME appliance is used as retainer for first 3 months.

➤ The hole of the screw is filled with self-cure acrylic to prevent accidental unwinding
of the screw.

➤ Removable retainers are given from the fourth month.

➤ Removable retainers are worn full time for about 9 months after expansion.

➤ After 9 months, half time wear is advised.

Classification of slow expansion appliances
➤ Slow expansion appliances are designed primarily to produce dentoalveolar
expansion or changes.

➤ In young children, slow expansion appliances might produce skeletal expansion with
opening of midpalatal suture.

Indications
➤ To relieve crowding (<4 mm) in minimal space discrepancy cases.

➤ Posterior dental crossbite in one or two teeth.

➤ Cleft palate cases with collapsed maxilla.

➤ Constricted maxillary arch.

Advantages
➤ Slow expansion elicits a more physiological response.

➤ Less damage to the teeth.

➤ Produces skeletal effect in young children.

Disadvantage
➤ Slow expansion produces predominantly tipping rather than bodily expansion of
teeth.

Classification
The various slow expansion appliances can be broadly classified as:

1. Removable slow expansion

a. Expansion plate with jackscrews

b. Coffin springs

c. Removable quad helix

2. Fixed slow expansion

a. W arch appliance

b. Quad helix

c. Expansion screw

d. Fixed appliance
Removable slow expansion appliances
The various removable expansion appliances are (i) expansion plates, (ii) coffin spring
and (iii) removable quad helix.

Expansion plates
Martin Schwarz is the pioneer in expansion plate. Following are the components of
expansion plates:

a. Base plate

• Base plates are made of acrylic, which are split into two
halves with midline screws.

• Base plate is thoroughly adapted to the contours of the

palate.

• Apart from providing the framework, and anchorage, the

base plate actually delivers the force from the screws to the
tooth.
b. Retentive part

• Retention is provided by Adams’ clasp on first molars.

• In case requiring additional retention, extra clasps are placed

in premolars or deciduous molars, e.g. triangular clasp.

• South end clasps are used for retention in anterior teeth.

c. Active component

• Jackscrews are used. The different types of screws used:

1. Bad cock
 2. Nord

3. Glenross

4. Sprung Glenross

5. Double screw.
Clinical management
➤ The expansion screw delivers controlled and equal force to both sides.

➤ Screw is activated very slowly.

➤ Tooth movement is about 1 mm/month.

➤ Excessive activation causes displacement of the appliance.

➤ Activation is done once or twice a week.

➤ For each activation, quarter turn is given.

➤ Quarter turn will produce 0.25 mm activation.

➤ This corresponds to the average width of the periodontal ligament.

Modifications of expansion plate

Apart from the horizontal placement for transverse expansion, screws can be placed in
the following ways:

1. Screws are placed in the anterior aspect of the palate parallel to the midpalatal suture
for anterior expansion. This is given in cases of anterior crossbite (Fig. 21.2).

2. A ‘Y’-shaped plate will produce simultaneous lateral expansion of posterior teeth and
anterior expansion.

3. Distalization of buccal segments can be achieved using expansion screws (Fig. 21.3).

4. Expansion plates can be modified for asymmetric expansion (Fig. 21.4).

FIG. 21.2. Expansion appliance for labial movement of upper anteriors.

FIG. 21.3. Distalization of buccal segments.

 FIG. 21.4. Asymmetric expansion.

Disadvantages
➤ Expansion plates are patient-dependent for both wearing and activation.

➤ Excessive activation causes dislodgement of the appliance.

➤ Requires readjustment, even if the appliance is not worn for one day.

➤ Appliances are bulky.

Coffin springs (refer to fig. 18.32)

Coffin spring was introduced by Walter Coffin.

➤ Wire used: 1.25-mm heavy stainless steel wire.

Indications
➤ Expansion of constricted maxillary arch.

➤ Correction of crossbite.

➤ Conditions requiring differential expansion.

Spring design
➤ The spring consists of U- or omega-shaped loop positioned in the midpalatal region.
The distal ends of the U-loop are limited to the distal of first permanent molar.
➤ Anteriorly, the loop gets constricted and recurved into the base plate.

➤ It is a continuous type of spring where both ends are fixed to the base plate.

➤ The wire should be placed 1 mm away from the mucosa.

Advantages
➤ Cheaper when compared to expansion screws.

➤ Differential expansion of arch in the premolar or molar region is possible.

➤ Less bulky.

Disadvantage
➤ Coffin spring tends to be unstable, if it is not made precisely.

Activation
➤ Marking pits are made on both sides of the plate by drilling. This allows the width of
the appliance to be checked.

➤ Pliers should not be used for activation.

➤ Appliance is activated by expanding the appliance manually by pulling the sides

apart, first in the anterior region and then in the posterior region.

➤ Adequate care should be taken to maintain the two sides of the appliance in the same
plane. If the plane changes, appliance may not fit properly.

➤ An expansion of 2–3 mm is made during activation.

Removable quad helix appliances

Removable quad helix is inserted into the lingual attachment which is welded or
soldered to the molar band. This permits adjustment of the appliance outside the
mouth.
Fixed slow expansion appliances
The various fixed slow expansion appliances are (i) W-arch, (ii) quad helix, (iii)
expansion screw and (iv) expansion with fixed appliances.
The fixed expansion appliances have to be anchored firmly to the maxilla to exert
controlled and equal expansible force.

W-arch (fig. 21.5)

➤ This fixed slow expansion appliance is constructed with 0.036 inch stainless steel
wire.

➤ Wire is adapted to the form of ‘W’ which extends from the first permanent molar to
the canine in the anterior palate.

➤ Free ends of the ‘W’ are adapted closely to the palatal surfaces of
premolars/deciduous molars.

➤ Appliances should be away from the palatal mucosa to prevent tissue irritation.

➤ Lingual arch is soldered to bands on molars.

➤ The finished appliance is cemented to the first permanent molars.

FIG. 21.5. W-arch appliance.

Activation
➤ For anterior expansion – opening of apices of ‘W’ (position 2).

➤ For posterior expansion – opening near anterior region (position 1).

Quad helix
➤ Quad helix was introduced by Robert M Ricketts: Quad helix incorporates four
helices or coils to increase flexibility (Fig. 21.6). Basically, the appliance is constructed
using 0.038 inch elgiloy or stainless steel wire, which is cemented either to the
maxillary first permanent molars or to the deciduous second molars.

FIG. 21.6. Quad helix appliance.

Parts of quad helix

➤ The parts of the quad helix (Fig. 21.7) are (i) posterior helix, (ii) palatal bridge, (iii)
anterior helix, (iv) anterior bridge and (v) outer arm.

➤ There is an anterior bridge between the anterior helices in the canine region.

➤ Two lateral or palatal bridges one on either side between the anterior and posterior
helices.

➤ The posterior helix should not extend more than 2 mm distal to the first permanent
molar.
➤ The outer arm or buccal arms are soldered to molar bands.

FIG. 21.7. Parts of quad helix: (A) posterior helix, (B) palatal bridge, (C) anterior helix, (D)
anterior bridge and (E) outer arm.

Activation
➤ Quad helix can be activated at four positions.

➤ In the anterior bridge: Results in expansion in the molar region.

➤ In the palatal bridge: Derotation and expansion of molar on the same side and
distalization of molar on the opposite side.

➤ Outer arms are activated to expand canines and premolars.

➤ Opening of posterior helix expands the buccal arm.

An initial expansion of 8 mm will produce 14 ounces of force.

➤ Average force is 200–400 g depending upon the amount of expansion or activation.

Variations
➤ Occasionally, a habit breaking appliance may be incorporated into a variation of
quad helix.

➤ Quad helix appliance can rotate the upper first permanent molars.

➤ When anterior crossbite is present, another helix is incorporated (Fig. 21.8).

➤ Quad helix can be used as a space maintainer.

➤ It is used to reinforce anchorage.

 FIG. 21.8. Incorporation of additional helices. Arrows denote labial movement of palatally
placed maxillary incisors.

Advantages of quad helix

➤ Provides excellent expansion in cleft palate patients.

➤ Expansion is smooth and controlled.

➤ In young children, skeletal expansion can be achieved.

➤ Anterior bridge with helices acts as reminder for habit breaking.

Expansion screw
➤ RME screws can be used to produce slow expansion.

➤ They are activated slowly once or twice a week to produce slow expansion.

Fixed appliances
➤ Expansion archwires of fixed appliance also can produce slow expansion.

➤ Heavy wires are used with fixed appliance to induce slow expansion.
Differences between RME and slow expansion
Table 21.1 depicts differences between RME and slow expansion.

Table 21.1.
Differences between RME and slow expansion

ACCESSORY POINTS
➤ The type of expansion achieved with Frankel appliance is passive expansion.

➤ Pain experienced during treatment with RME is due to build-up of forces.

➤ Midpalatal suture opens in a V-shaped fashion with RME.

➤ Force recorded during rapid expansion is in the range of 10–20 pounds.

➤ Appearance of median diastema is a characteristic sign during RME.

➤ Relapse after rapid maxillary treatment is highest during the first 6 weeks after
expansion.

➤ Type of RME appliance used in high angle case is bonded RME.

➤ Quad helix was introduced by Ricketts.

➤ Quad helix produces skeletal expansion in young children.

CHAPTER 22
Fixed appliances

CHAPTER OUTLINE
❖ Various components of fixed appliances
❖ Evolution of various fixed appliance techniques
❖ Bonding techniques in orthodontics
❖ Latex elastics
❖ Management of dental problems during orthodontic treatment
❖ Advantages and limitations of fixed appliances
❖ Accessory points
❖ Advanced learning
❖ Lingual orthodontics
❖ Self-ligating brackets
Various components of fixed appliances
The parts of fixed appliances are broadly classified into two parts: Active parts and
passive parts.

Active components of fixed appliances

1. Separators

• Separators are used to create space for banding teeth.

• Tight proximal contact does not allow proper banding of

teeth.
Principles of separators:

• It is a device to wedge the teeth in place between the teeth.

• It causes tooth movement and separation of teeth for easy

placement of bands.
Types (Fig. 22.1):

i. Metal separators:

a. 0.020 inch brass wire

b. Kesling separating spring

ii. Elastic separators:

a. Elastic thread

b. Maxian elastic separator

 c. Elastomeric rings (or) doughnut

• Brass wire is rotated through the embrasure between teeth

and kept for 5–7 days.

• Separating springs exert a scissors-like action when kept for

7 days.

• Elastomeric separators placed above and below the contact

point are effective after 2 or 3 days.
2. Archwires (Fig. 22.2)

• Archwire exerts force to the teeth through the brackets and

is used for achieving all types of tooth movements.

• Depending upon the cross-section, it is divided into: (i)

round wire, (ii) rectangular wire and (iii) square wire.

• Depending upon the modifications incorporated to produce

the desired tooth movement, archwires are classified into: (i)
plain archwires and (ii) archwire with loops.
3. Elastics

Elastics are used to move the teeth, to fix archwire to the teeth,
for separation of teeth. It is available in the form of bands,
threads, modules and rotational wedges.

Rotation wedges are used to correct a rotated tooth.

4. Springs

Types:
 i. Coil springs:

• These are two types of coil springs: open-coil spring and

closed-coil spring.

• These are used to close or open the spaces.

• It is generally used in such a way that they are opened to

close spaces and closed to open the space.

ii. Uprighting springs: These are used for root movement to

correct mesial distal tipping.

iii. Rotation springs: These are used to correct rotation.

FIG. 22.1. (A) Maxian elastic separator, (B) elastic ring separator and (C) Kesling separator in
position.
 FIG. 22.2. Archwire with other attachments.

Expansion screws
➤ Expansion screws are used in cases of maxillary constriction to achieve expansion.

Passive parts of fixed appliances

1. Bands

Bands are thin strips of stainless steel which are adapted to the
contours of the tooth to which attachments are welded or
soldered.

Classification:

I. Based on tooth used (Table 22.1)

II. Based on fabrication:

1. Preformed: It is available ready-made in assorted sizes.

 2. Custom made: These are contoured by the orthodontists
using special pliers.

• Bands are mainly used for the posterior teeth.

• With the advent of direct bonding of brackets, bands are

rarely used for anterior teeth.
2. Attachments to bands

• Buccal tubes: It holds the archwires and the inner bow of the
face bow attachment.

• Lingual sheaths: Receive and attach lingual archwires.

• Molar hooks, lingual buttons and cleats: These are used for
engaging elastic bands and modules.
3. Orthodontic brackets

• The force required for orthodontic tooth movement is

transmitted from the active components through the
brackets.

• Orthodontic brackets can be compared to door handles.

Classification of orthodontic brackets:

I. Based on the technique

• Edgewise brackets

• Begg brackets

• Preadjusted edgewise
• Lingual orthodontic brackets

II. Based on the type of material

• Metallic brackets

• Plastic brackets

• Ceramic bracket

III. Based on the method of fixing

• Bondable

• Weldable
4. Accessories

Accessories include:

1. Lock pins (Fig. 22.3)

• Lock pins are used to connect or engage the archwire into

the vertical slot of the Begg brackets.

• These are made from brass.

Types:

• Stage I

• Stage II

• Stage III
• T pins

2. Ligature wires

• These are used to tie the archwire to the brackets.

• These are made from dead soft fully annealed stainless steel
wires.

• They are highly flexible.

• Size is about 0.010 inch.

3. Modules

• Modules are used to fix the archwire to the bracket slot.

• These are elastomeric rings which are used in preadjusted

edgewise technique.

Table 22.1.
Band material: Types

Teeth Size (in inches)

Molar band 0.005 × 0.20
0.005 × 0.18
Premolars 0.004 × 0.150
Incisors 0.003 × 0.125
FIG. 22.3. (A) stage 1 and (B) stage 2 lock pins.
Evolution of various fixed appliance techniques
The sequence of development of fixed appliance technique is as given in flowchart.
Sequence of development of fixed appliance

Edgewise appliance (angle, 1928)

➤ In this technique, archwire is inserted through the narrowest portion into the slot.
Hence, it is called edgewise technique.

➤ This technique allowed excellent control of crown and root in all the three planes.

➤ The dimension of the slot is 0.022 × 0.028 inches.

➤ The three bends used to accomplish tooth movements are as follows:

1. First order bends – in and out or labiolingual corrections.

2. Second order bends – mesiodistal corrections.

3. Third order bends – buccolingual corrections.

Straight wire appliance or preadjusted edgewise appliance
➤ Andrews introduced the straight wire concept in 1970s.

➤ It eliminated the difficult wire-bending procedures by modifying the brackets.

➤ In this technique, different brackets are used for the teeth.

➤ The type of tooth movement achieved is bodily movement.

➤ Hence, anchorage preparation is vital in preadjusted appliance technique.

Appliance prescription
➤ The angulations and torque values built into the preadjusted bracket are called
appliance prescription.

➤ The dimensions of slot are 0.022 × 0.028 inches or 0.018 × 0.025 inches

Stages of preadjusted edgewise treatment

Stage 1

• Initial aligning and levelling of arches done.

• Crowding correction and establishing normal overjet.

Stage 2

• Space closure and molar relationship correction.

• Establishing class I molar relation and establishing normal

overjet.
Stage 3

• Finishing and detailing.

• Root movement and torque correction.

Compensations in preadjusted edgewise technique when compared to edgewise are
depicted in Table 22.2.

Table 22.2.
Pre-adjusted edgewise versus edgewise technique comparison

Edgewise technique
Purpose Compensation in straight wire
wire bending
First-order bends or in- To compensate for the difference in the thickness of labial Compensation is built into the bracket base by varying the
out surface of individual teeth thickness of base
Second-order bend or tip Required for mesiodistal root positioning Compensated by angulating the bracket base or bracket slot
back bends
Third-order bend or Required to compensate for the difference in inclination of facial Bracket slots are inclined in the preadjusted appliances to
torque bends surface to the true vertical compensate for third-order bends
Begg technique or modified ribbon arch technique
➤ Raymond P Begg introduced this technique in 1950s.

➤ He introduced the concept of differential force technique where the bodily

movements of anchor molars were pitted against the tipping movement of anterior
teeth. Hence, light forces are used in this technique. The type of tooth movement
achieved in this technique is tipping.

➤ Anchorage preparation is not very critical.

Stages in begg treatment

There are three stages:

Stage 1: Corrections achieved during stage 1:

• Overjet reduction

• Overbite correction

• Correction of crowding

• Correction of spacing

• Correction of rotation

• Crossbite correction
Stage 2: Involves root following treatment objectives:

• Maintaining correction achieved in stage 1

• Space closure

• Molar correction
Stage 3: Involves movement by auxiliary archwires:

• Root uprighting
• Root torquing

Other fixed appliance techniques

Tip edge
➤ Tip edge technique was introduced by Peter Kesling in 1980s.

➤ This is a preadjusted type of Begg appliance.

➤ Early stages of treatment resemble Begg technique.

➤ Treatment is finished in preadjusted technique method.

Bonding techniques in orthodontics
Prior to the development of bonding procedures, banding of teeth was practiced in
orthodontics. The negative factors of banding:

➤ It requires more time and skill

➤ Difficult to band impacted/partially erupted teeth

➤ Decalcification and discolouration of banded tooth occurs

➤ Gingival irritation

➤ Require closure of band spaces after debanding

➤ Unaesthetic

➤ Placement of separators is painful

With the introduction of acid etching by Michael Buonocore in

1955, the search for a technique to directly attach brackets
and tubes led to the development of bonding technique in
clinical orthodontics.

Newmann G in 1965 started using epoxy resin as bonding

material to attach brackets to the tooth surface. Attachment
of the bracket using bonding resins to the enamel surface
can be classified into:

1. Direct bonding technique

2. Indirect bonding technique

Advantages of bonding technique

➤ Aesthetics is superior

➤ Faster and simpler

➤ Less patient discomfort

➤ Arch length not increased

➤ No band space closure

➤ Partially erupted or fractured teeth can be controlled

➤ In lingual orthodontics

➤ Interproximal enamel reduction and composite build up possible

➤ Bonding of artificial tooth surface

➤ Caries risk eliminated

➤ Bracket may be recycled

➤ More hygienic

Direct bonding procedure

Direct bonding refers to the direct attachment of the bracket to the etched enamel using
self- or light-cure agent. Widely used as it is simple and reliable.
The steps involved in direct or indirect bonding on facial on lingual surface are as
follows:

➤ Cleaning

➤ Enamel conditioning

➤ Sealing

➤ Bonding

Cleaning
Removal of plaque and the organic pellicle that normally covers all teeth is the first step
in bonding. Thorough cleaning of teeth with water slurry of pumice or prophylaxis
paste is essential to achieve this.

Enamel conditioning
This step involves two procedures, namely moisture control and enamel pretreatment.

Moisture control
Complete dry working field is absolutely necessary for effective bonding. This is
achieved by using any of the following aids:

➤ Lip expanders and cheek retractors

➤ Saliva ejectors

➤ Tongue guards with bite-blocks

➤ Salivary duct obstructors

➤ Cotton or gauze rolls

➤ Antisialagogues like atropine sulphate or probanthine bromide can be used.

Enamel pretreatment or acid etching

After drying the tooth, a conditioning solution or gel (usually 37% phosphoric acid) is
applied lightly over enamel surface with a pellet or brush for 15–60 s. Etchant is rinsed
off with abundant water spray for about 15 s. If salivary contamination occurs after
etching, rinse with water spray and re-etch for another 30 s. Dry the tooth thoroughly to
obtain dull frosty white appearance.
Etching is also done by 10% polyacrylic acid or 10% maleic acid. The other alternate
methods of etching are given in Box 22.1.
Box 22.1.
Alternate methods to acid etching
Crystal growth conditioning
• A proposed alternative to etching for retention of adhesive is to grow crystals on the
enamel surface. This technique is called crystal bonding. Crystal growth system relies
on the creation of a micromechanical, crystalline, retentive surface on the enamel to
which bonding adhesives are applied. It produces 60–80% of bond strength compared
to acid etching acidic primer.

• It includes application of poly (acrylic acid) solution containing sulphate ions, which
cause growth of calcium sulphate dehydrate crystals on the enamel. Potassium,
lithium and magnesium sulphates act as crystal growth agents.

Advantages
• Easy debonding

• Less residual adhesive left on the tooth

• Less enamel damage

Laser etching
• This new concept was proposed in 1993 by JA Von Fraunhofer. He showed that at 3
watts for 12 s laser etching produced acceptable bond strength though significantly
 less than conventional acid etching. He used Nd: YAG (neodymium–yttrium–
aluminium–garnet) as laser source.

Disadvantage
• High laser produces heat in sufficient magnitude to cause possible irreversible
damage to pulpal tissue immediately opposite the site of laser irradiation.

The rationale for acid etching is as follows:

➤ Removes about 3–10 microns of enamel surface.

➤ Etching also increases the wetability and surface area of the enamel substrate.

➤ Resin tags penetrate up to the depth of 80 microns or more.

➤ Primary attachment mechanism of resin is ‘resin tags’.

It provides a micromechanical bond. There are four patterns of enamel loss after
etching (Fig. 22.4).

FIG. 22.4. A. Honeycomb appearance with loss of enamel prism in the centre; B. Cobblestone
appearance with prism edges lost; C. Surface loss of enamel with map-like appearance; D.
Granulation of enamel with numerous holes.
Sealing
Sealants are unfilled resins with low viscosity. After etching, a thin layer of sealant may
be painted over entire enamel surface. It is best applied with a small foam pellet or
brush. It should be thin and even.

1. They might be necessary to achieve proper bond strength.

2. It is necessary to improve resistance to microleakage.

3. After sealant coating, moisture control may not be extremely important.

4. It provides enamel cover in areas of adhesive voids.

5. Sealant might permit easier bracket removal and protects against enamel tear outs
during debonding.

Sealants are either self-cured or light-cured.

• Light-polymerizing sealants: Protects enamel adjacent to

brackets from dissolutions and subsurface lesions.

• Self-polymerizing sealant: Polymerize poorly, exhibit drift,

have low resistance to abrasion.

• The newly developed primers are given in Box 22.2.

Box 22.2.
Recent advances in primers
Moisture insensitive primers
These are hydrophilic primers that can bond in wet field. Hydrophilic primers are
manufactured with ethanol and/or acetone as ingredient to displace moisture from the
enamel surface to be bonded. They will not compensate for saliva contamination.
Indications
• Bonding second molars

• Partially erupted teeth

• Impacted canine

• High risk of blood contamination

Self-etching primers (SEP)
Combined etchant and primer in one chemical compound. This is a methacrylated
phosphoric acid that dissolves calcium from hydroxyapatite. The removed calcium
forms a complex and is incorporated into the network when primer polymerizes.
SEP Acid etching
3–4 microns thick, irregular but smooth hybrid layer with no apparent indentation of Distinct honeycomb structure of enamel formed with micro- and
enamel prism macro-tags
Minimal etching with more of a chemical bond with calcium in enamel Mechanical bonding achieved

Advantages
• Cost-effectiveness

• Time-saving

• Minimal damage to enamel

Adhesion promoter
Chemical adhesions have been introduced which enhance bond strength with resin.
May be used to bond with gold, porcelain.

Example: All bond 2

Scotch prime

Bonding
The recommended bracket bonding procedure with any adhesive consists of following
steps (Fig. 22.5).

1. Transfer of bracket

2. Positioning of bracket
3. Fitting

4. Removal of excess

FIG. 22.5. Different steps in bonding: (A) Transfer, (B) positioning, (C) fitting, (D) removal of
excess.

Transfer of bracket
Grip the bracket with a reverse action tweezers. Apply adhesive to the bracket base and
place the bracket immediately on the tooth close to its correct position.

Positioning of bracket
A placement scaler is used to position the bracket mesiodistally and incisogingivally
and to angulate them correct. Proper horizontal and vertical position of bracket should
be ensured.

Fitting
In the next step, bracket is pushed firmly towards the tooth surface. The tight fit will
result in good bond strength. Once the bracket is in correct position, no attempts to
disturb the bracket are done which will compromise the bond strength.

Removal of excess adhesive

The last step in direct bonding is removal of excess adhesive.
Purpose of removing excess adhesive:
➤ To prevent or minimize gingival irritation, plaque builds up around the periphery of
the bonding base.

➤ To prevent periodontal problem and enamel decalcification.

➤ To ensure a clean and aesthetic environment. Removal of excess after setting is done
with oval or tapered tungsten carbide bur as it causes least damage to enamel surface.

Indirect bonding procedure

Refers to the attachment of the brackets to the working cast using water-soluble resins
initially, and then transferring it to the mouth using a custom tray.
Indirect bonding is done by placing the brackets on a model in the laboratory, then
using a template or tray to transfer the laboratory positioning to the teeth.

Advantages of indirect bonding

➤ More precise location of brackets is possible.

➤ Indirect bonding shortens the chairside bonding process and relocates the time factor
to laboratory.

➤ Patient comfort and hygiene are improved.

➤ It is superior in lingual bonding where visualization is difficult.

Disadvantages of indirect bonding

➤ Indirect bonding is technique-sensitive.

➤ Additional sets of impressions are needed.

➤ Increased lab time.

➤ Achieving consistent and predictable adhesion is difficult.

➤ Accidental removal of brackets with tray is not unusual.

➤ Failure rates are slightly higher (Zachrisson BU and Brobakken BO).

➤ Closer fitting of bracket base is better achieved by one point contact of scaler in direct
bonding than when transfer tray should be held in place by finger pressure in indirect
bonding.

Technique
➤ Alginate impressions for indirect working casts are taken 1 or 2 weeks before
 bonding procedure.

➤ Preparation of working casts:

1. Pour the impressions immediately in a hard stone.

2. When the casts are dry, fill in any voids and remove
bubbles.

3. Mark the position of the brackets with pencil.

4. Apply two thin coats of liquid-separating medium to the

facial surfaces of the teeth on the cast, and allow it to dry.
➤ Placement of brackets on cast:

Position the brackets using light/self/thermocure unfilled resin

on the models.
➤ Fabrication of transfer trays:

Inject the Memosil (a silicone-based, addition-cured elastomer

of medium viscosity) over the brackets with a syringe, so
that it covers all the buccal, occlusal and lingual surfaces of
the teeth to be bonded. Allow the tray to set for 10 min.

Soak the cast and Memosil tray in cold water for 20 min and
then separate both trays from the cast. The brackets will
easily release from the stone and remain seated in the tray.

Trim away excess composite from around the brackets with a

scalpel. Trim the trays.
Chairside bonding procedure
1. Etch the teeth to be bonded as usual.
2. Paint a thin layer of unfilled resin over the etched enamel and over the cured
composite in the tray.

3. Place the Memosil tray in the mouth, and light cure each tooth for 30 s.

4. Peel the transfer tray away from the teeth. Cut the Memosil with a scalpel, if
necessary to ease its removal.
Latex elastics
Elastics are one of the active orthodontic components used to apply forces to move teeth
in all three dimensions. They are usually made of latex.

Chemistry
The major source of natural rubber is the rubber tree (Hevea brasiliensis). The chemical
structure of natural rubber is cis-1,4 polyisoprene which contains approximately 500
isoprene units in the average natural rubber polymer chain.
The characteristic property of reversible extensibility results from the randomly
coiled structure of long, folded polymer chains. Upon extension, these randomly coiled
chains are elongated into an ordered structure consisting of linear chains except when
cross-linked. This tendency to revert to the original disordered state upon removal of
elongation stress accounts for the elastic behaviour.
Prevulcanized latex is produced by mixing pure natural latex, which has the highest
molecular weight, with stabilizers such as zinc oxide and chemically vulcanized
materials. The resulting mixture is then heated until 70°C.
Antiozone and antioxidant agents are also added to latex during the manufacture of
orthodontic elastics. This process has the advantage of producing latex with higher
mechanical properties, thus increasing its strength and elasticity.
Latex allergy occurs in 3–17% of the cases. Amongst the allergic reactions caused by
orthodontic elastics, swelling, stomatitis, erythematous oral lesions, respiratory
reactions and even anaphylactic shock, the most severe form of allergy has been cited.

Advantages
➤ They are inexpensive, relatively hygienic and easily applied.

➤ Rubber bands are also easier for the patient to remove and replace.

➤ The material is relatively compatible with the mucosa.

➤ The great elastic range of elastics allows the extreme stretching produced when a
patient opens the mouth while wearing rubber bands without destroying the
appliance.

➤ Resiliency of natural latex rubber makes it useful for the application of intraoral
traction forces in the range up to 6 or 8 ounces.

Disadvantages
➤ Elastics experience a rapid loss of force due to stress relaxation, resulting in a gradual
loss of effectiveness.
➤ When extended and exposed to an oral environment, they absorb water and saliva,
permanently stain and suffer a breakdown of internal bonds that leads to permanent
deformation.

Force degradation
The physical and chemical properties of latex cause orthodontic elastics to undergo
fatigue, and force relaxation resulting in force degradation that is likely to be
accentuated under adverse environmental conditions like exposure to air, exposure to
ozone, temperature changes, pH variations, oral fluid rinses, salivary enzymes and
masticatory forces.
The force decay under constant force application to latex elastic showed that the
greatest amount of force decay occurred during the first 3 hours after extension,
regardless of size, manufacturer or force level of the elastics.

Application in orthodontics
Mechanotherapy in orthodontics often involves the use of interarch latex elastics to
correct sagittal discrepancies, intra-arch elastics to close spaces or vertical elastics to
improve the interdigitation of teeth.
The various clinical applications of latex elastics are given in Table 22.3.

Table 22.3.
Use of elastics in different clinical situations

Name Application Picture

Class I Space closure

intramaxillary

Class II Used in class II

malocclusion for
retraction of
anterior teeth in
the upper arch
and correction of
molar relation by
 mesial movement
of lower molar

Class III Used in class III

malocclusion for
retraction of
anterior teeth in
lower arch and
correction of
molar relation by
mesial movement
of upper molar

Through the To correct

bite elastics crossbite when
both the teeth are
out of position
Zigzag To establish
proper
interdigitation

Triangular Open bite

correction (lateral)

Box elastics Open bite

correction
Settling Are used at the
elastics end of the
treatment for final
posterior settling

Asymmetric They are used to

elastics correct dental
asymmetries
usually with class
II on one side and
class III on other
side; also helps in
midline correction

Cross-palatal Cross-palate
elastics elastics may be
used to correct
undesired
expansion of the
upper molars
during the third
stage of Begg
technique

Lingual Used in retraction

elastics and correction of
rotated tooth
Diagonal To correct midline
elastics discrepancy

Check elastics For bite opening

and retraction of
upper anterior
teeth

Extraoral 8,12,14, 16 Oz
elastics elastics are
available and used
along with
facemask for
orthopaedic
effects
Management of dental problems during
orthodontic treatment
➤ Patients undergoing orthodontic treatment should have routine dental check-ups.

➤ Dental check-ups should be done at least once in 4 months to avoid or prevent

problems during orthodontic treatment. The problems encountered are (1) caries and
decalcification, (2) deformed (or) loose bands and (3) soft tissue problems.

1. Caries and decalcification

• Correctly contoured orthodontic bands will protect the tooth

surface from caries attack.

• Formation of caries or decalcified areas during orthodontic

treatment can be due to:

- Accumulation of food debris.

- pH of the cement used for luting the bands.

- Breakage of cement seal between band and tooth surface.

- Protection of tooth surface by fluoride application helps in

reduction of caries and decalcification spots.
2. Deformed bands

• Molar or incisor bands should be recemented at 6 months

interval.

• Due to constant occlusal forces, the margins or periphery of

the band get peeled off.

• Any damage or distortion of the band breaks the cement seal

 and hence these surfaces become more prone to caries.

• Distorted bands should be recontoured and cemented or

replaced with a new band.
3. Soft tissue problems

• Adequate soft tissue care during orthodontic treatment

should be given.

• Improper oral hygiene or irritation from appliance will cause

inflammation, enlargement of gingival papilla and
ulcerations.

• Hormonal imbalance could also act as an aggravating factor.

Oral hygiene during orthodontic treatment

➤ Periodical clinical examinations and radiograph help to detect and reduce problem.

➤ Well-planned home care is vital throughout the orthodontic treatment.

Orthodontic brushes
Special orthodontic brushes wherein the middle row is shortened are used for home
care (Fig. 22.6).
 FIG. 22.6. Orthodontic brushes.

Brushing technique
➤ The brushes should be placed at 45° angle to the tooth on the buccal surface pointing
towards gum.

➤ Brush should cover wires and the gum where it meets the tooth.

➤ Small circular motions are carried out.

➤ Brushing is done for upper teeth and then for lower teeth.

➤ Brushing is done for lingual surface and occlusal surface.

➤ Disclosing solutions will help the patients identify the unclean areas.

Other aids
➤ Electric toothbrushes can be used for children who lack good motor control.

➤ Digital gum massage (Fig. 22.7) for about 5 min daily in the morning and evening to
control gingival proliferation is recommended.

➤ Interdental stimulation also helps to prevent soft tissue proliferation (Fig. 22.8).

➤ Waterpik is also very effective in removing the debris. In this, jet stream of water
mixed with mouthwash effectively removes the debris.

FIG. 22.7. Digital gum massage.

FIG. 22.8. Interdental stimulation.
Advantages and limitations of fixed appliances
Advantages
➤ Fixed appliance produces variety of tooth movement, e.g. bodily movement,
rotation, uprighting, torquing, and intrusion.

➤ Grossly misplaced teeth can be corrected by using fixed appliances.

➤ Fixed appliances are efficient in treating lower arch problem when compared to
removable appliances.

➤ Space closure following extractions is best done with fixed appliances.

➤ Multiple tooth movements: Fixed appliances allow for the control of position of
several teeth during treatment.

➤ Establishing normal incisor relationship with both crown and root movement is
possible.

➤ Extraoral forces can be effectively applied through fixed appliances.

➤ Precise control over force distribution to individual tooth is possible.

Limitations of fixed appliance

➤ Fixed appliance technique is complex and requires special training.

➤ Chairside time is long.

➤ Maintenance of good oral hygiene is difficult.

➤ Rate of tooth movement depends on the individual’s biological response.

➤ Patient cooperation is required in the maintenance of appliance, wearing of elastics,

and headgears.

➤ Treatment effects are restricted to dentoalveolar structure.

➤ Skeletal discrepancy cannot be corrected by fixed appliance alone.

➤ Aesthetically less pleasing.

➤ Frequent breakage leads to improper correction.

➤ Expensive.

ACCESSORY POINTS
➤ Straight wire appliance: Lawrence Andrews (1972).

➤ Lingual orthodontics: Curz.

➤ Lingual orthodontics is also called the invisible appliance.

➤ Twin wire appliance: Joseph Johnson.

➤ Tip edge appliance: Peter Kesling.

➤ Edgewise appliance makes use of rectangular wires.

➤ The empirical rule which indicates that the elastics exert the reported force at an
extension of 300% of their diameter is called rule of ‘3’.

➤ Elastics used:

• Class I: Intra-arch space closure

• Class II: Interarch, maxillary anterior retraction, class II

molar correction

• Class III: Interarch, mandibular anterior retraction, class III

molar correction

• Box elastics: Open bite correction

• Cross-elastics: For posterior crossbite correction

• Triangular and settling elastics: For occlusal settling

➤ First order or in–out bends in archwires are given in horizontal direction.

➤ Second order or tip back bends in archwires are given in vertical direction.

➤ In Begg’s technique, there is single point contact.

➤ In preadjusted edgewise and edgewise technique, there is two-point contact.

➤ Anchorage used in class I elastics is intramaxillary anchorage.

➤ Anchorage used in class II elastics is intermaxillary anchorage.

Advanced Learning
Lingual orthodontics
This technique involves placement of brackets and other attachments on the lingual
surface of the teeth.
The appliance is not visible and hence does not affect the aesthetics of the patient.
This technique is called invisible orthodontics. Craven Curz is credited with the
development of lingual appliances.
History of lingual appliance concept
➤ First suggestion of lingual appliance was given by Pierre Fauchard in 1726.

➤ To protect sumo wrestlers from soft-tissue injury from labial appliances, Kinya Fujita
submitted the concept of lingual orthodontics in 1967, and published the method in
1978.

➤ Craven Curz (1975) developed plastic brackets on lingual surface for easy reshaping
and better fit. Ormco company along with Craven Curz, Craig Andreiko Frank Miller
developed first generation Curz bracket in 1976.

Drawbacks of lingual orthodontics

➤ Difficult to place brackets on the lingual surface.

➤ Access is more difficult for orthodontist.

➤ Tooth control is not very effective when compared to conventional labial technique.

➤ There is limited scope for complex problem.

➤ Difficult in patients with short clinical crowns.

➤ Treatment is highly expensive.

Indications
The indications for lingual orthodontic technique:

➤ Cases with mild incisor crowding and with anterior deep bite
➤ Long and uniform lingual tooth surfaces without fillings, crowns or bridges

➤ Good gingival and periodontal health

➤ Keen, compliant patient

➤ Skeletal class I pattern

➤ In individuals with mesocephalic or mild/moderate brachycephalic skeletal pattern

➤ Patients who are able to adequately open their mouths and extend their neck

Indirect bonding
Indirect bonding is mandatory in lingual orthodontics because

➤ Of irregular lingual tooth morphology.

➤ It is difficult to visualize angulations and bracket heights.

➤ It is difficult to obtain a direct line of sight for bonding on lingual surfaces.

➤ Moisture control is difficult.

Evolution of lingual orthodontic brackets

Refer Table 22.4 for development of lingual brackets.

Table 22.4.
Evolution of lingual brackets

First generation (1976) • Included a flat maxillary occlusal bite plane and rounded margins
• Hooks were absent
• Brackets were large
Second generation (1980) • Hooks were added to canine brackets
Third generation (1981) • Hooks were added to all brackets
• First molar had a bracket with internal hook
Fourth generation (1982–1984) • Included a lower profile anterior inclined plane on the central and lateral incisors facilitating insertion of the archwire
• Hooks were optional
Fifth generation (1985–1986) • The bite plane became more pronounced
• The torque was increased
• The molar brackets included an accessory tube for a transpalatal bar
Sixth generation (1987–1990) • The hooks were elongated, the transpalatal bar attachment was optional
• The hinge-cap tube for the second molar was developed (self-ligated bracket)
Seventh generation (1990) • The square bite plane became rhomboid-shaped, increasing the interbracket distance
• Premolar brackets were widened mesiodistally for better rotational control

Self-ligating brackets
Definition: A self-ligating bracket is defined as ‘a bracket, which utilizes a permanently
installed, movable component to entrap the archwire’.
Types
Self-ligating brackets are divided into two types: Passive and active. Passive brackets use
a rigid, movable component (Fig. 22.9) to entrap the archwire. Hence tooth control is
determined entirely by the fit between bracket slot and archwire. Active brackets use a
flexible component to entrap the archwire. This flexible component constrains the
archwire in the slot. Hence, there is precise and controlled movement with active self-
ligating brackets.

FIG. 22.9. An example for self-ligating bracket: (A) Open position; (B) closed position.

Brief history of self-ligating brackets

Charles K Boyd (1933) was the first person to patent self-ligating brackets. A brief
history of self-ligating brackets is given in Table 22.5.

Table 22.5.
Chronology of development of self-ligating brackets

Year Bracket Mode of action

1933 Boyd bond bracket Passive
1933 Ford lock design Passive
1972 Edge lock Passive
1972 Speed Active
1986 Activa Passive
1996 Damon Passive
2000 In-ovation Active
2004 Damon 3 Passive

Advantages
➤ Reduced friction during tooth translation with all self-ligating bracket (Pizzoni L,
Ravnholt G, Melsen B, 1998; Berger JL 1990).

➤ Greater patient comfort

➤ Shorter treatment time

➤ Greater and precise control of tooth translation (Damon DH 1998; Hanson GH 1994)

➤ Reduced risk of percutaneous injury

➤ Decreased possibility of soft tissue laceration

➤ Improved oral hygiene

Disadvantages (Roth, RH, Sapunar, A, Frantz. RC, 2005)

➤ Breakage of lock mechanism

➤ Inability to control torque

SECTION VII
Treatment Planning In Orthodontics
OUTLINE

23. General considerations in treatment planning

24. Methods of gaining space

CHAPTER 23
General considerations in treatment
planning

CHAPTER OUTLINE
❖ Treatment planning in orthodontics
❖ Analyses and treatment approach of arch length discrepancy
❖ Principles of growth modification
❖ Accessory points
❖ Advanced learning
❖ Total space analysis
Treatment planning in orthodontics
After a complete orthodontic diagnosis is made, the next important step is treatment
planning. The main objective of treatment planning is to design a strategy to correct the
problems. Good strategy helps to design the best appliance indicated for the patient.

Sequence in treatment planning

The sequence in treatment planning is as follows:

1. Correction of pathologic problems

Any problems of diseases and pathology have to be brought

under control before orthodontic treatment.

Examples

• Control of systemic diseases.

• Periodontal therapy.

• Restorations of decay.

• Complex medical problems – patients to be referred to

specialists.
2. Establishing treatment goals or priorities of treatment

• Establishing the priorities for correction of orthodontic

problem is a major step in orthodontic planning.

• Identify the most important problems.

• Focus should be on patient’s chief complaint. The usual

order of setting goals for orthodontic treatment is:

1. Improvement of the facial appearance

2. Reduction of overjet

3. Correction of crowding

4. Establishing normal overbite

5. Establishing functional occlusion

6. Correction of molar relationship

7. Maintaining stability of correction achieved.

3. Differentiate moderate from severe problems or orthodontic triage

A thorough database and complete problem list help in

differentiating severe problems. Differentiating into mild,
 moderate or severe problems helps in proper treatment
planning. The process of orthodontic triage is depicted in
flowchart (Fig. 23.1).

Orthodontic triage:

• Triage is the process used to separate casualties by the

severity of their injuries. This helps in the following two
ways:

1. To segregate patients who can be treated at the scene of

injury from those who need referral to other centres

2. To develop a sequence for handling or managing patients

• In orthodontics, malocclusion is never an emergency, hence

orthodontic triage is analogous in only one sense namely,
sorting of problems by their severity.

• Orthodontic triage involves a logical scheme to categorize

patients on the basis of the severity of malocclusion and the
complexity of treatment.

• The less severe problems can be handled by the orthodontist

alone, but in the interest of the patients, more severe
problems should be handled by a team involving oral and
maxillofacial surgeon, orthodontist and other specialists.

• An adequate database and a thorough problem list are

necessary to carry out triage process.

• Proper case history, thorough clinical examination, study

casts and appropriate radiographs (panoramic film,
 bitewings, occlusal and cephalometric) are essential to
practice orthodontic triage.

• Severe problems may require investigations with

computerized tomograms and magnetic resonance imaging.

• Team or multidisciplinary approach will be the key to

success in the management of very severe problems.

• Fig. 23.1 explains in detail the approach to orthodontic triage

and lists the various mild, moderate, severe and very severe
problems.
4. Treatment possibilities

• The objective of this stage of treatment planning is to make

sure that all the possibilities of treatment are analysed.

• There are occasions when one problem can be corrected by

two or three methods.

• The best possible method which is feasible should be

undertaken for the patient.

• For example, deep bite correction can be achieved in

different ways.

a. Deep bite correction (Fig. 23.2)

1. Extrusion

• Extrusion of posterior teeth can cause opening of the bite.

• This, in turn, will rotate the mandible downward and

 backward.

• So, bite opening by extrusion of posterior is

contraindicated in high-angle cases.

• In low-angle case, it is advisable.

2. Intrusion

• Bite opening can be achieved by absolute intrusion of

upper and lower incisors.

• Intrusion is usually done in patient who already have

gummy smile.

• Intrusion is done for patients with high angle.

3. Relative intrusion

• In relative intrusion, the incisors are held in their position,

allowing the posterior teeth to erupt along with growth of
mandible.

• Relative intrusion cannot be expected in an individual

who is above 17 years of age.

b. Crowding

Crowding can be corrected by:

1. Expansion: This is indicated in patients who already have

flattened facial profile and narrow arches.

2. Extraction: This is indicated in severe arch length

 discrepancy.

3. Proximal slicing: This is indicated in minimal space

discrepancy cases.

c. Skeletal tendency

The methods of correcting skeletal problems are:

• Growth modulation

• Camouflage

• Surgery

The selected treatment procedure should be effective in

producing the desired result and efficient without
producing undesirable side effects in minimum possible
time.
5. Treatment planning/age considerations in orthodontic treatment/timing of treatment
 FIG. 23.1. Flowchart: Orthodontic triage.

FIG. 23.2. Deep bite correction: (A) Absolute intrusion, (B) relative intrusion, and (C)
extrusion.

Timing of orthodontic treatment

Orthodontic treatment in majority of cases is started during late mixed dentition. But
many times early treatment is required.

Treatment timing
Early treatment – primary dentition and early mixed period.

Late treatment – late mixed and early permanent dentition period.

Very late – adult.

Early treatment: Early treatment involves either preventive or interceptive orthodontic

procedures.

Advantages of early treatment

➤ Early treatment of deleterious habits is easier.

➤ Rapid change in skeletal and dental structures is seen when treatment is done on
primary or early mixed dentition.

➤ Moderate biomechanical forces are effective.

➤ Significant correction of jaw problems can be achieved.

➤ Growth modification is effective in class II cases.

➤ There are psychological advantages to early treatment in some children.

Disadvantages
➤ Continuous growth nullifies the effects of treatment.

➤ Child behaviour management may be difficult.

➤ Usually requires second phase of treatment. Therefore, there is lengthened

chronologic treatment time.

Mixed dentition stages

➤ More malocclusions are best treated during mixed dentition or early permanent
dentition. It is the time of greatest opportunity for occlusal guidance and interception
of malocclusion.

Advantages of late treatment

➤ Most patients are treated during early adolescence or early permanent dentition.

➤ Child cooperation is good.

➤ Care of the appliance also is better when compared to children in primary dentition.

➤ Adequate growth remains, so growth modification is possible.

➤ The entire permanent teeth problem can be controlled.

➤ Limited duration of treatment when compared to early treatment.

Disadvantage
➤ Delayed correction of protruding incisors can cause trauma to incisors.

An overview of treatment planning is depicted in Table 23.1. The table shows the
different conditions of malocclusion treated during primary, early mixed, late mixed
dentition and in adults.

Table 23.1.
Overview of treatment planning

Treatment planning for preschool children/primary dentition

1. Alignment problems

• Spacing in primary dentition is normal and desirable as the

chances for development of crowding in the permanent
dentition is less.

• Well-aligned primary arches with no spacing will lead to

alignment problems in permanent teeth.

• Expansion of primary arches is done in cases where future

crowding is expected. Expanded primary teeth will ease the
permanent teeth to erupt in expanded position.

Loss of primary teeth, its effect and management:

• Loss of incisors does not require space maintenance. Partial
denture for aesthetic purpose can be given.

• Loss of primary canine causes the distal drift of incisors which

creates a midline shift and dental asymmetry.

• Loss of first molar leads to dental asymmetry. Space

maintenance is required very early.

• Loss of second molar before the eruption of first permanent

molar: Distal shoe space maintainer is indicated to prevent
the eruption of first permanent molar in second premolar
space.
2. Incisor proclination/retroclination

• Incisor proclination is caused by deleterious sucking habits.

Incisor proclination is self-correcting at this stage, if the
habit is stopped.

• Anterior crossbite in primary dentition is extremely rare. If it

is due to occlusal prematurities, selective grinding will
correct the problem.
3. Posterior crossbite

• Sucking habits produce constricted upper arch. There is

more constriction in the primary canine arch area. This leads
to occlusal interferences and functional shift.

• Narrow maxilla with functional shift produces unilateral

crossbite in a preschool child.

• Occlusal prematurities should be corrected by selective

 grinding.

• If there is bilateral constriction of maxilla, expansion of arch

is indicated.
4. Anteroposterior discrepancies

• Any sagittal deviation which is very extreme, growth

modification is attempted.
5. Vertical problems

a. Deep bite – self-correcting

b. Open bite – due to sucking habits can be treated with

habit breaking appliance.
Treatment planning in preadolescents
Children in early mixed dentition stage belong to this category.

1. Moderate problems

Children with only dental problems are considered as patients

with moderate problems (Table 23.2).
2. Severe problems

Severe problems in preadolescents and their management are

depicted in Table 23.3.

Table 23.2.
Treatment planning for moderate problems in preadolescents

Moderate problems Treatment planning

Missing primary teeth with space remaining Space maintainer
Space loss <3 mm Space regainers
Moderate crowding Expansion
Proclined upper incisor Retracted to prevent trauma
Median diastema Ugly duckling stage – no treatment
Anterior crossbite If the maxillary lateral incisors are lingually placed extraction of maxillary primary canines is done
Posterior crossbite Removable or fixed expansion appliances
Anterior open bite Habit breaking appliance
Retained primary tooth Extraction of retained tooth, if the permanent successor is present and 3/4th of root is formed

Table 23.3.
Treatment planning in severe problems

Problems Treatment plan

Skeletal problems Growth modification
Incisor protrusion Extraction deferred. Wait and watch
Space discrepancy >5 mm Model analysis for space calculation: Space gaining procedures and treat with fixed appliances, serial extraction

Treatment planning for adolescents (late mixed and early permanent

dentitions)
Adolescent is the ideal time for correction of crowding and malalignment with fixed
appliance mechanotherapy. Table 23.4 depicts the management of orthodontic problems
in adolescents.

Table 23.4.
Treatment planning in adolescents

Problem Treatment plan

Crowding and proclination Space analyses done. Extraction carried out and treated with fixed appliance
Tooth size discrepancies Bolton analysis carried out
Transverse problems Skeletal expansion, if required, with rapid expansion appliances

Dental expansion with removable appliance or fixed expansion

Single tooth crossbite – crossbite elastic

Skeletal asymmetry – hybrid appliance

Anteroposterior problems Growth modification should start before adolescent growth spurt (skeletal problem)

Camouflage (skeletal problem)

Dentoalveolar protrusion is treated with fixed appliance

Vertical problems Anterior open bite (AOB)

Skeletal open bite – growth modification

Dental – habit breaking appliance

Deep over bite – levelling of curve of Spee can be done by relative intrusion, intrusion or extrusion

Impacted teeth Favourably positioned tooth – surgical exposure and appliance to bring the tooth into occlusion

Treatment planning for adults

Various orthodontic problems and their management in adults are depicted in Table
23.5.

Table 23.5.
Treatment planning: Adults

Problem Treatment plan

Skeletal or dentofacial problem Severe – combined surgery and orthodontics

Moderate – camouflage
Missing teeth Orthodontic closure

Alignment and replacement by fixed bridge

Crowding Extraction and space closure

Crossbite Fixed or removable appliance
Deep bite with flared maxillary incisors Levelling of curve of Spee and retraction with fixed appliance
Open bite with flaring and spacing in maxillary anterior teeth Retraction with removable or fixed appliance
Analyses and treatment approach of arch length
discrepancy
➤ Arch length: Arch length is the measured distance from the mesial of the first
permanent molar from one side to the opposite side.

➤ Arch length is measured using a brass wire or divider.

➤ Tooth material: The sum of all the mesiodistal width of the teeth mesial to first
permanent molars.

➤ Calculation of arch length and tooth size discrepancy is done by finding the
difference between the available arch length and total tooth material of 12 teeth.

➤ The difference can be either tooth material excess/arch length discrepancy or arch
length excess.

➤ Arch length excess usually presents as spacing. Macrognathia or microdontia could

be the cause for arch length excess.

➤ Arch length discrepancy: It is manifested in the form of crowding, rotations or

proclination. Micrognathia and macrodontia are the reasons for arch length
discrepancy.

Investigations
➤ A thorough model analysis will reveal the nature and reason for arch length
deficiency.

➤ Bolton’s analysis will reveal the interarch relationship between the teeth.

➤ Various model analyses used are as follows:

1. Analyses to study the size relationships of groups of teeth

a. Bolton’s tooth ratio analysis

b. Sanin–Savara analysis

c. Peck and Peck ratio

2. Analyses to study the relationships of tooth size to the size of supporting structures

a. Ashley Howe’s analysis

b. Pont’s analysis

c. Linderhearth’s analysis

d. Diagnostic set-up

e. Korkhaus analysis
3. Analyses to study the relationships of tooth size and available space during the
mixed dentition (mixed dentition analysis)

a. Moyer’s mixed dentition analysis

b. Tanaka–Johnston analysis

c. Staley and Kerber analysis

d. Radiographic method
4. Analyses to study the relationship of tooth size and available space in the
permanent dentition

a. Carey’s analysis

b. Arch perimeter analysis

c. Total space analysis

Treatment approach to arch length discrepancy

1. Changing the inclination of teeth: Changing the axial inclination of the incisors
compensates for small size difference between arch length and tooth size.
2. Proximal slicing: Reducing the width of few teeth by proximal slicing is done in cases
with small arch size difference.

3. Extraction or expansion: When the space discrepancy is more, extractions are carried
out. The choice of extraction depends on the individual problem. Minor space
discrepancy conditions can be corrected by expansion.

4. Build up the width of small tooth: Sometime a small peg lateral will create a
permanent space. In this situation, building up of the width of that tooth is a remedy.

5. Accept a small space: Acceptance of small space in conditions where everything is

normal except a small space. Usually, a small space is seen distal to maxillary lateral
incisors.
Principles of growth modification
Introduction
➤ The most ideal method of treating a patient with jaw discrepancy is to increase the
growth to the normal level.

➤ The extent of correction of jaw discrepancy by growth modification depends on

factors like timing of treatment, cooperation of the patient and response of the patient
due to the varying growth pattern.

➤ Growth modification is successful when more growth remains.

➤ The important logic in growth modification is that growth can be modified only
when it is occurring.

➤ Timing of growth modification treatment is very crucial.

➤ Growth modifications can be studied under the following headings:

1. Transverse maxillary deficiency

Clinical features

• Maxilla is narrow when compared to the rest of the face.

• Posterior crossbite is present.

• Teeth are not tipped into crossbite.

Principle of maxillary expansion

2. Prognathic maxilla

• Prognathic maxilla is a condition in which maxilla is

prominent or protrusive.

• In preadolescent patients with skeletal class II base due to

prognathic maxilla, headgear can be used to hold the
maxilla from downward and forward growth.

• Mandibular growth expresses itself and class II correction is

normally achieved in 12–18 months.

• Force value is 350–450 g/side but not to exceed 1000 g in total

duration of wearing for 10–12 h/day.

• Application of forces in the range of 350–450 g/side restrict

forward movement of the maxilla.
3. Retrognathic maxilla

• Retrognathic maxilla can be corrected by two ways–reverse-

pull headgear and functional appliances.
Correction with reverse-pull headgear

• Elastic traction pulls the maxilla forward. Force parameters:

Force value: Initial force of 300 g/side, two weeks later 450–500
g/side.

Force direction: Force applied 20° downward to the occlusal

plane produces translation of maxilla forward. Elastics
parallel to the occlusal plane produce an upward rotation
along with forward movement of maxilla.

Duration: Time of wear is 20 h/day but after 6 months it is

reduced to night-time wear for retention. Active treatment
takes about 4–6 months.

Timing of treatment: Early mixed dentition is the ideal age for

starting the treatment but till 10 years of age, response is
good. After 10 years of age, response reduces.

Functional appliances: Functional appliances are used in the

management of class III due to retrognathic maxilla in a
growing child. Examples: FR III, reverse bionator, twin
block.
4. Prognathic mandible

Prognathic mandible is corrected using chin cup therapy.

a. Occipital-pull chin cup

• Occipital-pull chin cup is used in cases of skeletal class III

due to mild to moderate mandibular prognathism with
horizontal growth pattern.
• The headgear is around the occipital and the parietal bone
just like high-pull headgear.

Force can be directed in two ways:

i. Through the condyle of the mandible which restricts the

downward and forward growth of mandible.

ii. Below the condyle, producing a downward and backward

rotation of the mandible.

b. Vertical-pull chin cup

• Vertical-pull chin cup is used to correct anterior open bite

conditions.

• In this chin cup, headgear is near the coronal suture, and

there is a horizontal strap to the back of the head.

• The vertical force reduces the anterior facial height by

rotating the mandible up.

• Elastic strap is attached to the hook on the chin cup.

5. Retrognathic mandible

• Retrognathic mandible is corrected by functional appliance.

• The basic idea of functional appliance is by forcing the

patient to function with the lower jaw forward, it would
stimulate mandibular growth, and thereby corrects class II
skeletal problem due to retrognathic mandible.

• Functional appliance produces growth acceleration.

• Growth acceleration means increased growth rate during the
initial months of functional appliance wear, but the final size
is not larger than that without treatment.

• Functional appliance because of the elastic stretch produces

restrictive effect on the maxilla like a headgear.

• It also causes supraeruption of the posterior teeth and

opening of bite.

• Other changes seen are proclination of lower anterior teeth

and arch expansion.
6. Short face

Principles in correction of short face:

• Prevent eruption of lower incisors.

• Facilitate eruption of lower posterior teeth.

• Limited controlled eruption of upper posterior teeth.

• The appliances used for short face corrections:

a. Headgears and functional appliances.

b. Removable functional appliances are very effective.

7. Long face

Principles in correction of long face:

• Restrict vertical maxillary development.

• Promote anteroposterior mandibular growth.

• Best method of treatment is high-pull headgear combined

with functional appliance with occlusal bite-blocks.

ACCESSORY POINTS
➤ Space maintainer is indicated, if the permanent successor will take more than 6
months to erupt.

➤ Ideal time for comprehensive treatment of dental crowding and malalignment is late
mixed dentition and early permanent dentition (9–12 years).

➤ Overbite must be reduced during initial stages of treatment of class II division 1 to

permit full overjet correction.

➤ Bite opening by extrusion of molars without rotation of mandible downward and

backward is called relative intrusion.

➤ Constriction of maxilla in children with abnormal habits is more in primary canine

region.

➤ ‘Think organized’ means – to analyse a malocclusion first in the anteroposterior, then

the vertical and finally the transverse plane.

➤ Pseudo-class I occlusion is a skeletal class I in which the maxillary teeth are located too
mesially in relation to the mandibular teeth, but a class I interdigitation has been
obtained in the buccal segments through mandibular anterior crowding (Jan de Baets,
1997). Rotation of the maxillary first molar also plays a role in the establishment of the
Angle’s class I molar relationship.

Advanced Learning
Total space analysis
Proffit WR (2000) defines total space analysis as the quantification of space required in
each arch for the correction of malocclusion.
It consists of analysing space requirement in three areas of the arch–anterior, middle
and posterior.
The resulting values for each area are added together to get the final deficit.
Uses
Total space analysis can be used:

➤ To assess the need for extraction.

➤ In planning of extraction.

➤ In anchorage preparation.

➤ To plan the mechanics to be employed.

Procedure based on graber and vanersdall

Anterior area
Required space calculation

Tooth Sum of the mesiodistal widths of central incisors, lateral incisors and canines.
measurement

Cephalometric Subtract the actual FMIA (in degrees) from the proposed angle. The difference (in degrees) to be multiplied by a constant (0.8) to give the
correction difference in millimetres.

Soft tissue Measure the Z angle of Merrifield. Add cephalometric correction (in degrees) to it. If the corrected angle is greater than 80°, the mandibular
correction incisor inclination is modified. If the corrected angle is less than 75°, additional uprighting is required.

Measure the upper lip thickness from the vermilion border to the greatest curvature of the labial surface of the central incisor. Total chin
thickness is measured from the soft tissue chin to the N–B line.

If the lip thickness is greater than the chin thickness, the difference in millimetres is measured, multiplied by 2 and added to the space
required. If it is less than or equal to chin thickness, no soft tissue correction is required.

Calculation of available space

In mixed Place a brass wire (0.033 inch) from the mesiobuccal of the primary first molar to mesiobuccal of opposite molar. Wire is then straightened
dentition and measured.

In permanent Measured from the mesiobuccal of first premolar to first premolar of opposite side.
dentition
The value is then subtracted from total space required.

Middle area
Required space calculation

Tooth Sum of the mesiodistal widths of permanent first molars are added to the widths of premolars obtained through radiographs (in mixed
measurement dentition) or directly in permanent dentition.

Curve of Spee Place a flat object on the occlusal surfaces of the first molars in mixed dentition or on the last erupted molar in the case of permanent dentition
correction and the incisors (Fig. 23.3). The deepest point between the flat surface and the occlusal surface of primary molars or premolars is measured
on both sides. The space required for levelling is calculated using the formula:

FIG. 23.3. Space calculation for levelling curve of Spee.

Molar correction Space required for achieving class I molar relationship is recorded.
Calculation of available space

In mixed dentition Space available is determined by placing two brass wires from the mesiobuccal of primary first molars to the distobuccal of permanent
first molars.

In permanent Measured from the mesiobuccal of first premolar to distobuccal of permanent first molars.
dentition
The measured value is added together and subtracted from the space required.

Posterior area
Required space calculation:
Consists of the sum of the mesiodistal widths of the second and third molars. In

unerupted molars, Wheeler’s measurements are used

Where X is the estimated value of the permanent third molar in the individual patient.

X1 is the Wheeler’s value for third molar.

Y is the actual size of permanent mandibular first molar on the cast.

Y1 is Wheeler’s value for first molar.

Calculation of available space:

Consists of the space presently available plus the estimated increase or prediction.
The estimated increase is 3 mm per year (1.5 mm each side) up to 14 years in girls and
16 years in boys.
Conclusion
The total deficit or the discrepancy is derived by comparing the space required and
space available in anterior, middle and posterior areas. Thus, this analysis helps to
locate precisely where the discrepancy is present.
CHAPTER 24
Methods of gaining space

CHAPTER OUTLINE
❖ Classification of various methods of gaining space in orthodontics
❖ Proximal slicing
❖ Expansion
❖ Advancement or labial proclination of anterior teeth
❖ Distalization of molars
❖ Contraindications and complications of molar distalization
❖ Derotation of posterior teeth
❖ Uprighting of tipped tooth
❖ Extractions in orthodontics
❖ Accessory points
❖ Advanced learning
❖ Various appliances used for molar distalization
Classification of various methods of gaining
space in orthodontics
Space gaining procedures in orthodontics can be broadly classified into two types.

1. Procedures with reduction of tooth material

a. Proximal slicing

b. Extraction
2. Procedures without reduction of tooth material

a. Expansion

b. Labial proclination or advancement

c. Distalization of molars

d. Derotation of posterior teeth

e. Uprighting
Proximal slicing
Definition
Proximal slicing is a space-gaining procedure in which the mesiodistal width of the
crown is reduced by slicing.
Proximal slicing is done when small amounts of space are needed to bring teeth into
better alignment.

Synonyms
➤ Slenderization

➤ Reproximation

➤ Proximal stripping

➤ Proximal disking

➤ Interproximal reduction

Procedure
The procedure of proximal stripping can be divided into three steps.

1. Investigations

a. Carey’s/arch perimeter analysis

• This analysis will give the amount of arch length deficiency.

• Proximal slicing is indicated in minimal discrepancy cases

where the arch length tooth size discrepancy is less than 2.5
mm.

b. Bolton analysis

• Discrepancies between the maxillary and mandibular tooth

material leads to failure to establish normal interarch
 relationship.

• Bolton analysis will reveal the area of tooth material excess.

• Depending upon the location of problem – proximal

reduction is carried out.

• Proximal reduction is done, only if the discrepancy is

minimal.

c. Diagnostic set-up

• Diagnostic set-up helps to localize the problem.

• It also helps to disclose the amount of enamel reduction.

• It helps to locate the site where space is needed.

d. Intraoral periapical radiograph

• Radiograph, like diagnostic set-up helps to disclose the

amount of enamel reduction.

• Extent of pulp horn can be studied using the intraoral

radiograph.

e. Peck and Peck ratio

• When the labiolingual and mesiodistal ratio is altered,

crowding results.

• This is calculated by using Peck and Peck ratio.

2. Proximal reduction
• There are two types of proximal reduction, localized reduction
and generalized reduction.

• Localized reduction is usually done in lower anterior and

upper anterior teeth.

• Sometimes generalized interproximal reduction is carried

out in moderate space discrepancy cases.

• Proximal reduction is performed using:

- Abrasive strips

- Safe-sided diamond disc

- Safe-sided carborundum disc

- Very thin and long-tapered fissure burs

• Care should be taken to establish proper contact between the

teeth.

• Contact points are usually converted into contact area.

• Not more than 40% of the enamel thickness should be

reduced.
Air-rotor stripping (ARS) technique of Sheridan
Sheridan has advocated sequential striping, beginning from the posterior
interproximal areas (Fig. 24.1).

3. Fluoride application

• Subsequent to interproximal reduction, topical fluoride

application is recommended. This is done for two fold
 purpose: (i) To reduce the post-proximal slicing sensitivity
and (ii) to reduce caries attack.

Advantages

• Proximal slicing helps to establish normal interarch

relationship in patients with Bolton’s discrepancy.

• Since the contact area is wide, the lower incisors are stable in
their new position. Contact points are converted to contact
areas which prevent slipping of contact.

• Extractions are avoided.

• Minor interarch problems are corrected by proximal slicing,

e.g. single tooth crossbite.

Drawbacks of proximal reduction

• Improper proximal reduction results in loss of normal

contact between teeth which results in food impaction.

• Altered aesthetics, if the shape of the tooth is grossly altered.

• More chances for proximal caries.

• Plaque and calculus deposits result in gingivitis.

• Hypersensitivity.

• Unsightly appearance with enlarged embrasures.

FIG. 24.1. (A) Compressed coil spring placed to open space distal to second premolar, (B)
space created distal to second premolar, (C) ARS carried out in open embrasure, (D) ARS
done in space between first and second premolars and (E) ARS of interproximal space
between canine and first premolar.
Expansion
Refer to Chapter 21 on Expansion Appliances.
Advancement or labial proclination of anterior
teeth
➤ This is primarily indicated in cases where proclination of teeth will not affect the
facial profile of the patient.

➤ Advancement or labial proclination is done in patients whose nasolabial angle is

obtuse.

➤ Advancement is also done in retroclined incisors.

Distalization of molars
➤ Distalization of maxillary molars helps to gain space which can be utilized to correct
mild to moderate problems in the maxillary arch.

➤ Distalization of molars is easier, if done before the eruption of second molar.

Indications
For upper molar distalization:

➤ Class II molar relation due to maxillary prognathism

➤ Minimal or moderate protrusion

➤ Minimal or moderate crowding in maxillary arch

➤ Normal mandible

➤ Midline discrepancy

➤ When there is anchorage loss during orthodontic treatment

➤ As a space regainer

➤ Lower molar distalization is done in mild arch length discrepancy in lower arch.

Methods of molar distalization

1. Maxillary molar distalization

i. Extraoral methods (headgears)

ii. Intraoral methods

a. Removable b. Fixed
1. Finger springs 1. Open coil springs
2. Expansion plate 2. Pendulum appliance
3. Repelling magnets
4. Jones jig
5. Lokar appliance

2. Mandibular molar distalization

Lip bumper
Contraindications and complications of molar
distalization
The following are the contraindications for molar distalization.

Dental criteria
➤ Class I or III molar relation

➤ Dental open bite

➤ Maxillary first molar distally inclined

➤ Severe overjet

➤ Bimaxillary protrusion cases

Skeletal criteria
➤ Severe class II skeletal pattern

➤ Skeletal open bites

➤ Excess lower anterior face height

Soft tissue criteria

➤ Concave profile

Functional criteria
➤ Patients with signs and symptoms of temporomandibular joint disturbance

➤ Posteriorly and superiorly displaced condyle

Complications of molar distalization

Complications of molar distalization can be studied under the following headings:

Anchorage loss
➤ Anterior movement of anchor unit
➤ Incisor flaring

➤ Mesial tipping of premolars

➤ Increase in overjet

Tipping of molars
It causes more tipping and less bodily movement of molars.

Vertical effects
Lower anterior facial height increases due to extrusion of molars.

Eruption status of second and third molars

Molar distalization might interfere with the eruption of second and third molars.
Derotation of posterior teeth
➤ Rotated posterior teeth occupy more space.

➤ By correcting a rotated tooth, little amount of space can be gained.

➤ Rotation correction can be achieved by using couple.

Uprighting of tipped tooth
➤ Mesially or distally tipped tooth occupies more space in the arch.

➤ Uprighting a mesially tipped tooth results in space gaining.

➤ Unlike rotation, tilted tooth both in anterior and posterior regions occupies more
space.

➤ Uprighting springs (or) coil springs are used for uprighting.

Extractions in orthodontics
Introduction
➤ Calvin S Case is known as the pioneer of extraction philosophy in orthodontics.

➤ Subsequently, Charles Tweed also supported extractions in orthodontic treatment.

➤ Extractions form a main part in the space gaining procedures in clinical orthodontics.

Reasons for extraction

➤ There are several situations which require extraction of teeth as part of orthodontic
treatment. They are as follows:

1. For the relief of crowding

• Severe discrepancies between the tooth material and

available arch length cause crowding in the individual
arches which can be alleviated by extraction of teeth.

• A careful analysis of tooth size–arch length discrepancy

should be done prior to extraction.

• Excess tooth material or deficient arch length results in

crowding.
2. For the correction of anteroposterior dental arch relations

• In class II malocclusion – either upper I premolars alone or

upper I premolars and lower II premolars as in camouflage
treatment.

• In class III malocclusion – extraction of lower premolars

alone or upper II premolars and lower I premolars as in
camouflage.
• Anteroposterior problems include increased overjet, reverse
overjet and class II or class III molar relationship.
3. For the correction of vertical problems

• Vertical problem corrections like intrusion, levelling of curve

of Spee require space.
4. Abnormal form, position and size of teeth

• Conditions like deformed teeth interfere with normal

occlusion.

• Tooth with dilacerated root may not erupt into occlusal

position.

• Impacted teeth which are unfavourably positioned; all these

teeth have to be extracted.
5. Presence of supernumerary tooth

6. Preservation of symmetry

7. As part of surgical correction of jaw deformities

When teeth are extracted for orthodontic correction, it is called therapeutic extraction.

Choice of teeth for extractions

The following factors are taken into consideration before deciding upon the extraction.

➤ Condition of the teeth

➤ Position of teeth (Table 24.1)

➤ Position of crowding

Table 24.1.
Choice of teeth for extraction

S. No. Teeth extracted Indication

1. Upper incisor Rarely extracted; extracted when:
1. Grossly decayed
2. Unfavourable impaction
3. Dilacerated incisor which does not erupt
4. Imbrication exists in upper incisor region with lateral incisors completely blocked inside and unfavourably positioned
2. Lower incisors 1. Incisors with extreme bone loss
2. When the canine is tipped distally extremely (Canut JA, 1996)
3. Totally locked incisor with otherwise normal occlusion (Thomas D. Schaad and Harold E Thompson, 1974)
Drawbacks of lower incisor extraction:
• Collapse of the arch
• Lingual tipping of lower incisors
• Deepening of the bite
3. Canines Seldom extracted

Unfavourable impaction

Ectopic eruption which cannot be corrected

4. First premolar Teeth of choice for extraction

For crowding correction and overjet reduction

5. Second premolar 1. Minimal discrepancy cases

2. Hypoplastic condition
3. Grossly decayed
4. Impacted
5. In high-angle cases
6. First molar Indicated only when the prognosis is bad
7. Second molar 1. Indicated when crowding is present distal to first molar
2. For distalization of first molar
8. Third molar Extraction is not useful for orthodontic treatment

Contraindications to extraction
➤ Extractions should not be used as a shortcut for correction of crowding.

➤ Extraction should not be done, if it is going to affect the soft tissue profile.

➤ Contraindicated, if it will affect the soft tissue balance.

Extraction techniques
1. Wilkinson’s extraction technique

Wilkinson LC advised extraction of the entire four first

permanent molars between the ages of 8.5 and 9.5 years.

This is indicated in children who are more prone for caries.

Advantages of Wilkinson’s extraction

• Provides space for third molars.

• Relief of crowding.
• Probability of caries is reduced to the remaining teeth since
there is no crowding.

• Effective oral hygiene is possible.

Disadvantages

• Offers little space for alleviation of crowding in the anterior

region.

• The position of second and third molars varies. Often they

tend to get rotated.

• Mesial tipping of second molars takes place.

• Mesial tipping results in improper proximal contact leading

to food accumulation and periodontal problems.

• Anchorage for tooth movement is lost.

2. Balanced extraction

Balanced extraction is the removal of teeth symmetrically on

each side of the arch. The effects of unbalanced extraction
are explained in the flowchart (Fig. 24.2). Fig. 24.3 depicts
the effects of unbalanced extraction and balanced extraction.
3. Compensating extractions

• Procedure in which extraction of teeth is carried out in

opposing arches is called compensating extractions.

• This is done to maintain lateral symmetry.

• Compensating extractions preserve the interarch
relationship.
4. Stobies extraction

• Extraction of two premolars at the same time.

5. Multiple extraction

• Occasionally extraction of four teeth, e.g. first premolar does

not give enough space to treat the orthodontic problems.

• In this situation, extraction of more teeth may be indicated.

• Such situations are rare and are not advised.

6. Serial extraction

• Extraction of certain deciduous teeth and permanent teeth in

selective cases to alleviate crowding.

• Usual sequence of extraction is primary canines, primary

first molars and first premolar.

• Concept of serial extraction was introduced by Robert Bunon

and the name serial extraction was coined by Birger
Kjellgren.

• Nance HN is called the father of serial extraction.

7. Driftodontics

• In a few situations after extraction, no active orthodontic

treatment is given.
• The space closure occurs both by the movement of teeth
mesial and distal to extraction site.

• Wick Alexander advocated this in the case of lower arch.

• After extractions of lower first premolars, crowding settles

automatically by distal tipping of the incisors into the
extracted area.

• This is called driftodontics.

8. Extractions in camouflage treatment

• In class II malocclusions, extractions of upper first premolars

and lower second premolars are done.

• In class II malocclusion, sometimes upper first premolars

alone are extracted.

• In class III malocclusion, upper second premolars and lower

first premolars are extracted.

FIG. 24.2. Unbalanced and balanced extractions.

 FIG. 24.3. (A) Effect of unbalanced extraction and (B) effect of balancing the extraction.

ACCESSORY POINTS
➤ Extraction of maxillary first molar may be indicated when their prognosis is poor.

➤ Wilkinson extraction is extraction of all first permanent molars.

➤ Procedure in which extraction of teeth is carried out in opposing arches is called

compensating extractions.

➤ Removal of teeth symmetrically on each side of the arch is called balancing extraction.

➤ Proximal slicing in the lower incisors converts contact point to contact areas.

Advanced Learning
Various appliances used for molar distalization
The various appliances used for molar distalization can be studied under the headings
given in Fig. 24.4.

Extraoral appliances: Refer to chapter on Orthopaedic Appliances.

 FIG. 24.4. Various appliances for molar distalization.

Removable intraoral appliances

Cetlin plate
The appliance involves a combination of extraoral force in the form of headgear and an
intraoral force in the form of a removable appliance.
Design
Appliance consists of:

➤ Active part: Two 0.028 inch stainless steel distalizing springs that lie against the
mesial surface at the gingival level of the upper first permanent molar.

➤ Adams’ clasp on premolars and an anterior 0.017 × 0.025 inch arch covered by labial
screen.

➤ Anterior bite plane to disclude posterior enhancing distalization and to correct curve
of Spee.

Activation
The spring is activated only 2–2.5 mm per side and it supplies 30 g of force on the
molars.
Disadvantage
It relies on patient compliance.
Pendulum appliance
It was introduced by James Hilgers in 1992. It produces broad swinging arc (pendulum)
of force from midline of palate to upper molars, hence it is called so.
Design ( fig. 24.5)
➤ Consists of a large acrylic Nance button that covers mid-portion of the palate.
Posteriorly directed springs, made of 0.032 TMA wire, extend from distal aspect of
palatal acrylic to form a helical loop near the midline and then extends laterally to
insert into lingual sheath on bands cemented on maxillary first molar.

FIG. 24.5. Design of pendulum appliance.

➤ Springs have adjustment loop that can be manipulated to increase molar expansion,
rotation and distal root tip.

➤ The anterior portion of the appliance can be retained in place with occlusally bonded
rests or soldered to bands on either the deciduous molars or the first and second
bicuspids.

Activation
Springs prefabricated to lie parallel to midsagittal plane, which produces 60° of
activation after insertion.
As molar distalizes, it moves on an arc (distopalatal arc) towards midline producing
crossbite in molar. This is counteracted by opening the horizontal loop.
Drawbacks/disadvantages
➤ The pendulum appliance not only drives the molars distally, there is also a slight
lingual tipping.

➤ The Nance button causes proclination of front teeth.

➤ Not very easy to fabricate.

➤ Pure bodily movement of the molar is not seen.

Advantages
➤ Excellent patient tolerance

➤ Up to 5 mm distalization in 4 months

➤ Distalization + expansion can be achieved

Modifications of pendulum appliance

The different types of pendulum appliances and their design, use are given in Table
24.2.

Table 24.2.
Different types of pendulum appliances
Fixed intraoral molar distalizers
Jones jig: It was introduced by Jones RD and White MJ in 1992.
Design ( fig. 24.6)
Jones jig consists of a heavy round wire and a light wire projecting through the molar
tubes. Both wires are soldered to a fixed attachment sheath and hook posteriorly.
Anteriorly, a sliding sheath is placed. Between the two sheaths an open coil nickel–
titanium spring is placed to deliver 70–75 g of force, over a compression range of 1–5
mm, to the molars.
 FIG. 24.6. Jones jig: (A) lateral view, (B) occlusal view.

A modified Nance button attached to the second premolar bands is used for
anchorage.
Activation
Nickel–titanium coil spring is activated when the sliding anterior sheath is tied back
using a ligature of 0.014 inch.
Drawbacks
➤ Use of the Nance appliance causes palatal tissue impingement.

➤ Distal tipping of molar, and mesial tipping of premolars.

➤ Cannot be used with fully banded treatment.

➤ Frequent breakage of the appliance.

Advantage
➤ Light forces used (from nickel titanium (NiTi) open coil spring).
➤ Activation is easier (simply by placing a ligature tie).

➤ Can be used without bonding anterior teeth.

Distal jet

➤ Distal jet was designed by Aldo Carano and Mauro Testa in 1996.

Design ( fig. 24.7)

➤ The appliance consists of a bilateral piston and tube system with the tube embedded
in an acrylic button in the palate. The tube extends distally, adjacent to the palatal
tissues and parallel to the occlusal plane up to the molars.

➤ A bayonet wire, inserted into the lingual sheath on the first molar bands, extends
into the tube like a piston.

➤ A super elastic nickel–titanium open coil spring (180 g or 240 g) is placed around this
tube and piston arrangement along with an activation lock that is used to compress
the spring distally.

➤ An anchor wire from the Nance button is soldered to bands on the second premolars.

FIG. 24.7. Distal jet appliance.

Activation
➤ The activation lock is pushed distally to compress the spring and locked on the tube
with a small Allen hex wrench.

➤ The activated coil spring causes the molar to translate (bodily) distally as the force is
 applied near the C res of the molar root because of the bayonet bend.

Advantages
➤ Bodily movement

➤ Easy insertion

➤ Well tolerated

➤ Aesthetic

➤ Unilateral and bilateral distalization possible

➤ Permits simultaneous use of full bonded appliances

Disadvantages
➤ Anchor loss resulting from Nance holding arch.

➤ Construction not deep enough into the palate to be at or apical to the centroid in
patients with shallow palate.

Lokar molar distalizing appliance

Design
The Lokar appliance inserts into the molar attachment with appropriately sized
rectangular wire. It consists of compression spring and a sliding sleeve (Fig. 24.8).
Sliding sleeve is kept in place by resting in the groove which is formed by the flat
guiding bar and the round posterior guiding rod. This guiding rod is soldered to the
mesially positioned sliding sleeve, and the flat anterior guiding bar is soldered to the
immovable posterior sleeve.

FIG. 24.8. Parts of Lokar appliance: A, Inserts into molar attachment with a rectangular wire;
B, compression spring; C, sliding sleeve; D, groove; E, flat guiding bar; F, round posterior
guiding rod; G, immovable posterior rod.

Activation
Compression coil is activated by sliding sleeve which is tied to the most distal tooth
mesial of the first molar by a ligature wire.
Advantages
➤ Can be used in conjunction with complete edgewise appliance.

➤ Extraoral or lip bumper forces may be applied concurrently as the molar tube is not
used up.

➤ Precise amount of force can be delivered.

➤ Easy insertion, activation.

Disadvantage
➤ Distal tipping of molar

K-loop molar distalizing appliance

K-loop molar distalizer was introduced by Varun Kalra in 1995.
Design
The appliance consists of:

➤ K-loop to provide the forces and moments.

➤ The K-loop is made of 0.017 × 0.025 inch TMA wire which can be activated twice as
much as stainless steel, before it undergoes permanent plastic deformation.

➤ It has a Nance button to reinforce anchorage.

➤ K-loop construction and activation (Fig. 24.9).

 FIG. 24.9. A. The loop of the ‘K’ should be 8 mm long and 1.5 mm wide; B. The legs of the ‘K’
are to be bent down 20° and inserted into the molar tube and the premolar bracket; C. The
wires are marked at the mesial of the molar tube and the distal of the premolar bracket; D.
Stops are bent into the wire 1 mm distal to the distal mark and 1 mm mesial to the mesial
mark. Each stop is well defined and is about 1.5 mm long; E. These bends help keep the
appliances away from the mucobuccal fold, allowing a 2 mm activation of the loop.

Advantages
➤ Simple and efficient

➤ Controls moment to force ratio to produce bodily movement

➤ Easy fabrication and placement

➤ Hygienic and comfortable to the patient

➤ Low cost

Keles slider

➤ Introduced by Ahmet Keles

Design
➤ This consists of (Fig. 24.10):
a. Acrylic anterior bite plane to disclude the posteriors,
enhancing distalization.

FIG. 24.10. Keles slider. The parts are explained in the text. Adjustable screw (d) is activated
using a special wrench which compresses the coil spring.

b. First premolars are attached to the acrylic through retaining

wires.

c. 0.04 inch wire rod for distal sliding of maxillary first molar.
Anterior end is embedded in the acrylic button while
distally the wire rod pass through the molar tube placed in
the maxillary first molar palatally. The wire rod is oriented
parallel to occlusal plane.

d. NiTi coil spring placed between the lock on the wire and the
tube in full compression.

Advantages
➤ Produces bodily distalization of molars as the distal force is applied at the level of C
res of maxillary first molar.

➤ Effective in deep bite correction because of the anterior bite plane

➤ Ease of activation
➤ Short chair side time for activation

➤ It can be easily converted into a sort of Nance holding appliance at the end of molar
distalization.
SECTION VIII
Early Orthodontic Treatment
OUTLINE

25. Preventive orthodontics

26. Interceptive orthodontics

CHAPTER 25
Preventive orthodontics

CHAPTER OUTLINE
❖ Preventive orthodontics: definition and various preventive orthodontic procedures
❖ Rationale and principles of preventive orthodontics
❖ Non-appliance preventive orthodontic procedures
❖ Classification of space maintainers
❖ Planning for space maintenance and factors for consideration
❖ Ideal requirements, indications and contraindications of space maintainers
❖ Removable space maintainers
❖ Fixed space maintainers
❖ Mouth protectors or guards
❖ Accessory points
❖ Advanced learning
❖ Various space maintainers according to different
conditions or areas in the arch
Preventive orthodontics: Definition and various
preventive orthodontic procedures
Graber’s definition
Preventive orthodontics is the action taken to preserve the integrity of what appears to be a
normal occlusion at a specific time.
The various preventive orthodontic procedures can be studied under two headings:

1. Preventive procedures without appliances

• Predental procedures

• Parent education

• Oral hygiene

• Caries prevention

• Monitoring of primary dentition and transition stage

• Removal of supernumerary tooth

• Restoration of decayed teeth

• Occlusal equilibration

• Habit corrections

• Extraction of retained deciduous tooth

• Management of mucosal barrier

• Tongue-tie management
• Disking

• Locked permanent first molar

2. Preventive procedures with appliances

• Mouth protectors

• Space maintenance
Rationale and principles of preventive
orthodontics
‘An ounce of prevention is worth a pound of cure’. This statement holds good in
orthodontics also.
Preventive orthodontics means a dynamic, constant vigilance to prevent malocclusion
by both dentist and patient.

Requirements
1. Need for patient–dental surgeon rapport:

• A good rapport between patient and dental surgeon is

essential for effective prevention.

• Patient should be educated about the advantages of

prevention.

• Periodical check-up helps in identifying the problems early.

2. Need for diagnostic records:

• Child has to be seen by the dentist by 2.5 years of age.

• Diagnostic records include:

i. Clinical examination

ii. Intraoral radiographs

iii. Panoramic radiograph

• By 5 years, child should be prepared for longitudinal

records.
• If there are any signs of developing malocclusion, periapical
radiographs should be taken once a year.
3. Importance of study casts:

• Study cast makes up an invaluable record during 6–12 years

of age.

• If required, study cast should be prepared every year to

compare and evaluate potential problems.

Identification of future orthodontic problems

➤ The preventive orthodontic phase offers the best opportunity to render worthwhile
service for the community.

➤ Recognition of future problem is the critical step in preventive orthodontics.

➤ Timely detection of future problem saves time and money for the patient.

➤ It also improves patient–dentist relationship.

➤ The possible future problems can be identified by two ways: Clinical and
radiographic indicators.

➤ A thorough visual examination will reveal potential problems.

➤ Dentist should be able to differentiate potential problems from self-correcting

malocclusions.

➤ Identification of proximal caries and planning for space maintenance are examples.

➤ There are psychological advantages to prevention of malocclusion.

➤ Prevention may remove aetiologic factors and restore normal growth.

➤ There is possibility of achieving better results.

➤ Economical.

➤ Early treatment of deleterious habits is easier.

Clinical indicators
➤ A thorough visual examination will reveal potential problems.

➤ Dentist should be able to differentiate potential problems from self- correcting

malocclusions.

➤ Identification of proximal caries, planning for space maintenance are examples.

Radiographic indicators
➤ Most important radiographic indicators of orthodontic problems:

i. Resorption pattern of primary dentition.

ii. Eruption pattern of the permanent dentition.

Non-appliance preventive orthodontic
procedures
Preventive orthodontics is the action taken to preserve the integrity of what appears to
be a normal occlusion at a specific time.
The various preventive orthodontic procedures without appliances can be studied as
under:

1. Predental procedures

• Preventive procedures are instituted before the eruption of

teeth.

• Malocclusion can be initiated by improper selection of

feeding nipple in the bottle-fed baby and also by improper
positioning of the bottle.

• Nipple should be long. It should rest on the anterior third of

tongue.

• Physiologic nipples are advised.

2. Parent education

• Parents are educated on: (i) importance of nutrition, (ii)

mode of feeding, (iii) maintenance of oral hygiene.

• A highly nutritious diet is recommended during the

developmental stages of a child.

• The drawbacks of bottle-feeding and importance of mother’s

milk should be stressed.

• Parents should be taught brushing technique for children.

Parents themselves should brush for very young children
 who cannot brush on their own.
3. Oral hygiene

Parents and children should be taught oral hygiene measures.

• Infants (0–1 year old): Plaque removal activity or brushing

should start with the eruption of first primary teeth. Parents
should do the cleaning act. Moistened gauze or wash cloth
can be used to gently massage the gums and clean the teeth.

• Toddlers (1–3 years old): Toothbrush should be introduced.

Nonfluoridated pastes are advised since the child may
ingest the toothpaste. Parents should brush for the child.

• Preschoolers (3–6 years old): Children should brush under

parental care. Fluoride toothpaste is introduced.

• School aged (6–12 years old): Proper brushing technique

and regular brushing by the child.
4. Caries prevention

Dental caries:

• Effect of restoration: If under contoured, it results in loss of

contact with reduction in arch length. If over contoured, it
consumes more space resulting in irregularity.

• Pulpal involvement causes extraction, leads to premature

loss of tooth and derangement of occlusion.

• Proximal caries causes reduction in arch length.

• All possible caries prevention methods are to be used.

• Proper brushing, will reduce chances of caries attack.

• Fluoride prophylaxis – Knutson’s technique, at ages 3, 7, 9

and 11, four sittings at weekly intervals, is advised.
5. Monitoring of primary dentition and transition stage

• Careful monitoring of resorption pattern of primary teeth

helps in establishing good occlusion.

• Abnormalities of resorption are usually associated with

space-deficiency problems.

• Deciduous canines and second deciduous molars are prone

for aberrant resorption.

• In ideal sequence, both right and left side deciduous teeth

exfoliate at the same time.

• After exfoliation of primary tooth, the permanent successor

should erupt within 3–6 months after exfoliation.

• If the primary tooth is retained, extraction should be done

when indicated by the state of development of their
permanent successor.
6. Removal of supernumerary tooth

• Supernumerary tooth should be extracted, if their retention

will interfere with normal eruption pattern and establishing
normal occlusion.
7. Restoration of decayed teeth
Interproximal fillings should be done at the earliest to prevent
space loss. The effects of overextended proximal restoration
and unattended proximal caries are given in Fig. 25.1.
8. Occlusal equilibration

Occlusal equilibration is performed as preventive, interceptive

and corrective orthodontic procedures.

• Most of the functional prematurities are transient in primary

dentition.

• Functional shifts which lead to pseudo-class III and

crossbites should be checked and eliminated.

• Overextended restorations may cause occlusal prematurities.

They have to be reduced.

• Any abnormalities in shape which lead to occlusal

derangement should be trimmed, e.g. Epstein pearls, extra
cusps.
9. Early detection of habits

• Early correction of habits is easier and helps in elimination

of the unfavourable sequelae of habits which lead to
malocclusion.

• Early detection of mouth breathing and eliminating it

restores normal function. This helps in maintaining normal
growth.

• Other habits, like tongue thrusting and lip biting, should be

recognized and eliminated.
10. Extraction of deciduous teeth

• Extraction of retained deciduous tooth is done when

indicated by the state of development of permanent
successor.

• Sometimes removing primary tooth early allows permanent

teeth to align better.

• Early extraction of primary teeth also prevents permanent

teeth from erupting into abnormal location.
11. Management of mucosal barriers

• Soft tissue barriers to eruption and high frenal attachment

require attention.

• The mucosal impediments to eruption of teeth have to be

cleared.

• Delayed eruption of permanent teeth causes occlusal

derangement.
12. Early detection of tongue-tie

• Tongue-tie arises due to thickening of the genioglossus

muscles meeting in the midline of the tongue where they get
elevated into vertical fold.

• Tongue-tie usually disappears after 4 years of age.

• Frenum excision is not done before 4 years of age.

• Tongue-tie interferes with feeding in early infancy.

13. Disking

• Disking of oversized first or second deciduous molars is

done sometimes to facilitate eruption of permanent teeth
(Fig. 25.2).

• Disking of deciduous molar is done to provide space for

eruption of permanent canines.

• In cases of congenitally missing second premolars, the

deciduous second molar is reduced for the late mesial shift
to take place.
14. Locked permanent first molar

• Locked permanent first molar can be deeply or slightly

locked.

• Deeply locked permanent first molars require extraction of the

deciduous second molar and space maintenance for the
second premolars.

• Locked permanent first molars may resorb the second

deciduous molar at the cervical part of the tooth.

• The distal root may be severed and get embedded in the

bone.

• If the roots of the second deciduous molar are present,

disking of second deciduous molar will allow eruption of
permanent first molar.

• If root resorption is severe, deciduous second molar has to

be extracted.
• Slightly locked permanent first molar usually erupts without
treatment.

• Passing a ligature wire or separators interdentally frees the

slight lock.

FIG. 25.1. (A) Overextended restoration alters the occlusal relationship and (B) effect of
proximal caries on arch length. Arch length reduces.
FIG. 25.2. Disking.
Classification of space maintainers
Definition
Space maintainers are appliances that are used to maintain the lost space, functions and regain
minor amount of space lost. Space maintainers help to guide the unerupted tooth into
proper position and occlusion.

Classification
There are different methods of classification of space maintainers. The commonly used
methods of classification:
Planning for space maintenance and factors for
consideration
Space maintenance
During transition from primary dentition to permanent dentition, in the mixed
dentition, chain of events take place in an orderly and timed fashion. If this sequence is
disrupted, it results in an occlusion which is not functionally and aesthetically stable.
Hence, corrective measures are done to restore the normal process of occlusal
development. One such procedure is space maintenance. Space maintenance is
concerned with maintenance of space lost by early loss of primary tooth by passive
appliance or gaining of space lost.

Planning for space maintenance

While planning for space maintenance, considerations should be given for the factors
that influence the development of a malocclusion. Following are the influencing factors
of occlusion:

1. Abnormal oral musculature

2. Pernicious oral habits

3. Existing malocclusion

4. Stage of occlusal development

1. Abnormal oral musculature:

• Altered tongue position and strong mentalis muscle cause

damage to the occlusion after loss of mandibular primary
molar.

• Mandibular arch collapses and distal drift of anterior teeth

results.
2. Pernicious oral habits:

• Abnormal oral habits like sucking habits and tongue

thrusting alter the equilibrium or buccinator mechanism.
• Collapse of arch occurs after premature loss of primary
teeth.
3. Existing malocclusion: Early loss of primary tooth increases the severity of different
types of malocclusion like arch length discrepancy, class II division 1 malocclusion.

4. Stage of occlusal development: Space loss is more, if the tooth lost is adjacent to an
actively erupting tooth.

Factors to be considered for planning of space

maintenance
1. Time lapsed after loss of tooth:

• Maximum loss of space occurs during the first 6 months

after loss of a tooth.

• Hence, if space maintainer is indicated, it should be given

immediately after extraction of the primary tooth.
2. Dental age of the patient:

• When planning for space maintainers, the dental age is given

more consideration.

• Normally, tooth erupts when three-fourths of root is

developed.

• Therefore, space maintainers have to be planned depending

upon the root formation of the permanent successor.

• Space maintainers are indicated in cases with inadequate

root completion.

• Early loss of primary tooth causes delayed eruption of the

permanent successor.
3. Amount of bone covering the unerupted tooth:

• Guideline for emergence of erupting premolars usually is

that it requires 4–5 months to move through 1 mm of bone.

• If the thickness of the bone over the erupting tooth is more,

there will be delayed eruption of the permanent tooth.

• If the bone covering the tooth has been destroyed by

infection, there will be accelerated eruption of permanent
tooth.

• Cases with thick overlying bone require space maintainers,

even if the roots are fully developed.
4. Sequence of eruption of teeth:

• Relationship of developing and erupting teeth adjacent to

the space created by early loss of a tooth affects the space
closure.

• For example, when the permanent lateral incisor erupts, it

pushes the primary canine distally. At this stage, if there is
premature loss of primary first molar, the primary canine is
pushed distally very easily.

• If this occurs in lower arch, because of the ‘falling in’, bite

deepening results.
5. Delayed eruption of the permanent tooth:

• In cases where there is delayed eruption of the permanent

tooth with retained primary tooth, the primary tooth is
extracted and space maintainer given.
• This allows the permanent tooth to erupt into normal
position.
6. Congenital absence of the permanent tooth: There are two ways of dealing with the
problem: (i) Maintain the space – plan for replacement at later stage and (ii) allow the
space to close.

7. Time of tooth loss and stage of occlusion: This is another factor that needs
consideration. For example, loss of primary second molar before the eruption of
permanent first molars requires special type of space maintainer, namely distal shoe
space maintainer.
Ideal requirements, indications and
contraindications of space maintainers
Ideal requirements of space maintainers
➤ Space maintainers should maintain the desired mesiodistal dimension of the space.

➤ Should not impede with the vertical eruption of adjacent tooth.

➤ Maintain individual functional movement of the teeth.

➤ Should not interfere with eruption of the permanent tooth.

➤ If required, should be able to provide mesiodistal space opening.

➤ Should resist the masticatory forces.

➤ Should not get distorted or break.

➤ Should be easily cleansable.

➤ Should be easy to fabricate.

➤ Should not restrict normal development process in stages of occlusal development.

➤ They must not endanger the remaining teeth by imposing excessive stresses on them.

➤ Should prevent supraeruption of the opposing tooth.

Indications of space maintainers

Space maintainers are indicated in the following conditions:

➤ When a second primary molar is lost before the second premolars are ready to take
its place.

➤ Early loss of the primary first molar.

➤ Cases of congenital missing of second premolars when planned for prosthesis later.

➤ Early loss of primary anterior teeth.

➤ Early loss of primary second molar before the eruption of permanent first molars.
➤ Loss of permanent first molar after eruption of second permanent molar.

➤ When there is loss of space and minor amount of space has to be gained. In this
situation, active space maintainers or space regainers are used.

Contraindications to space maintainers

➤ When there is no bone or very minimal bone overlying the crown of erupting
permanent tooth.

➤ When the space remaining is in excess of the mesiodistal dimension of the erupting
successor.

➤ When the space available will be utilized for solving minor arch length discrepancy.

➤ When the permanent successor is absent.

➤ Space maintainer may not be necessary when the succedaneous tooth will be
erupting soon.
Removable space maintainers
Removable space maintainers are appliances which can be inserted and removed by the
patients themselves.
Types of removable space maintainers are:

1. Active or passive

2. Functional or non-functional

3. Unilateral or bilateral

Advantages of removable space maintainer

➤ It is easy to clean.

➤ Oral hygiene can be maintained.

➤ Maintains or restores vertical dimension.

➤ Can be used in conjunction with other preventive measures.

➤ When worn part time, allows for circulation of blood to the soft tissues.

➤ Aesthetically desirable.

➤ Facilitates chewing and speaking.

➤ Helps to keep the tongue in control by preventing tongue thrust into the extraction
space.

➤ Eruption of permanent teeth is stimulated.

➤ Less chairside time, as band construction is not required.

➤ Possibility for caries is less and check-up for caries is possible.

➤ Space for eruption of permanent tooth can be made in the appliance itself.

Disadvantages of removable space maintainers

➤ Possibility of the patient not wearing the appliance.

➤ Possibility of breakage of the appliance is more.

➤ Restriction of lateral jaw growth due to clasps.

➤ Soft tissue irritation and ulceration occurs.

➤ Appliance may be lost.

➤ Cannot be used in children with seizures.

➤ Cannot be used in children who are allergic to acrylic resins.

Indications of removable space maintainers

➤ Indicated when space maintenance with maintaining functional occlusion is
required.

➤ In anterior region for aesthetics in the form of partial denture.

➤ Conditions where banding of tooth is not possible like incomplete eruption.

➤ Children who are prone for caries.

➤ In multiple loss of teeth.

Examples for removable space maintainers

1. Acrylic partial denture

a. Indications and advantages

• It is used successfully after multiple loss of teeth in the

mandibular or maxillary arch.

• It is used in unilateral or bilateral loss of more than single

tooth.

• Inclusion of artificial teeth restores normal function.

• It is simple to construct.

• It meets the functional requirements.

• It is economical.

b. Disadvantages

• It requires parental and patient cooperation.

• Breakage of appliance is another drawback.

• Clasps might interfere with eruption of actively erupting

tooth.
2. Removable distal shoe space maintainer (Fig. 25.3)

• This is devised by Paul E. Starkey.

• Indicated in unilateral or bilateral early loss of primary

second molar before the eruption of permanent first molar.

• Fabrication: The tooth to be extracted is cut away and a

depression is made in the model to allow the processing of
acrylic extension.

• The acrylic extends into the alveolus and guides the erupting
first molar into position and maintains space for second
premolar.

• Extension is cut once the first permanent molar erupts into

occlusion.
3. Full dentures for children

• This is quite rare in children nowadays.

• Total extraction may be carried out in extensive decay due to

rampant caries or because of widespread infection.

FIG. 25.3. Diagrammatic representation of radiographic image of removable distal shoe space
maintainer.
Fixed space maintainers
The different types of fixed space maintainers can be studied under three headings.

I. Functional fixed space maintainers

1. Crown and bar

This is a functional type of space maintainer.

Indication: Loss of first primary molar with significant loss of

tooth material in abutment teeth.

Design: This is the simplest functional type of space

maintainer (Fig. 25.4). Proper-sized stainless steel crown
form is chosen for the abutment teeth. Stainless steel crowns
are contoured and fitted carefully. The abutment crowns are
joined together by 0.036 inch stainless steel bar which is
soldered to the crowns.
Advantages:

• It maintains mesiodistal space.

• It prevents supraeruption of the opposing tooth.

• It can be used in uncooperative patients.
Disadvantages:

• Rigid vertically.

• Difficult to fabricate.
Modification:

• Broken stress functional space maintainer (Fig. 25.5).

• Broken stress functional space maintainer allows for vertical

movement of the adjacent tooth consistent with functional
demands.

• Instead of soldering a rigid bar between the two adjacent

crowns, in a vertical tube L-shaped bar is fabricated to fit the
edentulous area.

2. Band and bar

• Band and bar is a functional type of fixed space maintainer.

• The difference from crown and bar is instead of crowns,

abutment teeth are banded (Fig. 25.6).

Indications

• Early loss of primary first molar with adequate tooth

structure of the abutment tooth.

• Unilateral loss of primary first molar.

• Uncooperative patient.
II. Fixed non-functional space maintainers

1. Band and loop

This is a fixed, semirigid, nonfunctional passive type of space

maintainer (Fig. 25.7).

Indication: Early loss of first primary molar.

Advantages: Ease of fabrication for the clinician; ease of

maintenance for the patient.

Disadvantage: Opposing tooth may supraerupt; slipping of

the loop towards the gingiva is also a disadvantage of this
appliance.

Design: The second deciduous molar is banded. 0.036 inch

wire is adapted to the contours of the tissue and made into a
loop. Loop is soldered on to the band. The loop extends
between the two abutment teeth.

Modifications:

1. Mayne’s modification (Fig. 25.8): In this, loop extends only

on the buccal side.

2. Crown and loop: When there is significant loss of tooth

substance of the abutment tooth, a full stainless steel
crown is given instead of the band.

3. Band and loop with vertical projection in which the loop

contacts the abutment tooth.

➤ This occlusal rest prevents tipping.

➤ It also helps in preventing the sliding of the loop gingivally.

2. Lower lingual holding arch (LLHA)

This is a non-functional passive fixed space maintainer (Fig.

25.9).

Indications:

• Bilateral loss of mandibular second primary molars.

• Multiple loss of primary teeth in the mandibular arch.

• Can be used for maxillary arch also.

Advantages:

• Maintains tooth space.

• Maintains leeway space.

• Eliminates patient cooperation.

Disadvantages:

• Susceptible to caries or decalcification.

• Prone for breakage, if not fabricated properly.

• Cannot be used in maxillary arch, if the bite is deep.

• Chances for distortion are more.

Design:
• 0.036 inch stainless steel wire is contoured to the lower arch.

• Contacts with the cingulum area of the incisors.

• Space for eruption of premolars and canines should be

given.

• Archwire extends posteriorly along the middle third of the

lingual surface of the molar band and soldered.

Modifications:

1. Mershon’s modification (Fig. 25.10):

➤ Spurs are placed distal to canine.

➤ Used in case of loss of both first and second primary

molars.

2. Fixed removable lingual arch: Instead of soldering the

lingual arch to the molar band, it is designed to be
inserted and removed from a vertical tube in the molar
bands.

3. Nance space holding appliance (Fig. 25.11)

Nance space holding appliance is a nonfunctional passive type

of fixed space maintainer. It is used in the maxillary arch.

Indication: Used in maxillary arch for bilateral space

maintenance.

Advantages:
• Maintains leeway space.

• Maintains mesiodistal space of lost tooth.

• Space maintainer in deep bite cases.

Disadvantages:

• Produces soft tissue irritation.

• Acrylic portion can get embedded in the palatal soft tissue.

Design:

• Nance arch is simply a maxillary lingual arch that does not

contact the anterior teeth.

• It approximates the anterior palate.

• The palatal portion incorporates an acrylic button that

contacts the palatal tissue.

• The portion of the wire where the acrylic is embedded is

bent into various configurations for the retention of acrylic.

4. Transpalatal arch

Transpalatal arch is a non-functional type of fixed space

maintainer (Fig. 25.12).

Indication: Best indication is for unilateral space maintenance

with intact one side arch.

Advantages:
• Transpalatal arch reduces the anterior molar movement by
preventing mesiolingual rotation of the lingual root.

• Provides adequate stability for space maintenance when

used with one side intact arch.

Disadvantages:

• In bilateral loss of primary second molar, TPA is not

effective. Both the permanent first molars tip mesially.

• Appliance becomes active and unexpected vertical and

transverse movements of permanent molar take place.

• Fails to maintain space adequately.

5. Bonded space maintainers

Bonded space maintainers are used because:

• They are easy to fabricate.

• Require less time; only chairside procedure.

• Aesthetically desirable.

• Direct bonding eliminates impression procedure.

III. Cantilever type fixed space maintainer/distal shoe space maintainer

Synonyms

• Distal shoe space maintainers

• Eruption guidance appliance

• Intra-alveolar appliance

• Willet’s appliance

• Roche’s appliance

• Cantilever fixed space maintainer

History

• Distal shoe appliance was first reported by RC Willett.

• The commonly used type is Roche type.

• Roche has got a V-shaped gingival extension.

Indication

Distal shoe space maintainer is indicated in case where there is

early loss of primary second molar before the eruption of
permanent first molar.

Types

1. Fixed: (a) functional and (b) non-functional

2. Removable.
 FIG. 25.4. Crown and bar space maintainers.

FIG. 25.5. Broken stress functional space maintainer.

FIG. 25.6. Band and bar type fixed space maintainer.

FIG. 25.7. Band and loop space maintainers.

FIG. 25.8. Mayne’s modification.

FIG. 25.9. Lingual holding arch.

 FIG. 25.10. Mershon’s modification.

FIG. 25.11. Nance space holding appliance.

 FIG. 25.12. Transpalatal arch.

Design of roche’s appliance

Roche has designed a crown and band appliance with a distal intragingival extension
which guides the first permanent molar to erupt (Fig. 25.13).

➤ The first primary molar is banded. The band is placed over the steel crown on the
abutment tooth.

➤ An impression is made with the bands in place. Subsequently, the bands are
removed from the teeth and placed and stabilized in the impression before pouring
the model.

➤ Stone model is prepared.

➤ If the second primary molar had not been extracted before taking the impression, it is
cut off from the stone model before proceeding to the next step.

➤ Hole to simulate the distal root of the second primary molar is prepared in the model
using a bur.

➤ The mesiodistal width of the second primary molar is measured.

➤ If there is no second primary molar, radiograph is taken to measure the mesiodistal

space.

➤ A simple method is to measure opposite side second primary molar.

➤ The V-shaped gingival extension should be about 1–1.5 mm below the mesial
marginal ridge of the first permanent molar.
 FIG. 25.13. Roche’s appliance.

Contraindications
➤ When several teeth are missing, abutment to support the appliance may be absent.

➤ In patients with poor oral hygiene.

➤ Lack of patient or parent cooperation reduces the success rate.

➤ Contraindicated in medically compromised situations like blood dyscrasias,

rheumatic fever, congenital heart defects and juvenile diabetes.

➤ Removable distal shoe space maintainer: Refer to removable space maintainer.

Mouth protectors or guards
A mouth protector or guard is constructed so that it does not interfere with normal
occlusion and affords protection against injuries to the teeth in contact sports. There are
two types of mouth guards:

1. Prefabricated mouth guards

• They are readily available.

• They are not very effective when compared to custom-made

mouth protectors.

• The fit will be loose.

2. Custom-made mouth guards

• They provide better fit and comfort to the patients.

• They are less likely to affect the patient’s speech.

• They are less likely to become loose.

• They afford maximal resistance to dislodgment since they fit

accurately to individual tooth and arch form.

Materials used
➤ Poly (vinyl acetate-ethylene) co-polymer thermoplastic

➤ Polyurethanes

➤ Laminated thermoplastic materials

Fabrication
Sequence of fabrication is as follows.
ACCESSORY POINTS
➤ Maximum loss of space by drifting of teeth occurs during the first 6 months after loss
of a tooth.

➤ Guideline for emergence of erupting premolars usually is that it requires 4–5 months
to move through 1 mm of bone.

➤ Loss of primary second molar before the eruption of permanent first molars requires
special type of space maintainer, namely distal shoe space maintainer.

➤ Distal shoe apart from maintaining space also performs the function of eruption
guidance.

➤ Removable distal shoe was designed by Starkey.

➤ A child’s first visit to an orthodontist should be at about 2.5 years of age.

➤ Deciduous teeth more prone for aberrant resorption are canines and deciduous
molars.

➤ Abnormal resorption of deciduous tooth is an early sign of space discrepancy.

➤ Very early loss of primary tooth may delay the eruption of permanent tooth due to
the formation of thick bone or mucosal barrier.

➤ A space maintainer is called functional, if it prevents supraeruption of opposing

tooth.

➤ Distal shoe space maintainer is a cantilever type of space maintainer.

➤ Bulk of the leeway space is contributed by deciduous second molar.

➤ Most common cause of large median diastema in the maxillary arch is the presence
of mesiodens.

➤ High frenal attachment with strong muscle pull is diagnosed radiographically by the
presence of notch in the alveolar crest.

➤ Unilateral posterior crossbite in a child is usually due to bilateral maxillary

constriction and functional shift.

➤ Most common ectopic tooth is maxillary first permanent molar.

Advanced Learning
Various space maintainers according to different conditions or areas in
the arch
1. Space maintenance for first and second primary molars and primary canine areas:
(i) Crown and bar, (ii) band and loop, (iii) lingual arch (iv) Nance space holding arch
and (v) TPA.

2. Loss of second primary molar before eruption of first permanent molar: (i) Distal
shoe space maintainer.

3. Space maintenance for primary and permanent incisor area: (i) Removable partial
denture and (ii) fixed appliance.

4. Space maintenance for areas of multiple tooth loss: (i) Acrylic partial denture, (ii)
lingual arches and (iii) full dentures for children.
CHAPTER 26
Interceptive orthodontics

CHAPTER OUTLINE
❖ Various interceptive orthodontic procedures
❖ Occlusal grinding/occlusal equilibration
❖ Management of developing anterior crossbite/tongue blade therapy
❖ Incipient malocclusions
❖ Classification of deleterious dentofacial habits
❖ Thumb sucking
❖ Tongue thrusting
❖ Management of lip biting and lip sucking
❖ Bruxism
❖ Mouth breathing and its management
❖ Space regainers/active space maintainers
❖ Serial extraction/guidance of eruption
❖ Accessory points
❖ Advanced learning
❖ Muscle exercises
❖ Interception of malocclusion
❖ Invisalign
Various interceptive orthodontic procedures
Definition
Interceptive orthodontics is defined as that phase of the art and science of orthodontics employed
to recognize and eliminate potential irregularities and malpositions of the developing dentofacial
complex.
Following are the various interceptive orthodontic procedures:

➤ Extraction of supernumerary tooth

➤ Extraction of ankylosed tooth

➤ Elimination of bony/tissue barriers for eruption

➤ Equilibration of occlusal disharmonies

➤ Developing crossbite correction: Anterior and posterior

➤ Control of abnormal habits:

• Muscle exercises

• Space regainers

• Serial extraction

• Interception of developing skeletal problems

➤ Disking

➤ Early straightening of permanent incisors

➤ Many of the interceptive orthodontic procedures are extension of preventive

orthodontic procedures

➤ There is difference only in timing of treatment

Occlusal grinding/occlusal equilibration
Introduction
Occlusal equilibration is the systematic reshaping of the occlusal anatomy of teeth to minimize or
eliminate the role of occlusal interferences in reflexly determined mandibular positions.

➤ Occlusal equilibration is done more during active growth and occlusal development
than in adulthood.

➤ Balanced occlusion is required during occlusal development.

➤ Premature contacts can develop into tooth guidance problems leading to functional
crossbite or functional class II or class III malocclusion.

Armamentaria used for detecting occlusal interferences

➤ Very thin articulation paper

➤ Base plate wax

➤ Diamond points

➤ Diamond discs

➤ Record casts

➤ Anatomic articulator to mount the study casts

Occlusal equilibration
It is essential to check for interferences in the retruded position, intercuspal position,
protrusive and lateral occlusal contacts. Occlusal equilibration is done in primary
dentition, mixed dentition and permanent dentitions.

1. Occlusal equilibration in the primary dentition

• Equilibrative procedures are carried out on the mounted

casts before doing it in the mouth.

Procedure:
• Teach the child to tap together with the midlines coinciding.

• Position should be guided by the dentist.

• Move the mandible to the various positions and look for any
interference.

a. Midline interferences: Midline interferences are present

in canines and/or first molar. The procedure of grinding
and the changes produced in primary cuspid and molar
are depicted in Fig. 26.1.

b. Anterior mandibular displacement:

• In this, the patient closes from rest position to initial contact

position.

• There is premature contact in the initial contact position

usually due to lingually placed maxillary lateral incisors
(Fig. 26.2).

• Condyle slides forward and the labioincisal margin of the

maxillary incisors glides down the lingual surface of the
mandibular incisor.

• By bevelling the labioincisal surface and the lingual incisal of

the maxillary incisors, a correct overjet can be established
(Fig. 26.3).

• This procedure is indicated only in cases with functional

shift and not in true class III.

c. Crossbite conditions:
• Tooth guidance sometimes guides the mandible laterally
also in the initial contact position.

• Prolonged thumb sucking leads to this condition.

• Initial elimination of the crossbite should be attempted.

• Judicial grinding can guide the tooth into normal position.

• The entire ground teeth surface should be coated with

topical fluoride.

d. Anteroposterior correction of functional malocclusion:

Occlusal grinding for anteroposterior correction is
depicted in Fig. 26.4.
2. Occlusal equilibration in mixed dentition

• Occlusal equilibration of the primary teeth only should be

done during mixed dentition stage.

• If the permanent teeth are abnormally positioned, they

should be moved to correct position with orthodontic
appliances.
3. Occlusal equilibration in the permanent dentition

The reasons for doing occlusal equilibration in permanent

teeth:

• Stabilization of corrected occlusion

• To provide favourable functional environment

• To minimize occlusal slides

Technique:

• In premature contact in the retruded contact, the opposing

groove or incline should be grounded, if the cuspal
interference is present in one position.

• When cuspal interference is present in more than one

position, the premature cusp should be grounded.

• A forward shift should be treated by grinding the interfering

mesioincisal incline of the upper teeth or the disto-occlusal
incline of the lower teeth.

• Lateral shift into occlusion should be corrected by widening

the central fossa.

FIG. 26.1. (A) Primary cuspid and (B) primary molar.

 FIG. 26.2. Premature initial contact.

FIG. 26.3. After occlusal equilibration.

FIG. 26.4. (A) Primary cuspid and (B) primary molars.
Management of developing anterior
crossbite/tongue blade therapy
➤ Sometimes the upper incisors erupt lingually and develop into a crossbite.

➤ This developing crossbite should be corrected before full-fledged crossbite occurs.

➤ Tongue blade therapy can be used to correct a developing crossbite.

Prerequisites for tongue blade therapy

➤ Children who are cooperative.

➤ There should be adequate space for the tooth in crossbite to be moved.

➤ Children with proper guidance and encouragement at home.

Procedure (fig. 26.5)

➤ The patient and the parents are instructed the method of using the tongue blade.

➤ Child is asked to place one portion of the tongue blade behind the in-locked tooth.

➤ The other portion of the tongue blade rests on the mandibular incisors or chin as
fulcrum.

➤ The tongue blade acts as a lever.

➤ The oral portion of the tongue blade is pressed or pushed upward and forward to
engage the lingual surface of the in-blocked tooth.

➤ Patient is asked to bite with constant force for about an hour or two daily for 14 days.

➤ This exercise may be advised during television time.

➤ The width of the tongue blade should be just that of the width of the malposed tooth.

➤ Wooden blades of the ice-cream bars are also used for this method.
 FIG. 26.5. Tongue blade therapy.

Contraindications of tongue blade

➤ Tongue blade therapy is less effective, if the tooth is fully erupted.

➤ Not effective in deep bite cases.

Incipient malocclusions
➤ Conditions which show a tendency to or which may develop into malocclusions are
called incipient malocclusions.

➤ Incipient malocclusions require interceptive procedure to prevent development of

malocclusion.

➤ Incipient malocclusions include:

• Occlusal prematurities which can lead to functional class II,

functional class III or crossbites.

• Dentofacial habits which can lead to malocclusions.

• Space loss due to movement of teeth.

• Deficiencies of growth and malrelationship of jaws.

• Premature loss of deciduous teeth.

• Prolonged retention of deciduous teeth.

• Developing crowding.

• Rotated or malposed tooth.

• Dental caries interfering with occlusion and mesiodistal

width of teeth.
Classification of deleterious dentofacial habits
All habits are learned patterns of muscle contractions of a very complex nature.
Habit can be defined as actions, which have become automatic or characteristic by repetition.
Another definition: Habit is an act which gets fixed to an individual due to constant
repetition.

The various deleterious oral habits are (i) thumb sucking and finger sucking, (ii)
tongue thrusting, (iii) mouth breathing, (iv) lip sucking and lip biting, (v) nail biting,
(vi) postural habits, (vii) bruxism, (viii) masochistic habits and (ix) frenum thrusting.
Thumb sucking
Introduction
Thumb sucking can be defined as the repeated forceful sucking of the thumb with associated
strong buccal and lip contractions.

➤ Digit sucking and pacifier sucking are the most common oral habits occurring at
some point of time in the majority of children.

➤ Most finger sucking habits begin very early in life.

➤ Thumb sucking in a child causes great concern in the minds of parents.

➤ The incidence of thumb sucking ranges from 16 to 45%.

Aetiology of thumb and finger sucking

The time of occurrence of digit sucking is significant. Accordingly, there are two types
of digit sucking, nutritive and non-nutritive sucking.

1. Nutritive sucking – appears during the very first weeks of life and is due to feeding
problems.

2. Non-nutritive digit sucking – due to various psychological reasons. Sucking could be

related to hunger, satisfying the sucking instinct, due to feeling of insecurity, desire to
attract attention.

Various psychological theories have tried to explain the cause

for thumb sucking. Most important theories are as follows:

1. Freudian theory: According to Sigmund Freud, during

the oral stage of development, oral cavity is the primary
zone of pleasure apart from taking nourishment.

• Therefore, thumb sucking has the objective of nursing or

nourishment.

• Freud says that attempts to stop the thumb-sucking habits

will lead to other habits.
 2. Oral drive theory (Sears RR and Wise GW): Sears and
Wise state that thumb sucking is not because of weaning
of feeding.

• Thumb sucking is the result of the prolonged drive for

suckling or nursing.

• They further stated that sucking increases the erratogenesis

of the mouth.

3. Benjamin theory: This theory attributes thumb sucking to

following reasons.

• Thumb sucking is an expression of the need to suck because

of the association with reinforcing aspect of suckling or
feeding.

• Another reason for thumb sucking is because of the rooting

and placing reflexes common to all mammals.

During infancy, the child will have a tendency to place the

objects in the mouth. It is maximum during 3 months of age
and gradually disappears by 7–8 months.

4. Learning theory: This theory states that thumb sucking is

associated with unrestricted or prolonged nutritive
sucking.

Pathogenesis
The mechanism by which digit sucking produces the various effects is shown in the
flowchart (Fig. 26.6).

➤ Children who sleep in the night with thumb or finger between the teeth can get
significant malocclusion due to the pressure produced by sleep of 6 hours or more.
➤ The type of malocclusion that develops is dependent on a number of factors like:

• Position of the digit.

• Associated orofacial muscle contractions.

• Position of the mandible during sucking.

• Duration, degree and intensity of sucking (trident of factors).

• Skeletal morphology.

FIG. 26.6. Pathogenesis of thumb sucking.

Clinical features
➤ Protraction of the maxillary anterior teeth.

➤ Mandibular postural retraction, if the weight of the hand forces the mandible into a
retruded position.

➤ Lingual tipping of mandibular incisors.

➤ Development of anterior open bite.

➤ Because of anterior open bite, associated simple tongue thrust.

➤ Narrowing of the maxillary arch due to contraction of cheek muscles.

➤ High palatal vault.

➤ Hypotonic upper lip

➤ Hypertonic lower lip.

Diagnosis
Diagnosis is based primarily on the history and clinical findings.

➤ Children or parents give definite history of thumb sucking.

➤ Feeding habits of the child should be asked for.

➤ Parental care of the child.

➤ Apart from the clinical findings, the child’s fingers and nails should be examined.

➤ Presence of callus in the finger used for sucking is a diagnostic feature.

➤ Children with digit sucking will have clean fingers.

Principles of management of thumb sucking

Treatment plan for a child with thumb sucking is depicted in Fig. 26.7.
 FIG. 26.7. Treatment plan for thumb sucking.

Basic considerations
➤ The rationale in treating thumb sucking must be physiologic and not mechanical.

➤ Treatment should aim to alter the afferent arm of the neuromuscular response.

➤ The appliance should not exert force; it should aim for muscle relearning.

➤ The treatment can be studied under the three distinct phases of development.

Phase I (normal and subclinically significant sucking)

➤ This phase extends from birth of the child to about 3 years of age.

➤ Many infants develop the thumb sucking during this stage.

➤ Usually, this sucking resolves by itself at the end of phase I.

➤ If the child shows any signs of malocclusion, prophylactic approaches can be made.

➤ Child can be treated by use of pacifier or with medicaments like asafoetida, neem
and pepper.
Phase II (clinically significant sucking)
➤ The second phase extends from 3 years of age to 7 years.

➤ A firm and definite plan of correction is required.

➤ Psychological counselling and appliances can be used.

Phase III (intractable sucking)

➤ Thumb sucking present after fourth year of life poses problem for the patient.

➤ Treatment should be twofold, psychotherapy and appliances.

Methods of correction
1. Psychological approach

The simplest approach to habit therapy is a discussion

between the child and dentist.

• This is most effective in older children.

• No threats or shaming should be used.

• A calm and friendly attempt should be made to educate the

child about the ill effects of the habit.

• Child may be shown photographs or study casts of children

who had the deleterious sucking habits.

• Cards can be given to children for scoring each morning to

indicate whether the thumb was sucked during night. This
produces good result.

Dunlap’s beta hypothesis:

• Knight Dunlap put forward beta hypothesis.

• According to this hypothesis, conscious purposeful
repetition is the best way to discontinue a habit.

• The child is made to sit in front of a large mirror and asked

to suck his/her finger, seeing him/her in the mirror.

• This procedure has proved effective in many children.

Audiovisual aids: These are used for explaining the effects of

thumb sucking.
2. Reminder therapy

• This method is effective for the child who wants to quit but
requires help.

• One of the simplest methods is to secure an adhesive

bandage with waterproof tape on the finger that is sucked.

• Socks can be used.

• Medicaments like asafoetida, neem paste or pepper paste

can be used.

• An elastic bandage loosely wrapped around the elbow

prevents the arm from flexing and fingers from being
sucked.
3. Reminder appliance or habit-breaking appliance

Ideal requirements of habit-breaking appliances:

• Appliance should offer no restraint to normal muscle

activity.
• It should not depend on patient’s cooperation.

• It should not have shame attached to its use.

• It should not involve patient’s parents.

Mechanism of action
➤ The appliance renders the habit meaningless by breaking the suction.

➤ Appliance prevents the finger pressure from displacing the incisors.

➤ Appliance re-educates the tongue to its normal posture and thereby the maxillary
constriction is prevented.

Removable appliances: These consist of upper Hawley

appliance with tongue spikes or cribs placed between the
canines.

Fixed re-education appliances (Fig. 26.8): This is an effective

means of stopping the habit.
➤ The assemblage consists of loops and spurs formed by 0.40″ wire bent at 45° to the
occlusal plane and soldered to the bands or crowns in second deciduous molar.

➤ Check-up appointments are made at 3–4 weeks.

➤ Habit appliances are worn for 4–6 months in most of the cases.

➤ Quad helix appliances can also be used as reminder appliance.

 FIG. 26.8. Fixed re-education appliance.

Blue grass appliance

➤ This appliance was introduced by Haskell, BS and Mink, JR.

➤ Six rollers made from Teflon are incorporated into a stainless steel wire and soldered
to molar bands.

➤ Patient is instructed to turn the roller whenever he/she feels like sucking the finger.

➤ Appliance is worn for 3–6 months.

Tongue thrusting
Tongue thrusting is described as a condition wherein during swallowing the tongue contacts
with teeth in the anterior region.

I. Classification of tongue thrusting

1. Moyer’s classification

• Simple tongue thrusting

• Complex thrusting

• Retained infantile swallow

2. According to area of tongue thrusting

• Anterior tongue thrust

• Lateral tongue thrust

3. According to Bahr and Holt

• Tongue thrust without deformation

• Tongue thrust causing anterior deformation (anterior open

bite)

• Tongue thrust causing buccal deformation (posterior open

bite)

• Combined tongue thrust causing both anterior and posterior

open bites
II. Aetiology of tongue thrusting
• Tongue thrusting is a residuum of thumb sucking habit.

• Tongue thrusting itself will develop as a habit.

• Tongue thrusting develops due to chronic tonsillitis or

pharyngitis.

• Continuous bottle-feeding.

• Neuromuscular problems can lead to tongue thrust patterns.

• Persistence of retained infantile swallow.

• Presence of macroglossia might contribute to tongue thrust.

III. Simple tongue thrusting

• Simple tongue thrusting is also called teeth-together

swallow.

• Associated with well-circumscribed open bite in the anterior

region.

• During swallowing, there is normal contact in the posterior

region.

• Posterior teeth show good intercuspation.

• Tongue is placed forwards to help anterior lip seal.

• Hyperactive mentalis activity will be present.

• Labioversion of maxillary incisors will be seen.

Treatment:
• If there is excessive labioversion, the teeth have to be
retracted first, if it is a case of simple tongue thrusting.

• Swallowing exercises should be taught to the patients.

1. Swallowing exercises/tongue exercise

Patient is instructed to place the tongue tip on the palate, close

the teeth, close the lips and then asked to swallow. This
tongue exercise should be done 40 times a day.

Small orthodontic elastics are held upon the tongue tip against
the palate during swallowing. If the swallow is correct,
patient will be able to hold the elastic. Otherwise the elastic
falls or will be swallowed.

2. Transferring to subconscious level

• Once the new swallowing pattern is learned, it has to be

reinforced to subconscious level.

• Flat, sugarless fruit drops are used to reinforce the

unconscious swallow.

• Patient is instructed to place the fruit drop against the palate

until the candy is dissolved. Initially, patients will be able to
hold the candy for few seconds only, but gradually the time
will increase.

3. A well-adapted fixed tongue spikes

• This can be inserted as the last step in treating simple tongue

thrust.
IV. Complex tongue thrusting

• Complex tongue thrusting is defined as tongue thrust with teeth

apart swallow.

• There are two important diagnostic features:

i. There is generalized open bite.

ii. Poor occlusal fit which leads into sliding occlusion.

• There is no definite occlusal intercuspation.

• The prognosis for correction of complex tongue thrusting is

not as good as simple tongue thrusting.

• In complex tongue thrusting, the mandible is not stabilized

by the elevator muscles.

Treatment:

• Preliminary step is the tongue exercises and habit-breaking

appliances.

• Correction of malocclusion follows later.

V. Retained infantile swallow

Infants consume food by suckling. This is an automatic reflex

in human beings.

• In infants, suckling and swallowing proceed together.

• In suckle–swallow reflex, there is:

 1. Caving in of the cheeks

2. Bobbing of the hyoid bone

3. Tongue elongated

4. Head extended

5. Anterior mandibular thrust

6. Lips pursed around the nipple

Robert E Moyers lists the features of the infantile swallow as:

• Jaws are apart with the tongue placed between the gum
pads.

• Mandible is positioned by muscles of the facial expression.

• Swallow is guided by the lips and tongue.

With the change in food from liquid to semisolid and the

eruption of teeth, there is a change in swallowing pattern
also.

• Little is known about the exact aetiology of this severe

problem.

• Prognosis for this condition is poor.

VI. Habit-breaking appliance (see Fig. 26.8)

• Tongue-thrusting appliance tends to force the tongue

downward and backward during swallowing.
• Tongue-thrusting appliance acts by two important ways:

i. Eliminates or reduces the anterior thrust and plunger-like

action during swallowing.

ii. Re-educate the tongue posture.

• The fixed tongue spikes are fabricated with 0.040 inch

stainless steel alloy. It is V-shaped with 3 or 4 projections
which extend up to the cingulum of lower incisors soldered
to the molar bands or crowns.

• The wire acts as a picket fence preventing or limiting the

tongue.

• The optimum age for placement of fixed tongue crib is

between 5 and 10 years.

• Modified tongue crib: In patients with lateral tongue thrusting,

modified tongue crib is used.
Management of lip biting and lip sucking
➤ Lip biting and lip sucking are seen usually in cases with excessive overjet.

➤ Lip biting involves cushioning the lower lip against the palatal surfaces of maxillary
incisors.

➤ Indirect pressure is delivered to the labial surface of mandibular incisors.

➤ Because of this, the maxillary incisors are flared forward and mandibular incisors
move lingually, increasing the overjet.

➤ Lower lip becomes hypertrophied.

➤ Associated hyperactive mentalis activity is seen.

Treatment (fig. 26.9)

➤ Lip bumpers are used when there is problem in the upper or lower lip.

➤ Appliance prevents the hyperactivity of the mentalis muscles in the same way as lip
shields or vestibular screen.

➤ Lip bumper prevents the abnormal force from acting on the incisors.

➤ The other effect of lip bumper is that it causes proclination of the incisors,
distalization of molars (Fig. 26.10).
 FIG. 26.9. Lip bumper appliance.

FIG. 26.10. Mechanism of action of lip bumper.

Bruxism
Synonyms: Stridor dentium, occlusal neurosis
Bruxism can be defined as the nonfunctional grinding or gnashing of teeth.

➤ It is a type of parafunctional movement of the mandible.

➤ Bruxism usually occurs at night and if continuous for a prolonged period causes
abrasion of primary and permanent teeth.

Aetiology
➤ Occlusal interferences may trigger bruxism.

➤ Bruxism may be associated with nervous tension.

➤ Discrepancy between centric relation (CR) and centric occlusion (CO) may cause
bruxism.

Features of bruxism
➤ Results in increased wear of the affected teeth.

➤ Teeth exhibit flattened occlusal facets which fit precisely into the opposing teeth.

➤ Bruxers exhibit high occlusal forces, hence fracture of restoration and teeth are
possible.

➤ When the habit is continued into adulthood, it results in periodontal disease.

➤ It can result in temporomandibular joint disturbances.

➤ Muscle tenderness can be elicited.

➤ Mobility of teeth in the morning when the patient gets up.

Investigations
➤ Articulating papers to assess the occlusal prematurities.

➤ Extraoral radiographs to assess temporo-mandibular joint.

➤ Intraoral radiograph to assess periodontal status.

➤ Electromyography (EMG) to assess muscles of mastication.

Treatment
➤ Relieving of emotional disturbance – by way of psychological counselling,
anxiolytics and massage.

➤ Relieving of occlusal discrepancy – occlusal equilibration should be the first step or

approach to treatment.

➤ Construction of palatal bite plane. This unloads the condyle and causes
supraeruption of attrited molars.

➤ Plastic bite guards or splints to cover the occlusal surfaces can be given. The occlusal
surfaces of the bite guard should be flat.

➤ Mouth guard sometimes helps in bruxism.

Mouth breathing and its management
Introduction
➤ Mouth breathing or interference with nasal respiration leads to changes in the
craniofacial growth and position of teeth.

➤ Mouth breathing has been defined by Sassouni V as the habitual respiration through the
mouth instead of nose.

➤ Continuous mouth breathing is quite rare in children.

➤ Mouth breathers are those who breathe orally even in relaxed and restful conditions.

➤ Nasal breathers, on the other hand, breathe through nose in rest conditions and
through mouth during exercise or running.

Classification of mouth breathers

➤ Anatomic mouth breathers: Short upper lip prevents complete closure without
effort.

➤ Obstructive mouth breathers: Children who have increased resistance to the normal
flow of air through the nose.

➤ Habitual mouth breathers: Children who breathe through mouth by way of habit.

Aetiology of mouth breathing

1. Obstructive causes like:

a. Hypertrophied turbinate due to allergy, rhinitis and

chronic infection of nasal mucosa.

b. Deviated nasal septum.

c. Enlarged adenoids.

d. Nasal polyp.
 e. Upper respiratory infection.
2. Anatomic causes like:

a. Short upper lip

b. Underdeveloped nasal cavity

3. Ectomorphic individuals are more prone for nasal obstruction

4. Obstructive sleep apnoea

5. Associated with other habits like thumb sucking

Pathogenesis of mouth breathing–compression theory

Mouth breathing causes typical adenoid facies, long face with open bite.

Clinical features
The different morphologic features associated with mouth breathing have been
described in many terms. They are:

➤ Respiratory obstruction syndrome

➤ Adenoid facies

➤ Long face syndrome

➤ Vertical maxillary excess

Facial features associated with mouth breathing are:
➤ Excessive anterior facial height

➤ Narrow face

➤ Incompetent lip posture with lip trap

➤ Protruded maxillary teeth

➤ Widely flared external nares

➤ Constricted maxillary arch

➤ Posterior dental crossbite

➤ High palatal vault

➤ Steep mandibular plane

➤ Supraeruption of posterior teeth

➤ Open bite

➤ Extended head posture

➤ Forward inclination of cervical column

➤ Marginal gingivitis in the anterior region

Investigations
1. History: Patient’s parents usually give history of the child sleeping with mouth open.

2. Study the patient’s breathing without informing the patient: Nasal breathers lips will
contact during relaxed breathing. Mouth breathers keep the lips apart.

3. Ask the patient to take deep breath: Many respond by inspiring through mouth. Nasal
breather will inspire through nose with lips closed.

4. Ask the patient to close the lips and take deep breath: Nasal breathers demonstrate good
reflex control of the alar muscles, there is dilation of the external nares on inspiration.
Mouth breathers, even if they are capable of breathing through nose, do not change the
size or shape of the external nares.

5. Clinical tests: Tests for mouth breathing are depicted in Table 26.1.
6. Cephalometry: It will help in finding out the size of the nasopharyngeal space, size of
adenoids and also the skeletal relationships.

7. Rhinomanometry: Rhinomanometry helps in measuring the quantity of airflow

through the nasal passage. In mouth breathers, it will be reduced.

Table 26.1.
Tests for mouth breathers

Tests Procedure
Visual Size, shape and activity of external nares are observed; alar muscles are inactive in oral respiration
examination
Mirror test Two-surfaced mirrors are used; in nasal breathers, upper surface will cloud; in mouth breather lower surface of the mirror will cloud
Butterfly test Use of cotton butterfly to assess nasal breathing
Water holding test Patient is asked to sit with mouthful of water for 2 min; mouth breathers will find it difficult to retain water as it interferes with oral
respiration

Treatment
1. Elimination of the cause

• The first step in the management of mouth breathing is to

rule out any obstruction in the nasal air passage.

• Patient should be referred to an ENT surgeon.

• Removal of nasal obstruction by medicine or surgery should

be attempted.

• Rapid maxillary expansion is found to increase the nasal air

passage and reduction in nasal air resistance.
2. Habit interception

• Deep respiratory efforts with the mouth closed and lips in

contact should be practised.

• Consists of – breathing exercises, lip exercises, oral screen – a

passive oral screen is used to correct habitual mouth
breather. Breathing holes are placed first, which are closed
 gradually.
3. Symptomatic treatment or correction of malocclusion

• Mechanical appliances are used to correct the malocclusion.

• Functional appliances, like activator, also can be used. Care

should be taken not to increase the mandibular plane angle.
Space regainers/active space maintainers
➤ Potential space problems can be created by drift of permanent molars or incisors
after early loss of primary canines or molars.

➤ The space lost can be gained by the use of active space maintainers or space
regainers.

➤ Once the lost space is regained, it has to be maintained by a regular space maintainer.

➤ Amount of space that can be regained is usually about 2 mm per quadrant, if

bilateral.

➤ If there is unilateral space loss, 3 mm of space regaining can be achieved.

Indications
➤ Space regaining is required when primary maxillary or mandibular second molars
are lost prematurely.

➤ When there is ectopic eruption of the permanent first molar.

➤ Space regaining is indicated after early loss of primary mandibular canine, as the
space gets closed due to distal drift or lingual drift of incisors.

Types of space regainers

Removable space regainers
➤ Removable appliance with finger spring

➤ Removable lingual arch

➤ Knee spring

➤ Split saddle regainer

➤ Space regaining with expansion screws

Fixed space regainers

➤ Open coil space regainer

➤ Gerber space regainer

➤ Lingual arch

➤ Lip bumpers

➤ Headgears

➤ Fixed intra-arch appliances

Space regaining in the maxillary arch

➤ Space regaining is easier in maxilla when compared to mandible.

➤ If the space loss is due to mesial tipping and less than 3 mm, removable appliances
can be used to regain the space lost.

➤ Removable appliances used in maxillary arch for space regaining are (i) finger
springs, (ii) knee spring (Fig. 26.11), (iii) split saddle regainer and (iv) expansion
screw.

➤ If the space loss is more than 3 mm or when bodily movement is required, fixed
appliances can be used.

➤ The fixed space regainers or active fixed space maintainers used in maxilla are (i)
open coil spring, (ii) Gerber space regainers, (iii) headgear and (iv) fixed intra-arch
appliance.

FIG. 26.11. Knee spring.

Space regaining in the mandibular arch

➤ Removable appliances offer less result in mandibular arch and, therefore, are not
much used.

➤ Only removable lingual arch produces good results, that too for unilateral cases.

➤ Lip bumper produces good amount of space regaining.

➤ Other appliances used are coil spring space regainers, and Gerber space regainer.

Description of some of the space regainers

1. Gerber space regainer

• This is an active fixed space maintainer or fixed space

regainer (Fig. 26.12).

• This appliance is fabricated directly in the patient’s mouth or

in the laboratory.

• A preformed orthodontic band is selected for the abutment

tooth and fitted.

• A U-assembly is either soldered or welded to the band.

• A wire of U-shape which fits into the assembly is fabricated

with or without coil springs.

• With coil spring: If the appliance is used as a spring-loaded

space regainer, open coil springs are placed between the
tube and tube slope. The length of the coil spring is 1–2 mm
more than the existing length. This activates the spring.

• Without spring: The wire U-section is fitted in the tube,

appliance placed and wire section extended to contact the
tooth mesial to the edentulous area. Assembly is removed
and welded or soldered at this point. Occlusal rests are
added to reduce cantilever effect.
2. Open coil spring (Fig. 26.13)

• Band is fabricated for first permanent molar.

• Buccal and lingual tubes are welded to the molar band.

• Impression along with band is recorded and model poured.

• A U-shaped wire is adapted which fits passively in both the

lingual and buccal tubes.

• Stops are placed at the junction of the straight and curved

part of U-wire.

• Open coil spring is cut from the stop to the point about 2
mm distal to the mesial end of the buccal tubes.

• Band with the tube is taken out of model.

• The coil springs are inserted into the U-shaped wire.

• The whole assembly of bands with the wire and coil spring
is ready.

• Molar bands are cemented using luting cement.

• The compressed coil spring exerts reciprocal force mesially

to premolars and distally to molars.
 FIG. 26.12. Gerber space regainers.

FIG. 26.13. Open coil spring–steps in fabrication.

Serial extraction/guidance of eruption
Introduction
➤ Serial extraction is a procedure, where, in order to encourage the spontaneous
alignment of crowded teeth, the timely removal of certain deciduous and permanent
teeth is undertaken.

➤ The concept of serial extraction was introduced by Robert Bunon (1743).

➤ The word serial extraction was coined by Birger Kjellgren (1929).

➤ Nance HN is called the ‘father of serial extraction’ because he popularized the

technique.

➤ Hotz R renamed the technique as ‘guidance of eruption’.

Definition
Serial extraction is defined as the planned and sequential extraction of certain deciduous teeth
followed by removal of specific permanent teeth in order to encourage the spontaneous correction
of irregularities.

Rationale of serial extraction

➤ Dental crowding is the result of inadequate arch size. Serial extraction aims to correct
this discrepancy by reducing the tooth material.

➤ Physiological tooth movement or drifting occurs at the time and site of extraction.
Teeth move both mesially and drift distally. This principle is being utilized in serial
extraction for self-correction.

➤ The normal growth of dental, skeletal and soft tissue influences the result of serial
extraction.

Benefits of serial extraction

➤ Serial extraction guides or encourages eruption of permanent teeth in a favourable
position.

➤ Reduces malposition of individual teeth.

➤ Avoids loss of labial alveolar bone.

➤ Reduces treatment time when active orthodontic treatment is required.

Factors to be taken into consideration

➤ Relationship of the mesiodistal diameter of deciduous dentition and permanent
dentition is the most important factor to be considered.

➤ Direction of growth: Indicated in normal class I skeletal base.

➤ Shape of the dental arch.

➤ Size of the teeth.

➤ Relation of the tooth crowns to the alveolar crest and to the adjacent teeth should be
evaluated.

Indications
➤ Class I malocclusion with space discrepancy (10 mm or more).

➤ Lingual eruption of the lateral incisor.

➤ Midline shift due to displacement of lateral incisor.

➤ Premature loss of primary canine.

➤ Crowding associated with proclination.

➤ Labially placed but unerupted permanent canine.

➤ Extreme labial displacement of mandibular incisors.

➤ Gingival recession of labially placed incisors.

➤ Absence of developmental spacing in the primary dentition.

➤ Aberrant eruption pattern of permanent teeth.

Contraindications
➤ Class I malocclusion with minimal arch size tooth size discrepancy

➤ Class II division 2

➤ Skeletal class III

➤ Class III

➤ Partial anodontia or missing teeth

➤ Presence of midline diastema

➤ Presence of deep overbite

➤ Presence of open bite

➤ When there is collapsed arch

➤ In cleft lip and palate cases

Investigations
➤ Clinical examination

➤ Study model analysis – mixed dentition analysis

➤ Radiographs:

• Intraoral periapical radiograph (IOPA)

• Panoramic radiograph (OPG)

• Cephalogram
➤ Photographs

Treatment procedure
Dewel’s method (extraction of CD4): Dewel’s methods consist of three stages: (i) Early
extraction of deciduous canine, (ii) extraction of deciduous first molars and (iii)
extraction of first premolar.

Removal of deciduous canines (fig. 26.14)

Purpose of extraction:

➤ Permit the eruption and optimal alignment of the lateral incisors.

➤ Improvement in position of central incisors also can be expected.

➤ Prevents lingual eruption of the lateral incisors into a crossbite.

➤ Correct positioning of lateral incisor prevents mesial migration of permanent canine.

FIG. 26.14. Removal of deciduous canine facilitates proper alignment of lateral incisor.

Age of extraction: Removed between 8 and 9 years of age.

Removal of first deciduous molars (fig. 26.15)

Purpose of extraction:

➤ To accelerate the eruption of the first premolar ahead of canine.

➤ Sometimes along with extraction of first deciduous molar, enucleation of first

premolar is done.
 FIG. 26.15. Deciduous first molars removal.

Time of extraction:

➤ Twelve months after extraction of deciduous canines.

➤ Approximately between 9 and 10 years of age.

Removal of erupting first premolars (fig. 26.16)

➤ Before extraction, radiographs should be taken to confirm the presence of third
molars.

Purpose of extraction:

➤ To allow the canine to drop distally into the space created by extraction of first
premolar.
 FIG. 26.16. Erupting first premolar’s removal guides canine into good position.

Tweed’s technique (extraction of D4C)

➤ At 8 years of age: All four deciduous first molars are extracted. This is done to hasten
the eruption of first premolars. Extractions of first premolars are done when their
eruption is about the level of crest of the alveolar bone. Deciduous canines are also
extracted at about the same time as extraction of first premolar.

➤ Nance method: This method is similar to Tweed’s method.

Disadvantages of serial extraction

➤ This is not a definitive treatment. Often treatment continuous with fixed appliance
mechanotherapy.

➤ Deepening of bite occurs.

➤ Ditching of teeth occurs, i.e. distoaxial inclination of canines and mesial inclination of
second premolar takes place.

➤ Difficult to bring the impacted canine into position with serial extraction alone.

➤ Not suitable for skeletal cases.

➤ Requires prolonged patient follow-up.

ACCESSORY POINTS
➤ Bruxism is also called stridor dentium.

➤ Tongue blade therapy is contraindicated, if the tooth is fully erupted.

➤ Onychophagy is the other name for nail biting.

➤ Trident of factors for the severity of malocclusion due to habits is duration, degree and
intensity of sucking.

➤ Rooting and placing reflexes as cause for thumb sucking was stated by Benjamin LS.

➤ Muscles are called the living orthodontic appliances by Roger AP.

➤ The concept of serial extraction was introduced by Robert Bunon (1743).

➤ The word serial extraction was coined by Kjellgren B (1929).

➤ Nance HN is called the ‘father of serial extraction’ because he popularized the

technique.

➤ Hotz R renamed the serial extraction technique as ‘guidance of eruption’.

➤ Correction of developing crossbite is an example for interceptive orthodontics.

➤ In Dewel’s method of serial extraction, the order of extraction of various teeth is CD4.

➤ In Tweed’s method of serial extraction, the order of extraction of various teeth is

D4C.

➤ Serial extraction is best indicated in class I skeletal malocclusion with tooth size and arch
size discrepancy of about 10 mm.

➤ Beta hypothesis is used in the treatment of thumb sucking.

➤ A person with mouth breathing and long face will have high FMA (Frankfurt
mandibular angle)

➤ Habits that have acquired a fixation in child and the child practices the habit when
security is threatened is called compulsive habits.

Advanced Learning
Muscle exercises
➤ The teeth and supporting structures are constantly under the influence of the
surrounding musculature.
➤ Buccinator mechanism and tongue hold the teeth and the supporting structure in a
state of equilibrium.

➤ Any imbalance in the equilibrium alters the balance and leads to malocclusion.

➤ Muscle exercises help to intercept aberrant muscle activity and the resultant
malocclusion.

➤ Roger called muscles as living orthodontic appliances.

➤ The various muscle exercises are as follows:

1. Exercise for lips ( Fig. 26.17A)

Upper lip (Fig. 26.17B):

FIG. 26.17. (A) Habitual posture, (B) exercise for upper lip and (C) exercise for upper and
lower lips.

• Hypotonicity and flaccidity are the most common problems.

• Child is instructed to extend the upper lip as far as possible,

curving the vermilion border under the upper incisors.

• Exercises are done for 15–30 min for 4 to 5 months.

Upper and lower lips (Fig. 26.17C):

• Upper lip is first extended over the incisors first.

• Lower lip is placed against the extended upper lip and

pressed hard against the upper lip.

• This exercise helps to retract the proclined maxillary

incisors.

• It also helps to increase the tonicity of upper and lower lips.

Orbicularis oris:

• Place a piece of paper between the lips and hold it for some
time.

• Take a large sip of water. Ask the patient to expel the water
through the interproximal spaces into the lip fold and then
back into lingual fold.

• Place a threaded button behind the lips and pull the thread
outside. Using lip pressure, the button should be prevented
from coming out.
2. Exercise for masticatory muscles

• Patient is asked to clench the teeth repeatedly. It causes the

alternate contraction and relaxation of masseter and
temporalis muscles.
3. Exercise for mouth breather

• Deep respiratory efforts with the mouth closed and lips in

contact are advised.
4. Exercise for retrognathic mandible
• Repeated positioning of mandibular incisors anterior to
maxillary incisors is recommended.
5. Exercise for tongue thrusting correction

a. Swallowing exercises/tongue exercise

• Patient is instructed to place the tongue tip on the palate,

close the teeth, close the lips, then asked to swallow.

• This tongue exercise should be done 40 times a day.

• Small orthodontic elastics are held upon the tongue tip

against the palate during swallowing. If the swallow is
correct, patient will be able to hold the elastic. Otherwise the
elastic falls or will be swallowed.

b. Transferring to subconscious level

• Once the new swallowing pattern is learned, it has to be

reinforced to subconscious level.

• Flat, sugarless fruit drops are used to reinforce the

unconscious swallow.

• Patient is instructed to place the fruit drop against the palate

until the candy is dissolved. Initially, patients will be able to
hold the candy for few seconds only, but gradually the time
will increase.

Interception of malocclusion
The interceptive method of treatment for various skeletal malocclusions is depicted in
Table 26.2.

Table 26.2.
Malocclusion–treatment

Type of malocclusion Treatment

Class II due to retrognathic mandible Functional appliances
Class II due to prognathic maxilla Maxillary intrusion splints; headgears
Class II due to combination of retrognathic mandible and prognathic maxilla Combined functional appliances with headgears
Class III due to retrognathic maxilla Functional appliances; reverse-pull headgear
Class III due to prognathic mandible Chin cup
Class III due to combination of retrognathic maxilla and prognathic mandible Reverse-pull headgear

Invisalign
➤ The Invisalign system is developed by Align technology.

➤ The advantage of Invisalign is to perform tooth movements with a clear and

removable system.

➤ Though it has been recommended for interceptive and corrective orthodontic

treatment, the response to interceptive treatment seems to be encouraging.

Procedure
The fabrication of Invisalign is as follows:

➤ An accurate rubber base impression of the patient (polyvinyl siloxane), along with
the radiographs, photographs and treatment plan, is sent to the laboratory.

➤ After checking the accuracy of impression, the impression is scanned using

computed tomography and a highly accurate three-dimensional digital model is
made.

➤ Virtual correction of the malocclusion based on orthodontic treatment plan is

generated by technicians. This is then reviewed by the orthodontist. ‘Clincheck’ is the
name given for this process.

➤ After final approval, the treatment is divided into sequence of algorithmic stages.
Each stage can perform a maximum tooth movement of 0.25 mm per appliance.

➤ Subsequently, models are made by the computer for each stage. This process is called
‘stereolithography’.

➤ From these computer-generated models, individual Invisalign appliances are

fabricated.

Treatment protocol
➤ Each appliance produces only 0.25 mm of tooth movement.

➤ Hence, as many as 25–30 appliances may be needed for one particular patient.
➤ Patients are instructed to wear the appliances 24 h and should be removed only for
toothbrushing and eating.

➤ Interproximal slicing may be done to obtain space for mild to moderate crowding.

Disadvantage
➤ Highly expensive.

➤ Ability to perform complex tooth movement has to be studied.

SECTION IX
Surgical Considerations in Orthodontics
OUTLINE

27. Surgical orthodontics

28. Cleft lip and palate

CHAPTER 27
Surgical orthodontics

CHAPTER OUTLINE
❖ Various surgical orthodontic procedures
❖ Minor oral surgical procedures in relation to orthodontics
❖ Frenectomy
❖ Surgical exposure of impacted canine
❖ Pericision
❖ Corticotomy
❖ Transpositioning of teeth/autotranspositioning/surgical repositioning of teeth
❖ Dentofacial deformities and their management by orthognathic surgery
❖ Diagnosis and treatment planning in surgical orthodontics
❖ Presurgical and postsurgical orthodontics
❖ Model surgery
❖ Surgical procedures for mandibular prognathism and maxillary retrusion/skeletal
class III correction
❖ Surgical correction of receding chin/deficient chin
❖ Surgical correction of class II malocclusion
❖ Surgical procedures for vertical malocclusion
❖ Timing of orthognathic surgery
❖ Therapeutic aids in surgical care
❖ Accessory points
❖ Advanced learning
❖ Distraction osteogenesis
❖ Implants in orthodontics
Various surgical orthodontic procedures
Definition
Surgical orthodontics denotes the surgical procedures that are carried out before, during or after
active orthodontic treatment. Surgical procedures can prevent or correct periodontal
problems, facilitate and hasten orthodontic treatment, reduce relapse, add to
postorthodontic stability and improve aesthetics and function for the patients.
The various surgical orthodontic procedures can be studied under two headings.
They are:
Minor surgical procedures Major surgical procedures
1. Frenectomy 1. Resections/orthognathic surgeries
2. Surgical exposure of impacted tooth 2. Cosmetic surgeries
3. Pericision 3. Cleft lip and palate surgery
4. Corticotomy 4. Surgically assisted rapid maxillary expansion
5. Transpositioning of teeth 5. Distraction osteogenesis
6. Removal of soft tissue barrier
7. Extractions
a. Therapeutic extractions
b. Serial extractions
c. Removal of supernumerary tooth
d. Removal of fractured roots
e. Removal of impacted tooth
f. Removal of grossly mutilated tooth
8. Removal of cysts and odontomes
9. Orthodontic implants
Minor oral surgical procedures in relation to
orthodontics
Frenectomy
Maxillary midline frenum, mandibular labial frenum and lingual frenum might
contribute to orthodontic problem.

Maxillary midline frenum

➤ The presence of median diastema may be associated with a low attachment of the
labial frenum.

➤ Labial frenum may sometimes merge with the incisive papilla.

➤ Frenectomy is a surgical procedure designed to remove the entire frenum and if

required, the fibrous tissue present between the roots of the central incisors.

➤ A V-shaped radiographic appearance of the interproximal bone between the

maxillary central incisors is a diagnostic sign for high frenal attachment as the cause
for diastema.

➤ Frenectomy should be properly coordinated with orthodontic treatment.

➤ The timing of frenectomy is crucial.

➤ Frenectomy should be done at the end of space closure.

➤ If done so, the scar tissue formation during healing will stabilize the teeth in its
position.

➤ The most important aspect of frenectomy is removal of interdental fibrous tissue.

➤ Frenum should be excised and then sutured at a higher level (Fig. 27.1).
 FIG. 27.1. Frenectomy: (A) frontal view and (B) occlusal view.

Mandibular midline labial frenum

➤ A high attachment causes movement of the marginal gingiva and gingival recession.

➤ Therefore, frenectomy has to be done to prevent gingival recession.

➤ If gingival recession is present, reposition flap or free gingival graft is recommended

along with frenectomy.

Tight lingual frenum

➤ Tight lingual frenum with high attachment also contributes to diastema. This has to
be divided horizontally near the alveolar ridge and sutured vertically.
Surgical exposure of impacted canine
➤ Maxillary canine is impacted due to variety of reasons.

➤ Most common causes are:

1. Arch length discrepancy

2. Abnormal developmental position of the tooth germ

3. Deflection of canine during eruption

➤ Canine has got the longest path of eruption.

➤ When the maxillary canine is not erupted by 13 years of

age, the position of the tooth should be determined by
clinical inspection and radiographic localization.

Radiographic investigation
Intraoral periapical view radiograph: To locate whether the canine is labially or palatally
placed, tube shift technique or parallax can be employed (Fig. 27.2).
 FIG. 27.2. Tube shift technique.

Parallax method
➤ This method is frequently employed in orthodontic practice.

➤ One standard projection is taken and then the tube is shifted horizontally or
vertically.

➤ On each film, the image of root of lateral incisor and crown of canine will be seen.

➤ If the tooth is placed palatally, the image moves in the same direction as the X-ray
tube.

➤ If the tooth is labially placed, the image moves in the opposite direction as the X-ray
tube.

Occlusal view radiograph will also help in localizing the tooth. The following features
should be looked for in radiographs:

➤ Resorption of roots of incisors

➤ Cystic changes
➤ Dilacerations of roots

➤ Displacement of adjacent teeth

Methods of treatment
There are four possible methodologies of treatment.

1. Leave alone

If the canine is asymptomatic without evidence of any

infection or pathology, the tooth is left as such in a well-
aligned arch. Periodic annual review is necessary (Ericson S
and Kurol J, 1988).
2. Extract

• Tooth which is unfavourably positioned.

• Tooth showing signs of pathology.

• Tooth which causes resorption and displacement of adjacent

tooth should be extracted.
3. Only surgical exposure

Surgical exposure alone is indicated in the following

conditions:

• Favourably positioned canine with the apex close to normal

position.

• Unobstructed path of eruption.

• Availability of adequate room or space to accommodate the

canine.
• Tooth is not deeply placed.

• Tooth is well within the eruptive period.

4. Surgical exposure and orthodontic alignment (Ferguson JW, 1990)

Indications:

• Insufficient space available.

• Tooth requires proper positioning.

• Associated with other orthodontic problems.

Correction of unerupted tooth into proper position consists of

three stages: (i) Surgical exposure, (ii) method of attachment
and (iii) mechanical alignment.

Surgical exposure
When planning for guiding the eruption of canine, the most important aspect is that the
tooth should be made to erupt through the attached gingiva and not through alveolar
mucosa.

Labially placed tooth:

• Flap is raised from the crest of the alveolus and sutured.

• Tooth then erupts through the attached gingiva and normal contour is maintained.

Palatally placed tooth: Here the flap design is less critical.

Methods of attachment
➤ Placement of wire ligature around the neck of the tooth results in loss of periodontal
attachment, because the bone destroyed does not regenerate when the wire is
removed. This method is not preferable.

➤ Sometimes a hole is prepared in the crown of the exposed tooth and a pin or wire
inserted into it. This is connected to the main archwire.
➤ Best approach is to expose the crown and directly bond an attachment to the exposed
surface. Bonded attachments can be hooks, buttons, brackets or chains.

Mechanical approaches to align the unerupted tooth

This consists of two stages, namely presurgical and postsurgical.
Pre-surgical Post-surgical
Creation of space for the exposed tooth Nitinol wires to align the impacted tooth
Stabilization of the rest of the arch with heavy archwire Use auxiliary alignment springs to align the unerupted tooth, e.g. PG springs
Use of magnets
Pericision
This procedure is carried out to help minimize the extent of rotational relapse of teeth.
This method was developed by Edwards JG.
Synonyms: Supracrestal fibrotomy, circumferential supracrestal fibrotomy, sulcus
slice procedure, Edwards procedure.

Principle of the supracrestal fibrotomy surgery

➤ The main reason for relapse after orthodontic treatment is rebound of the network of
elastic supracrestal gingival fibres (Fig. 27.3).

➤ When the teeth move to new position, these fibres are stretched and remodelling of
these fibres takes a long time.

➤ Pericision involves elimination of the pull of elastic supracrestal gingival fibres by

sectioning these fibres.

➤ Teeth are held in the corrected position when the fibres heal, thereby reducing the
relapse caused by elasticity of the gingival fibres.

FIG. 27.3. Stretch of supracrestal fibres following rotation correction.

Procedures
➤ Under local anaesthesia, the sharp point of the fine blade (No 15 BP blade) is inserted
into the gingival crevice up to the alveolar crest of the bone (Fig. 27.4).

➤ The blade is kept parallel to the tooth surface.

➤ Blade is passed around the circumference of the tooth. This severs the fibres
connecting tooth to the gingival soft tissues.

➤ Cuts are made interproximally on each side of the rotated tooth.

➤ Cuts are made along the labial and lingual gingival margins also. If the labial gingiva
is thin, this cut is eliminated.

FIG. 27.4. Pericision–procedure.

Alternative method
Papilla dividing procedure
➤ In this procedure, vertical incisions are made in the centre of each gingival papilla 1–
2 mm below the margin.

➤ The margins are left untouched.

➤ This reduces the chance of reduction of height of gingival attachment after the
surgery.

Time of surgery
➤ The teeth should be held in good alignment during the gingival healing.

➤ Therefore, surgery should be done few weeks before the removal of active
orthodontic appliance.

➤ Retainer must be given immediately after debonding of the active appliance.

Corticotomy
Corticotomy is the surgical creation of multiple small partial segments to speed up
orthodontic tooth movement.

➤ In this procedure, labial flaps are raised, interdental osteotomy cuts are made
between each tooth.

➤ The segments are not freed completely.

➤ After the surgical procedure, orthodontic force is applied.

➤ But since the base of the segments is not cut, the objective of the treatment namely to
speed up the orthodontic tooth movement is questionable.

➤ It is indicated in patients with generalized spacing due to macrognathia.

➤ In median diastema without any other features of malocclusion, corticotomy is

indicated.
Transpositioning of
teeth/autotranspositioning/surgical repositioning
of teeth
In a few cases, it is possible to do surgical repositioning or transplantation of a tooth.

➤ This eliminates the need for future prosthetic replacement or orthodontic treatment.

➤ There are two techniques–repositioning and transplantation.

➤ Both the techniques are different.

Repositioning
➤ The objective of this is to move the tooth into a functionally desirable position, at the
same time maintaining the vitality of the tooth.

➤ Procedure consists of moving the crown in a wide arc around the apex.

➤ Tooth is not moved from the socket.

➤ Success of this treatment depends on the vascularity of the tooth. Increased

vascularity of the apical region accounts for the regeneration of the roots.

Criteria for repositioning

➤ Adequate space should be available.

➤ Root maturation should be half to two-thirds of root formation.

➤ Degree of tooth rotation required at the apex: Minimal or moderate degree of

rotation at the apex will be successful, if repositioned.

Transplantation
➤ Transplantation is a technique wherein a tooth is reimplanted after being removed
into a modified or newly created socket.

Criteria for case selection

➤ Sufficient space should be available.

➤ Root apex should be wide open.

➤ Minimal trauma to the socket.

➤ Periodontal ligament and cementum should not be handled or damaged by over

instrumentation.

Procedure
Tooth to be transplanted is uncovered, loosened and lifted out of the crypt. It is put
back into the socket. Recipient site is prepared, i.e. cavity is prepared in the desired
area. Tooth to be transplanted is taken out of the crypt and placed in the bony cavity.
Flaps are sutured back. Teeth commonly transplanted are third molars into first molar
space and canines.
Dentofacial deformities and their management by
orthognathic surgery
The more severe problems of malocclusion that require a combination of surgery and
orthodontics for treatment are called dentofacial deformities.

Indications for orthognathic surgery

➤ Severe class II skeletal discrepancy

➤ Severe class III skeletal discrepancy

➤ Very severe dentoalveolar problems that cannot be corrected by orthodontics alone.

➤ Correction of vertical discrepancies–long face and short face

➤ Transverse discrepancies

➤ Congenital craniofacial syndromes like cleft lip and palate, synostosis, hemifacial
microsomia

➤ Patients with facial asymmetry

Envelope of discrepancy
Fig. 27.5 illustrates how much change can be obtained by various methods of
treatments. The inner circle indicates the limits to orthodontic treatment. The middle
circle indicates the limits to tooth movement combined with growth modification. The
outer circle indicates surgical correction. Note that the possibility of each treatment is
not symmetric with regard to the planes of space. For example, surgery to move the
lower jaw back has greater potential than surgery to advance it. Envelope of
discrepancy also acts as a guideline for indications to the three main types of treatment
namely: (i) Camouflage, (ii) orthodontics + growth modification and (iii) orthodontics +
surgery.
 FIG. 27.5. Envelop of discrepancy: (A) Maxilla and (B) mandible.

Contraindications
A number of risk factors may be contraindications to surgery (Table 27.1).

Table 27.1.
Contraindications to surgery

Diabetes mellitus Susceptible to periodontal breakdown, delayed wound healing

Hyperthyroidism Tendency to osteoporosis
Adrenal insufficiency Decreased stress tolerance, delayed healing
Pregnancy Hormonal changes and periodontal breakdown
Heart diseases Prone for endocarditis
Bleeding disorder Bleeding tendency
Behavioural disorder Bizarre reactions to surgery, slow orthodontic tooth movement due to drugs
Rheumatic arthritis Manipulation of temporomandibular joint may increase problem
Diagnosis and treatment planning in surgical
orthodontics
The sequence followed for planning orthognathic surgery is given in Fig. 27.6.

FIG. 27.6. Case history and clinical assessment.

Clinical photographs
➤ Clinical photographs are essential for documentation and are used for photometric
analysis.

➤ Soft tissue landmarks are used to obtain angular and linear measurements.

Radiographic evaluation
a. Panoramic radiographs are used to study:

• Stages of dental development

• Anatomy of mandible

• Any gross pathology

b. Intraoral periapical and occlusal view radiographs are obtained to assess the
dentition, supporting bone and interdental spaces.

c. Cephalometric radiographs

i. Lateral cephalograms are used for assessment of the

elements of the dentofacial skeleton from sagittal aspect.

• Maxilla can be related to the mandible and each related to

their position in the skull base.

• Soft tissue profile can be studied

• Analysis of dentition

ii. Frontal cephalogram: This is used for assessment of facial

asymmetry. Various angular and linear cephalometric
analyses are used.
d. Additional radiographs

• Hand–wrist radiographs to assess skeletal age.

• Three-dimensional computed tomography.

Models
➤ Careful analysis of models is essential.

➤ Models are assessed for space analysis, transverse arch width discrepancy and
individual tooth positions.

➤ Relationship of maxillary dentition to mandibular dentition can be assessed.

➤ Diagnosis is established from the clinical, photographic, radiographic and model

evaluation.

Diagnostic features of common dentofacial deformity

(table 27.2)
Table 27.2.
Dentofacial deformity–diagnostic features
Presurgical and postsurgical orthodontics
Presurgical orthodontic phase facilitates the planned skeletal and facial correction.

1. Goals of presurgical orthodontics: The goals of presurgical orthodontics are (i)

alignment of the teeth, (ii) levelling of the teeth, (iii) establish the desired
anteroposterior position of incisors (decompensation) and (iv) achieve arch
compatibility.

2. Significance of presurgical orthodontics:

• Without presurgical orthodontics, surgery cannot be carried

out effectively.

• The quality of the result will be diminished.

3. Appliance selection: The preadjusted edgewise appliance is used to achieve the goals
of presurgical orthodontics.

• The recommended slot size is 0.022.

• It is well adapted for tooth movement and for stabilization of

teeth.
4. Steps in treatment:

a. Alignment

• Alignment is achieved by tipping movement.

• Alignment denotes proper buccolingual and mesiodistal

positioning of teeth.

• Round A nitinol wires are used for initial alignment.

b. Levelling of the arch

• Levelling of the arch denotes vertical positioning of the
teeth.

• Removal of excessive or reverse curve of Spee is the

procedure done.

• In low angle or short face, levelling is done by extrusion of

posteriors.

• In high angle with deep bite or long face, levelling is done by

intrusion of incisors.

• For achieving intrusion, utility arches or Burstone intrusion

arch are used.

• Continuous archwire generally produces extrusion of

posterior teeth.

c. Anteroposterior mesiodistal position/decompensation

• One of the major goals of presurgical orthodontics is to

eliminate the dental compensation.

• In this stage, deliberately the condition is made worse by

decompensation.

• Hence, this part of treatment is also called reverse

orthodontics.

(i) Decompensation in class II

• The upper incisors are left in their original position or if

required advanced.
• The lower incisors are retracted.

• This causes increase in overjet and thereby increases the

distance, mandible can be advanced, or maxilla can be set
back.

(ii) Decompensation in class III

• The lower incisors are maintained in position or advanced.

• Upper incisors are retracted, increasing the reverse overjet.

• It also increases the distance that mandible can be set back to

or maxilla advanced.

d. Arch compatibility

• This is the last step in presurgical orthodontics.

• Similar maxillary and mandibular arch forms with

compatible arch width must be established.

• Expansion of arch is done, if it is constricted. Orthodontic

expansion should be restricted to 2–3 mm per side.

• If more expansion is required, it should be achieved by

surgery.

• Stabilizing archwires are placed with rectangular wires.

Postsurgical orthodontics
➤ Postsurgical orthodontics is started after satisfactory healing.

➤ On an average, 6–8 weeks is required for healing.

Steps in postsurgical orthodontics
➤ Removal of splints and stabilizing archwires

➤ Placement of working archwire (0.016″ stainless steel archwires)

➤ Light vertical elastics for positioning

➤ Transverse control with heavy archwires

Retention phase
➤ Full time retention is advised for 3–4 months.

➤ Part time wears for 6 months.

Table 27.3 depicts the orthodontic procedures carried out before and after orthognathic
surgery.

Table 27.3.
Pre- and post-surgical procedures

Before surgery After surgery Before and/or after surgery

Alignment Settling and levelling Posterior crossbite correction
Intrusion Root paralleling Extrusion
Arch compatibility Detailed tooth positioning
Model surgery
Model surgery is done on mounted articulators. Two types of articulators are used.

1. Arbitrary articulator: Indicated in conditions where the condylar position is not

altered in surgery.

2. Semiadjustable articulator: Indicated in cases where the condylar position is altered

during surgery.

After the models are articulated, cuts are made in the planned
area of the model. They are then repositioned in the desired
planned position. Model surgery has got two important
purposes:

a. To verify whether the planned movements are possible.

b. To process the occlusal wafer splints.

If surgery is planned in both the jaws, maxillary cast is moved

first and fixed on the articulator.

• Occlusal splint is made in this position for the first stage.

• Then the mandibular cast is repositioned to occlude with the

maxillary cast.

• The second stage occlusal splint is prepared.

Surgical procedures for mandibular prognathism
and maxillary retrusion/skeletal class III
correction
Mandibular prognathism
The various procedures employed for sagittal mandibular correction or setback:

1. Body ostectomy (Fig. 27.7)

Indications:

• Closure of gaps in the dental arch.

• Reduction of long body of the mandible.

• Restoration of asymmetry.

• To close anterior open bite.

Disadvantages:

• Injury to mental nerve

• Impaired union

• Remaining of vertical step on the lower border of mandible

• Double chin appearance

2. C and L osteotomies (Fig. 27.8)

These geometrically designed ramal cut procedures permit

repositioning of the body and dentoalveolar segment of the
 mandible in relation to ramus within the
pterygomandibular sling.

Indications:

• Closure of open bites

• Advancement of mandible

• Setback of mandible
3. Mandibular ramus osteotomy (Fig. 27.9)

• In this procedure, the entire body of the mandible is

repositioned in relation to the maxillary arch.

• This procedure permits greater flexibility in the

repositioning of the segments.

• Reduction should not be done more than 1 cm.

4. Sagittal split technique (Fig. 27.10)

• Bilateral sagittal split osteotomy (BSSO) is the most widely

used procedure for mandibular reduction.

• It is a versatile procedure.

• Correction of asymmetry and crossbite is possible with this

procedure.

• Performed through intraoral procedure.

5. Vertical subsigmoid osteotomy (Fig. 27.11)
• Vertical subsigmoid osteotomy technique is performed
intraorally.

• Degree of retrusion achieved is constrained by the width of

the ramus posteriorly or the impaction of coronoid process.

• Coronoidectomy is done in some instances.

FIG. 27.7. Body ostectomy.

 FIG. 27.8. C osteotomy.

FIG. 27.9. Mandibular ramus osteotomy.

 FIG. 27.10. Sagittal split technique.

FIG. 27.11. Vertical subsigmoid osteotomy.

Maxillary retrusion
Maxillary osteotomy (fig. 27.12)
➤ Maxilla is corrected using the ‘down fracturing’ modification of Le Fort I osteotomy.

➤ For advancement, a graft in the retromolar area or at a step created in the lateral wall
is required.

FIG. 27.12. Maxillary osteotomy.

Surgical correction of receding chin/deficient
chin
Recession of chin associated with normal mandible is seen in the following conditions:

➤ As a hereditary feature

➤ Trauma to chin

➤ After orthodontic correction of dentoalveolar problem

Methods of correction: The receding chin may be corrected surgically by:

1. Onlays to the chin (Fig. 27.13); may be in the form of autograft, homograft and
allograft.

a. Autograft onlays:

i. Onlay bone grafts to the chin may be inserted through

intraoral or submental approach.

ii. A block of iliac crest bone is contoured and used as a

graft.

iii. Grafts are held in position by transosseous wiring.

b. Homograft onlays:

i. Homograft onlays are used similar to autograft onlays.

ii. They are less reliable and more prone for infection.

c. Allograft onlays: Various allografts, like tantalum, stainless

steel, chrome–cobalt and silastic, have been tried. It is the
most unsatisfactory method in long term.
2. Sliding genioplasty (Fig. 27.14)
• Obwegeser HL described sliding genioplasty in the year
1957.

• In this procedure, bone is sectioned backwards from the

chin.

• The sectioned lower fragment is advanced to create a mental

prominence.
3. Buccal inlay

• It is a simple procedure, used in conjunction with

mandibular prosthesis.

• Acceptable restructure of the chin is achieved.

4. Bilateral osteotomy of the body of the mandible is done with advancement of the
anterior fragment and bilateral bone grafts to fill the defect (Fig. 27.15).

A vertical body osteotomy is made bilaterally at some convenient point between the
canines and first molar.

• Anterior fragment is tilted to put the chin in required correct

position.

• Iliac crest bone grafts are inserted into the gap created and
wired in place.

• Intermaxillary fixation is done.

 FIG. 27.13. Chin onlay.

FIG. 27.14. Sliding genioplasty.

FIG. 27.15. Bilateral osteotomy.
Surgical correction of class II malocclusion
The various methods of surgical correction for skeletal class II malocclusion can be
studied under three different situations.

1. Patients with normal maxilla and mandible but with receding chin

• Same as the answer for receding chin.

• Among the procedures available for genioplasty, sliding

genioplasty is the most advisable.
2. Prognathic maxilla

a. Prognathic maxilla with deficient chin: Wassmund

procedure in maxilla and sliding genioplasty.

b. With prominent chin: Wassmund procedure in maxilla

with reduction genioplasty.

c. With normal chin: Wassmund procedure to reduce the

prominence of the premaxilla (Fig. 27.16).
3. Retrognathic mandible

• BSSO of the mandibular ramus done from an intraoral

approach is the preferred procedure.

• Bilateral split permits the mandible to advance to new

position (Fig. 27.17).

• The lower incisor segment may be lowered and chin contour

improved as necessary by Kole procedure. Other
advancement procedures are inverted L osteotomy,
Eiselbug’s Z-shaped body osteotomy.
FIG. 27.16. Prognathic maxilla with normal chin: Wassmund procedure.

FIG. 27.17. Retrognathic mandible: BSSO with Kole procedure.

Surgical procedures for vertical malocclusion
Long face
➤ Long face patients are treated by superior repositioning of the maxilla.

➤ Superior repositioning with Le Fort I down fracture of maxilla after removal of bone
from the lateral walls of the nose, sinus and nasal system.

➤ Mandible responds to the surgery by upwards and forwards autorotation.

➤ New muscular adaptation stabilizes the position.

➤ Excellent stability of the vertical position of the maxilla is seen postoperatively.

Short face
➤ Short face patients are surgically treated by sagittal split mandibular ramus surgery.

➤ The mandible is rotated slightly forward and down.

➤ Gonial angle area is placed up.

Timing of orthognathic surgery
Orthodontist is the key person in deciding the appropriate time to initiate treatment in
surgical orthodontic cases.

➤ As a general rule, early jaw surgery has inhibitory effect on further growth. Hence,
orthognathic surgery should be delayed until growth is essentially completed in
patients, who have problems of excessive growth.

➤ For patients with growth deficiencies, surgery can be considered earlier. It should
never be done before adolescent growth spurt.

➤ The approximate time recommended for different surgical procedures is depicted in

Table 27.4.

Table 27.4.
Timing of surgery

Nature of
Recommended time of treatment
problem
Mandibular Treated best when growth is complete
excess
Assessed by hand–wrist radiograph or serial cephalometric tracing
Mandibular Girls: 14–16 years; boys: approximately 18 years
deficiency
Maxillary Maxillary advancement may be delayed till adolescent growth spurt
deficiency
Maxillary excess After growth completion
Short face Mandibular ramus surgery is preferred to increase face height and downward movement of the posterior maxilla; treatment time similar to
mandibular deficiency problem
Long face Le Fort I osteotomy to move maxilla up; this leads to mandibular autorotation; early surgery not recommended
Asymmetry Early surgical intervention recommended only when abnormal growth worsens the existing situation, e.g. craniofacial synostosis
Therapeutic aids in surgical care
The various therapeutic aids and their uses in surgical orthodontics are as follows:

Bite splint and superior repositioning splint:

These are used:

• To assess neuromuscular habits

• For deprogramming muscles of mastication

• For 1–6 months

High-pull headgear:

• To assess degree of patient cooperation

• To assess orthopaedic response of class II with vertical

maxillary growth

• Recommended to wear for 6–12 months

Reverse facemask

• To assess orthopaedic response in class III with mild to

moderate maxillary deficiency

• To assess maxillary horizontal growth acceleration

• Used for 6–12 months

Chin cup

• To control growth of mandible

• Used for a period of 6–24 months

ACCESSORY POINTS
➤ The word orthognathic surgery means (orthos – straight and gnathic – jaw) straight
jaw.

➤ Circumferential supracrestal fibrotomy is done to minimize relapse of derotated tooth.

➤ Transplantation is a technique wherein a tooth is reimplanted after being removed

into a modified or newly created socket.

➤ Frenectomy is usually done at the end of closure of median diastema.

➤ To locate whether a tooth is located labially or palatally, tube shift technique is

employed.

➤ Impacted canines which are unfavourably positioned are extracted.

➤ Sulcus slice procedure is the other name for supracrestal fibrotomy.

➤ Decompensation is indicated in surgical orthodontics.

➤ BSSO is the most widely used surgical procedure for mandible reduction.

➤ Patients with long face are surgically treated by superior repositioning of maxilla.

➤ Distraction osteogenesis was introduced by Gabriel Ilizarov.

➤ Most advisable procedure for genioplasty is sliding genioplasty.

➤ In tube shift technique, if the image moves in the same direction as the X-ray tube,
then the impacted tooth is placed palatally.

➤ Reverse orthodontics is the other name for dental decompensation achieved in

presurgical orthodontics.

➤ Sliding genioplasty was described by Obwegeser in the year 1957.

Advanced Learning
Distraction osteogenesis
Introduction
➤ Distraction osteogenesis is a surgical process for reconstruction of skeletal
 deformation.

➤ It involves gradual, controlled displacement of surgically created fractures and

results in simultaneous expansion of soft tissue and bone volume.

➤ Ability to reconstruct deficiency in both bone and soft tissue makes this a unique
process.

➤ Gabriel Ilizarov, a Russian orthopaedic surgeon, introduced the distraction

osteogenesis concept.

➤ The technique of bone formation under the influence of tensional stress is called
distraction osteogenesis.

Procedure
➤ The process involves three steps: (i) Mobilization of the bone, (ii) transport by means
of devices and (iii) fixation of a healthy segment.

➤ After surgically created fracture, the mechanical device namely the distraction device
is used to produce gradual, controlled movement of the mobilized bone segment.

➤ Once the desired repositioning of the bone segment is achieved, the distraction
device is left without activation. Now it acts as a fixation device.

➤ Regeneration takes place which heals by filling with bone.

➤ Simultaneous to bony expansion, soft tissue expansion also takes place.

Indications
Primary indications

➤ Combined deficiencies in bone and soft tissues.

➤ Compromised wound healing.

Secondary indications

➤ Expand alveolus for orthodontic tooth movement.

➤ Create site for dental implant.

➤ Create site for dental implant placement by alveolar distraction.

Limitations

➤ Requires minimum quantity of bone.

➤ Expansion is unidirectional.

➤ Patient cooperation is required for activation.

➤ Both the anchorage and transport segments must have adequate strength to
withstand forces of mobilization.

Complications

➤ There can be fracture of transport segment or distraction device.

➤ Fracture of anchorage segment.

➤ Possibility of premature consolidation.

➤ Undesirable vectors of force.

Classification of distraction devices

There are two types of distraction devices:

1. External devices

• These are attached to the bone by percutaneous pins and

connected externally by fixation clamps.

• Fixation clamps are joined together by distraction rod.

• When activated, the rod pushes the clamps and the attached
bone segments apart, forming new bone in its path.
• Devices can be unidirectional, bidirectional or
multidirectional.
2. Internal devices

• These are placed subcutaneously or inside the oral cavity

(intraorally).

• The intraoral devices can be placed above (extramucosal) or

below (submucosal) the soft tissues.

• They are bone-borne (attached to bone), tooth-borne or both

teeth- and bone-borne (hybrid).

Areas of distraction
1. Mandibular distraction

2. Midface distraction/maxillary distraction

3. Alveolar ridge distraction

4. Periodontal ligament distraction

Biological basis of new bone formation

There are five sequential stages in distraction osteogenesis.

1. Osteotomy

• Distraction osteogenesis begins with an osteotomy.

• Bone is divided into two segments.

• Bone repair is initiated.

2. Latency

• Period from bone division to the onset of traction is called

 latency period.

• Time is allowed for reparative callus formation.

• Soft callus is formed.

3. Distraction

• Normal healing process is interrupted.

• Gradual traction separates the bone tissue and stimulates

regeneration.

• Fibrous tissues of the soft callus are oriented longitudinally

parallel to the axis of distraction.

• Bone formation occurs along the vector of tension.

• Hard callus formation takes places.

4. Consolidation

• Consolidation is the period from stoppage of traction forces

and removal of distraction devices.

• Bone trabeculae continue to grow.

• Disappearance of soft callus stage.

5. Remodelling

• Remodelling period starts from removal of distraction

device to the application of full functional loading to the
distracted bone segment.
• Cortical bone and marrow cavity are restored.
Implants in orthodontics
The use of implants has increased vastly as a result of their long-term osseointegration.
In orthodontics also, there is increased use of implants.
Dental implant
Dental implant is a device made of biocompatible material which is placed within or
against the mandibular or maxillary bone to provide additional support for prosthesis
or tooth.

I. Types of implants

1. Endosteal implants: These are placed within fully or

partially edentulous ridges with sufficient residual available
bone to accommodate the selected implant.

a. Root form implants are designed to resemble the shaft of a

natural tooth root. They are circular in cross-section. They
can be threaded. Root forms must achieve osseointegration
to succeed. Hence they are positioned in nonfunctional state
during healing period.

b. Plate/blade form: Shape is that of a metal plate or blade in

cross-section. These are available in two forms: One-stage
type, and two-stage type.
c. Ramus frame implants: These are safe and effective and
intended to be used for the treatment of total mandibular
edentulism.

d. Transosteal implants: These are the most surgically invasive

and technique sensitive. They are limited to use in
mandible.

2. Subperiosteal implants

• In this, the implant is placed under the periosteum and

against bone on insertion.

• The subperiosteal implants are retained by periosteal

integration.
II. Materials used for implants

• Titanium is the most accepted ideal material for implant

fabrication.

• Other materials used are:

• Gold alloys

• Vitallium

• Cobalt–chromium

• Aluminium oxide ceramics

• Nickel–chromium–vanadium alloys
III. Protocol of placement
• Per-Ingvar Brånemark is known as the pioneer in implant.
Implants involve two-stage procedure.

• First stage: Implant fixture is countersunk into position and

a cover screw is placed.

• 4–6 months healing period.

• Second stage: Fitting of an abutment to the osseointegrated

abutment.

• Resolution period of 2 weeks.

• Age of the patient is an important consideration. In growing

children, it causes the following complications:

- Use of implants in the anterior maxilla is contraindicated as

this might cause opening of midpalatal sutures.

- Resorption in the posterior part resulting from growth

changes, could cause exposure of the implant into sinus.
IV. Uses of implants

1. Implants serve as a source of absolute anchorage.

2. Implants are used for anchorage and as abutments for

restorations.

3. Implant is also used in osteogenesis distraction.

As source of absolute anchorage:

• Retraction and realigning of anterior teeth without posterior

 support.

• Closing of edentulous space in first molar extraction sites –

retromolar implant anchorage (Fig. 27.18).

• Implant with external abutment is placed in the retromolar

area and used as an anchorage to stabilize the premolar
anterior to extracted site.

• Implant serves as an osseous anchorage. Maintaining a fixed

relationship with supporting bone is true osseous
anchorage.

• Intrusion and extrusion of teeth.

• Protraction or retraction of one arch.

• Orthopaedic anchorage.

• Stabilization of teeth.

• Midline correction due to missing posterior teeth.

V. Design of orthodontic implants

• The drawback of conventional two-stage implant is that it

requires a long healing period of 4–6 months.

• To overcome this, implants have been designed exclusively

for orthodontic purpose.
Ideal requirements of orthodontic implants (James Cope):

• They should be biocompatible.

• They should be inexpensive.

• There should be ease of insertion.

• There should be ease of removal.

• They should not occupy large space and should be small.

• They should osseointegrate.

• They should be stable and withstand orthodontic loading.

• They should withstand immediate loading.

The various orthodontic implants:

1. Onplant

2. Orthosystem implant

3. Aarhus implant

4. Mini implants

1. Onplant (Fig. 27.19)

- Introduced by Block MS and Hoffman DR.

- It is a disc-like structure which can be placed under local

anaesthesia.

- It is coated with hydroxyapatite and is 10 mm in diameter by

3 mm thick.

- It is placed subperiosteally in hard palate on the posterior

aspect.
- Healing period is 10 weeks.

2. Orthosystem implant (Fig. 27.20)

- Developed by Wehrbein H and Merz B.

- It is a one-piece device with an 8-week healing period.

- It is a screw type endosseous implant about 4–6 mm in

length.

3. Aarhus implant (Fig. 27.21)

- Developed by Melsen B.

- Early loading of implants is possible.

- It is very small in size and hence can be used in multiple sites

between roots.

4. Mini implants or microimplants (Fig. 27.22)

- These are developed by Kanomi R.

- These are very small, about 1.2 mm in diameter and 6 mm in

length.
FIG. 27.18. Retromolar implant anchorage. Arrows indicate closure of molar space.

FIG. 27.19. Onplant.

FIG. 27.20. Orthosystem implant.

FIG. 27.21. Aarhus implant.

FIG. 27.22. Mini implants.

CHAPTER 28
Cleft lip and palate

CHAPTER OUTLINE
❖ Classification of cleft lip and palate
❖ Aetiology, pathogenesis, clinical features and dental management of cleft lip and
palate
❖ Orthodontic management of cleft lip and palate
❖ Accessory points
❖ Advanced learning
❖ Nasoalveolar moulding (NAM)/presurgical
nasoalveolar moulding (PNAM)
❖ Prenatal diagnosis of cleft lip and palate
Classification of cleft lip and palate
Cleft lip and palate are congenital abnormalities that affect the upper lip and the hard
and soft palate of the mouth. Severity of the abnormalities may range from a small
notch in the lip to a complete fissure (groove) extending into the roof of the mouth and
nose. These features may occur separately or together.

1. Morphologic classification

Three main types occur morphologically:

1. Cleft lip (CL)

2. Cleft lip and palate (CLP)

3. Isolated cleft palate (CP)

• Clefts of the lip and combined lip and palate are twice as
common in males as females.

• Isolated clefts of the secondary palate are more common in

females.
2. Kernohan and Stark’s classification (1958)

I. Clefts of primary palate only

• Unilateral

• Complete

• Incomplete

• Median

• Bilateral
 II. Clefts of secondary palate only

• Complete

• Incomplete

• Submucous

III. Clefts of primary and secondary palate

• Unilateral

• Complete

• Incomplete

• Median

• Bilateral
3. Veau’s classification (1931)

V. Veau proposed the most widely used system of

classification. He classified clefts of the lip and palate as
follows:

a. Cleft palate

b. Cleft lip

Veau’s classification of cleft palate (Fig. 28.1)

• Group I: Cleft of the soft palate only

• Group II: Cleft of the soft and hard palate not involving the
 lips

• Group III: Unilateral complete cleft of lip and palate. This

involves soft palate, hard palate, alveolar ridge and lip

• Group IV: Bilateral complete cleft of lip and palate involving

alveolar ridge and lip

Veau’s classification of cleft lip

• Class I: A unilateral notching of the vermilion not extending

into the lip

• Class II: A unilateral notching of the vermilion border, with

the cleft extending into the lip but not including the floor of
the nose

• Class III: A unilateral clefting of the vermilion border of the

lip extending into the floor of the nose.

• Class IV: Any bilateral clefting of the lip, whether it be

incomplete notching or complete clefting
4. Davis and Ritchie classification (1922)

• Group I: Prealveolar clefts (clefts involving lip only)

• Group II: Postalveolar clefts (submucous cleft)

• Group III: Alveolar clefts (complete clefts)

• Unilateral, median, bilateral

5. Kernohan’s stripped Y-classification (Fig. 28.2)
• This classification employs numbered blocks which are
arranged in a stripped ‘Y’ pattern. Each block corresponds
to specific areas in oral cavity (Table 28.1).

FIG. 28.1. Veau’s classification of cleft palate.

 FIG. 28.2. Kernohan’s stripped Y-classification.

Table 28.1.
Block vis-à-vis areas in oral cavity

Blocks Area represented

Blocks 1 and 4 Lip
Blocks 2 and 5 Alveolus
Blocks 3 and 6 Hard palate anterior to the incisive foramen – premaxilla
Blocks 7 and 8 Hard palate behind incisive foramen
Block 9 Soft palate

Note: The figure as shown in 28.2 is drawn and the blocks where cleft are present are shaded.
Aetiology, pathogenesis, clinical features and
dental management of cleft lip and palate
➤ Worldwide incidence of cleft lip and palate is 1 in 800 live births. In India, incidence
is 3.6 in 1000 births.

• United States – 1:750.

• Asians – 1:500

• Caucasians – 1:1000

• Male–female – 2:1
➤ Thirty-two per cent of clefting deformities are the isolated cleft lip. Unilateral clefts
are more common on left sides (L:R ratio is 2:1).

Pathogenesis
The primary palate or premaxilla is a triangular area of the anterior hard palate
extending from anterior to the incisive foramen from point just lateral to the lateral
incisor teeth. It includes that portion of the alveolar ridge containing the four incisor
teeth.
The secondary palate consists of the remaining hard palate and all of the soft palate.
The clefts result due to interference with the embryological development.

Pathogenesis of clefts
1. Cleft lip – results from a failure to maintain an epithelial bridge due to lack of
mesodermal delivery and proliferation from the maxillary and nasal processes.

2. Cleft palate – failure of descent of the tongue, failure of mesodermal migration into
palatal shelves, delay of mesodermal migration into palatal shelves are the possible
causes for cleft palate.

Aetiology of cleft lip and palate

The various factors responsible for cleft lip and palates:

1. Maternal infection and toxicity

• Infection – rubella, influenza

• Toxicity – hypoxia, teratogenic drugs like valium, phenytoin,

corticosteroids; cytotoxic drugs like nitrogen mustard
2. Maternal dietary imbalance

• Folic acid deficient diet

• Hypervitaminosis A
3. Maternal hormone imbalance

Any imbalance in maternal hormone concentrations at the

time of conception is suspected to produce cleft lip and
palate.
4. Heredity

• Multifactorial inheritance plays the major role. Familial

inheritance occurs, but classic Mendelian inheritance is rare.

• Unaffected parents who have a child with a cleft lip and

palate have a 4.4% chance that their second child will also
have a cleft of the lip or palate and a 2.5% chance that their
second child will have an isolated cleft palate.

• If one parent has a cleft deformity, there is a 3.2% chance

that their first born will have a cleft lip or palate.
5. Syndromes associated with cleft palate

• Pierre Robin syndrome

• Apert syndrome
• Treacher Collins syndrome

• Patau syndrome

• Edwards syndrome

Clinical problems associated with clefts

I. Dental aberrations seen with cleft lip and cleft palate

• Presence of natal or neonatal teeth

• Presence of supernumerary teeth or missing teeth

• Ectopically erupting teeth

• Anomalies of tooth morphology

• Enamel hypoplasia

• Microdontia, macrodontia, fused teeth

• Spacing or crowding

• Mobile teeth with poor periodontal support

• Posterior and anterior crossbites

• Malalignment of alveolar arches

II. Aesthetic and growth problems

The degree of the deformity depends on the severity of the

cleft lip or palate. Most of these are a result of the growth
inhibition of maxilla by the surgical procedures performed
 to repair the cleft.

• Patient develops concave profile with characteristic midface

deficiency.

• The maxilla is hypoplastic on the cleft side.

• The columella is shortened on the side of the cleft.

• Floor of nose communicates freely with the oral cavity.

• Nasal tip is widened and flattened.

• The muscles of the soft palate are usually hypoplastic.

• Premaxilla is often grossly deficient in bone with bilateral

cleft.
III. Speech disorders

Errors in articulation are common in cleft palate patients,

especially those involving affricates and fricatives.
Velopharyngeal incompetence is associated with an audible
escape of air from the nose during production of pressure
sounds and is termed nasal snort.
IV. Ear disease

Cleft palate is very often associated with Eustachian tube

dysfunction and a resulting conductive hearing loss.
Eustachian tube dysfunction in these patients is due to an
abnormal insertion of the levator veli palatini and tensor
veli palatini muscles into the posterior margin of the hard
palate. With increasing age, the incidence of Eustachian tube
 dysfunction decreases.
V. Airway problems

Airway problems may arise in children with cleft palates. For

example, Pierre Robin sequence is the combination of
micrognathia, cleft palate and glossoptosis. Affected
patients may develop airway distress from their tongue
becoming lodged in the palatal defect.
VI. Psychological problems

Patient may suffer from the poor social image due to the poor
facial aesthetics. The additional problems, like poor speech
and hearing, exaggerate the patient’s disappointment.
Psychological counselling may be necessary.

Treatment of cleft lip and palate

Team approach is needed to handle complex problem. The treatment team for cleft lip
and palate is composed of:

➤ Plastic surgeon

➤ Paediatrician

➤ Paedodontist

➤ Otologist

➤ Orthodontist

➤ Speech pathologist

➤ Audiologist

➤ Geneticist

➤ Nurse

➤ Psychiatrist
➤ Social worker

➤ Prosthodontist

The treatment of the patient starts at birth.

I. Neonatal intervention and nursing care

• Dental specialist gets a call from plastic surgeon or

paediatrician.

• Early contact and counselling of parents should be done to

reassure them.

• First contact of the cleft treatment team with the patient and
parents takes place.

• Instructions on breastfeeding:

• Direct the nipple to the intact part of the palate.

• The infant is held upright in the lap to reduce nasal

regurgitation.

• Burping the infant is necessary now and then.

• Observe the child for choking, cyanosis and abdominal

distension.
II. 3–6 weeks

1. Infant orthopaedics

• Cleft lip and palate patients have a distorted maxillary arch

form especially when it is bilateral.
• Surgical closure of the lip is difficult since the premaxillary
segment has moved labially.

• Infant orthopaedics is undertaken to reposition the maxillary

segments and retract the premaxilla

• Different orthopaedic solutions:

1. Light elastic strap across premaxillary segment

2. Pressure from repaired cleft lip

3. Orthodontic appliance pinned to the segments for severe

cases

2. Feeding plate

• The child cannot build negative pressure required for

sucking due to oronasal fistula.

• Feeding appliances are removable plates that assist in

feeding by closing oronasal fistula.

• They reduce the discomfort associated with the

regurgitation.

• Infant orthopaedic appliances can serve as feeding plates.

• Feeding plates can be left in place for 1 year.

III. 2–3 months

1. Cleft lip repair

Treatment of cleft lip should be avoided during the first 6
weeks of life. This waiting period also allows for more
visible anatomical landmarks for repair.

Millard advocates the ‘rule of tens’ for cleft lip surgery.

• Ten weeks of age

• Ten grams of haemoglobin

• Ten pounds weight

Various methods of cleft lip repair:

I. Lip adhesion procedure

Used for the very difficult and wide cleft lip

Most commonly used in wide bilateral cleft

II. Rose–Thompson procedure

Used only for repair of the incomplete cleft

III. Tennison–Randall triangular flap

Little tissue is sacrificed

Randall’s modification is less likely to result in long lip

deformity
IV. Millard rotation-advancement flap

Most common approach

Used in incomplete, complete and wide cleft lip repairs
IV. 12–18 months

1. Paedodontic review

• Explanation of possible eruption abnormalities and dental

procedures that may be needed in the future.

2. Assessment by speech pathologist

3. Cleft palate repair is done either early or late.

1. Early repair (prior to 18 months):

• The earlier the repair, the more interference with facial

growth.

• Maxillary growth is reduced anteroposteriorly,

transversely and vertically.

• Even then, cleft palate is repaired early to help in

swallowing and to permit the development of speech and
hearing abilities.

2. Late repair (5–10 years):

• Less interference with facial growth

• The cleft palate patient suffers complications in speech

development due to:

a. Lack of neurosensory-motor mechanisms

 b. Lack of integrity of the speech apparatus

c. Receptive language problems due to middle ear

dysfunction

Bernard von langenbeck’s palatal closure by elevation of mucoperiosteal

flaps
➤ Minimizes dissection of large mucoperiosteal flaps.

➤ Patients speak well by the time of speech maturation.

➤ Lower incidence of lateral incisor crossbite and buccal segment collapse than with
the palatal pushback.

V-Y pushback palatoplasty

➤ Extension of the von Langenbeck’s procedure devised to add length to the palate.

➤ Relaxing incisions lateral to the greater palatine neurovascular bundle and anteriorly
into the cleft.

➤ Full-thickness mucoperiosteal flaps are elevated and muscular attachments along the
cleft are detached.

➤ Muscles are rotated medially.

➤ Palatal soft tissues are advanced posteriorly and a three-layer closure is attempted.

➤ Excessive palatal scarring is a negative aspect.

V. 2–6 years

• Paedodontic review to monitor growth and development

• Oral hygiene instruction

• Review appointments with plastic surgeon, audiologist and

speech pathologist
VI. 6–8 years
• Fissure sealing of primary molars on eruption

• Removal of deciduous/supernumerary teeth

• Restoration of hypoplastic incisors adjacent to the cleft

• Palatal expansion procedures to correct anterior and

posterior crossbite. Rapid or slow expansion may be used.

• Facemask maxillary protraction, if needed.

VII. 9–11 years

• Alveolar bone grafting

Surgical goals of alveolar bone grafting

1. Stabilization of dental osseous segments

2. Oronasal fistula closure

3. Improvement of alveolar ridge form

4. Prevention of tooth loss

5. Provision of nasal–alar base support

Timing of alveolar cleft bone grafting

➤ Primary bone grafting: Less than age of 2 years

➤ Early secondary grafting: Ages 2–6 years

➤ Secondary grafting: Ages 7–12 years

➤ Late secondary grafting: Adult

➤ Most commonly done at 9–11 years

Graft materials
1. Rib is used in primary bone grafting
2. Particulate marrow and cancellous iliac crest bone grafts are used for secondary
grafting

3. Cranial bone

4. Hydroxyapatite to restore alveolar ridge form

VIII. 12–13 years

1. Comprehensive orthodontic treatment

• Preadjusted edgewise appliances are preferred for precise

positioning of teeth.

• Establishing and coordinating arch forms in maxilla and

mandible is important.

• Impacted teeth are uncovered and brought into the arch.

• Chin cup can be used to redirect mandibular growth.

IX. 14–16 years

1. Maxillary protraction by orthognathic surgery

• Major basal bone discrepancies between maxilla and

mandible require orthognathic surgery.

• Le Fort I osteotomy is used to advance the maxilla and

correct the crossbite.

• Poor stability of the surgical result is seen when maxilla is

advanced too far. Two jaw surgeries (advancement of
maxilla and backward positioning of mandible) are required
in such cases.
• Complications like infection, necrosis and loss of teeth are
more common when a cleft patient is subjected to
orthognathic surgery.

2. Maxillary distraction osteogenesis

• It is a new technique that provides simultaneous maxillary

skeletal advancement and expansion of the soft tissues.

• After an incomplete Le Fort I osteotomy; a latency period of

3 days is provided.

• A rigid external distraction device or intraoral device is

placed and activated 1 mm a day.

• Distraction is stopped when the crossbite is overcorrected

and patient is placed in retention for 3 months.
2. First assessment by audiologist

Child is referred to audiologist for hearing assessment.

Conclusion
➤ The majority of clefts are capable of developing an essentially normal facial skeleton
except in the area of the cleft defect when left untreated.

➤ Repair of palate is shown to cause impaired maxillary growth producing midface

retrusion.

➤ Facial growth is related to age of repair. The earlier the repair, the more inhibited is
facial growth.

➤ Even then cleft palate is repaired early to help in swallowing and to permit the
development of speech and hearing abilities.

Timing of cleft lip and palate repair

Two basic philosophies exist:
I. Lip: Close at 3 months

Soft palate: 6–12 months

Hard palate: 5–10 years

Pharyngeal flap: Following hard palate closure

II. Lip: Close at 3 months

Soft and hard palate: Close prior to 18 months

Pharyngeal flap: Close at approximately age 5, if necessary.

Orthodontic management of cleft palate
Orthodontic management of cleft lip and palate can be studied under four stages. They
are as follows:

1. Infancy stage

Infant orthopaedics:

• Cleft lip and palate patients have a distorted maxillary arch

form, especially when it is bilateral.

• Surgical closure of the lip is difficult since the premaxillary

segment is moved labially and the posterior segments are
lingually collapsed.

• Infant orthopaedics is undertaken to reposition the maxillary

segments and retract the premaxilla.

• Different orthopaedic solutions to reposition the segments:

• Light elastic strap across premaxillary segment (Fig. 28.3)

• Pressure from repaired cleft lip

• Orthodontic appliance pinned to the segments for severe

cases

This procedure is usually carried out at 3–6 weeks of age to

facilitate lip closure which will be done at about 10 weeks of
age.

Feeding plates:
• The child cannot build negative pressure required for
sucking due to oronasal fistula.

• Feeding appliances are removable plates that assist in

feeding by closing oronasal fistula.

• They reduce the discomfort associated with the

regurgitation.

• Feeding plates can be left in place for 1 year.

2. Late primary and early mixed dentition treatment

• Orthodontic treatment is not required at this stage.

• The permanent incisors usually erupt rotated and in

crossbite. If necessary, these problems are corrected using
removable appliances.

• Placement of grafts is recommended between 7 and 10 years

of age. Placing of grafts before eruption of lateral incisors
and canines creates a healthy environment for permanent
teeth.
3. Early permanent dentition treatment

• There is tendency to develop posterior crossbites.

• Fixed appliance orthodontic treatment is commenced at this

stage.

• Space closure in missing tooth areas is carried out after

successful bone grafting.
• If space closure is not possible, semipermanent bridges are
placed to close the spaces.
4. After growth completion

Comprehensive orthodontic treatment:

• Preadjusted edgewise appliances are preferred for precise

positioning of teeth.

• Establishing and coordinating arch forms in maxilla and

mandible is important.

• Impacted teeth are uncovered and brought into the arch.

• Chin cup can be used to redirect mandibular growth.

Maxillary protraction by orthognathic surgery:

• Major basal bone discrepancies between maxilla and

mandible require orthognathic surgery.

• Le Fort I osteotomy is used to advance the maxilla and

correct the crossbite.

• Poor stability of the surgical result is seen when maxilla is

advanced too far. Two jaw surgeries (advancement of
maxilla and backward positioning of mandible) are required
in such cases.

• Complications like infection, necrosis and loss of teeth are

more common when a cleft patient is subjected to
orthognathic surgery.
Maxillary distraction osteogenesis:

• It is a new technique that provides simultaneous maxillary

skeletal advancement and expansion of the soft tissues.

• After an incomplete Le Fort I osteotomy; a latency period of

3 days is provided.

• A rigid external distraction device or intraoral device is

placed and activated 1 mm a day.

• Distraction is stopped when the crossbite is overcorrected

and patient is placed in retention for 3 months.

FIG. 28.3. Effect of premaxillary elastic strap on the maxillary posterior segment. Arrows
indicate repositioning of collapsed segment.

ACCESSORY POINTS
➤ Most common skeletal feature in patients with cleft is class III skeletal pattern.

➤ Millard advocates the ‘Rule of tens’

• Ten weeks of age

• Ten grams of haemoglobin

• Ten pounds weight

➤ The most common congenital defect of head and neck is cleft lip.

➤ Six centre study of cleft lip and palate was done in the following centres:

• Royal Dental College, Copenhagen, Denmark

• University Dental College, Manchester, UK

• Karolinska Institute, Stockholm, Sweden

• Hospital for Sick Children, London, UK

• Krije University, Amsterdam, The Netherlands

• University Hospital, Oslo, Norway

➤ The type of speech in cleft palate patient is called nasal snort.

➤ The three main factors which influence the outcome of surgery are surgical technique
used, skill of surgeon and timing of surgery.

Advanced Learning
Nasoalveolar moulding (NAM)/presurgical nasoalveolar moulding
(PNAM)
Nasoalveolar moulding (NAM) is a nonsurgical technique that has revolutionized the
treatment of children with large clefts of the lip and palate.
Dr Court Cutting and Dr Barry Grayson at New York University combined the
moulding techniques used in orthodontic work and the latest cosmetic surgical
techniques to develop nasoalveolar moulding.
Ideally, deficient tissue should be expanded and malpositioned structures should be
repositioned prior to surgical correction. Presurgical nasoalveolar moulding (PNAM)
includes not only reduction of the size of the intra-alveolar cleft due to moulding of the
bony segments, but also the active moulding and positioning of the surrounding soft
tissues affected by the cleft, including deformed soft tissue and cartilage in the cleft
nose.
The NAM is only effective in infants because their cartilage is malleable. After 6
months of age, child’s cartilage is no longer malleable, his/her teeth begin to come in
and he/she is able to take out the NAM appliance.
Goals of NAM
➤ To restore the correct skeletal, cartilaginous and soft tissue relationship presurgically

➤ To align and approximate the intraoral alveolar segments

➤ To correct the malpositioned nasal cartilages

➤ To correct the nasal tip and the alar base on the affected side(s), as well as the
position of the philtrum and columella

Advantages of NAM
➤ The NAM device reduces the number of surgeries required during a patient’s
lifetime, which in turn, reduces facial scarring, trauma, inconvenience and cost
involved in additional surgeries.

➤ Presurgical moulding means that things are where they should be (or as close as
possible) before the surgeon even makes the first incision.

➤ Because the NAM device covers the roof of the infant’s mouth, the NAM appliance
also helps with feeding.

➤ By the time of the surgery, the nose has been lifted and narrowed, the gap in the
gums is smaller and the lips are closer together.

➤ A smaller gap means less tension when the surgeon closes the cleft.

Procedure
➤ Step 1 is taking mould of the infant’s mouth.

➤ Step 2 involves creating a custom-made plastic plate of the child’s mouth, lip and
nostrils (Fig. 28.4).
 FIG. 28.4. The nasoalveolar moulding device. (A) The nasal stents and (B) the palatal
obturating segment.

➤ Step 3: Child will wear the plate 24 h a day for approximately 6 months. The plate is
held in the mouth by surgical skin tape that also helps guide the growth of the child’s
face.

➤ Step 4: Each week, the orthodontist will reshape the plate, reducing the child’s cleft
and reshaping his/her facial features.

Prenatal diagnosis of cleft lip and palate

Prenatal diagnosis of cleft lip and palate has become more common because of the
technical refinements of diagnostic tools.
Advantages of prenatal diagnosis (Lee W. Graber, Robert L. Vanarsdall Jr.,
and Katherine W. L. Vig)
➤ Prenatal diagnosis provides parents the opportunity to be psychologically prepared
for the birth of their infant with a facial anomaly.

➤ Prenatal counselling prepares the parents and caregivers to allow for realistic
expectations at the time of delivery.

➤ Helps in education of parents on the management of the cleft.

➤ Preparation for neonatal care.

➤ Coordinating with the geneticist will help in diagnosing chromosomal abnormalities.

➤ With the refinement of surgical procedure, possibility for fetal surgery.

➤ Increased choices for the parents on whether to continue the pregnancy.

Disadvantages of prenatal diagnosis
➤ There are reported incidences of emotional disturbances and high maternal anxiety
following prenatal diagnosis of cleft lip and/or palate.

➤ Potential for increased number of families choosing to terminate the pregnancy even
in the absence of other malformation.

Methods employed
1. 2-D ultrasonography

• Ultrasonography can detect 22–33% of facial clefting.

• Cleft lip is easy to diagnose with ultrasound than cleft

palate.

• Isolated cleft palate is more difficult to detect

sonographically.
2. 3-D ultrasonography

• This new technique helps in diagnosing clefts with greater

clarity.

• Sensitivity of three-dimensional imaging in cleft lip and

palate is greater.

• Permits to view different planes.

SECTION X
Corrective Orthodontics
OUTLINE

29. Management of intra-arch problems

30. Management of transverse malocclusions

31. Management of vertical malocclusions

32. Management of sagittal malocclusions

33. Management of problems in adult patients

CHAPTER 29
Management of intra-arch problems

CHAPTER OUTLINE
❖ Aetiology, clinical features and management of class I malocclusion with crowding
❖ Aetiology and management of class I malocclusion with spacing
❖ Median diastema
❖ Accessory points
❖ Advanced learning
❖ Transposition
❖ Rotation
Aetiology, clinical features and management of
class I malocclusion with crowding
Definition
Crowding is a condition where there is malalignment of teeth caused by inadequate
space (Fig. 29.1).

FIG. 29.1. Crowding.

Classification of crowding
There are different methods of classification of crowding.

1. Method I

• Hereditary crowding

• Environmental crowding
2. Method II
 1. Primary crowding: Determined genetically and is caused
by disproportionately sized teeth and jaws.

2. Secondary crowding: Acquired crowding is caused by

loss of arch length due to environmental cause.

3. Tertiary crowding: Also called late incisor crowding and

is due to late mandibular growth.
3. Method III

1. Simple crowding: This is due to disharmony between the

size of the teeth and the space available for them without
skeletal, muscular or functional occlusal problems.

2. Complex crowding: This is caused and associated with

skeletal, muscular and functional occlusal problems.
4. Crowding in mixed dentition

1. First-degree crowding: Slight malalignment of the

anterior teeth; no abnormality in supporting zone.

2. Second-degree crowding: Pronounced malalignment of

anterior teeth; no abnormality in supporting zone.

3. Third-degree crowding: Severe malalignment of all four

incisors; supporting zones restricted.

Aetiology of crowding
The aetiology of crowding can be broadly classified into:

Hereditary crowding
Tooth size–arch length discrepancy is the reason for hereditary crowding. True
hereditary crowding should be differentiated from environmental crowding. The signs
of hereditary crowding are:

1. Protrusion of incisors without spacing

2. Midline displacement of mandibular incisors with early exfoliation of deciduous

canine or blocked lateral incisor on the affected side

3. Ectopic eruption of first molars

Environmental crowding
1. Trauma

2. Discrepancy in individual tooth size

3. Iatrogenic treatment

4. Abnormal shape of the tooth

5. Abnormal eruption path

6. Rotation of tooth

7. Transposition of tooth

8. Ankylosed primary tooth

9. Premature loss of primary tooth

10. Prolonged retention of primary tooth

11. Altered eruption sequence

12. Proximal caries leading to arch length discrepancy

Clinical features of class I crowding

Molar relationship in class I; the signs of crowding are:

➤ Crowded mandibular incisor teeth

➤ Premature exfoliation of deciduous canines on the crowded side due to displacement

of erupting tooth

➤ Splaying out of maxillary permanent lateral incisor

➤ Gingival recession on the labial surface of prominent mandibular incisors

➤ Bulging of canines in the unerupted position

➤ Reduced leeway space

➤ Impaction of second permanent molar, if no treatment is given

➤ Vertical palisading of the permanent maxillary first, second and third molars

Management of crowding
Investigations: Mixed dentition model analysis like Moyer’s analysis is carried out to
find out the arch length discrepancy.
Management of crowding in mixed dentition is depicted in Table 29.1.

Table 29.1.
Crowding in mixed dentition–therapy

Note: Minimal or moderate crowding can be corrected by passive expansion achieved with functional regulator,
vestibular appliance.

Management of crowding in young adult

Investigations
➤ Arch length analysis for permanent dentition like Carey’s analysis should be carried
out.

➤ Complete Kesling’s diagnostic set-up should be carried out without proclining the
incisors.

➤ Treatment can be either by nonextraction or extraction.

Nonextraction
In cases with mild discrepancy, nonextraction method of treatment is followed.

➤ Proximal reduction and treatment with either removable appliances or fixed appliances.
➤ Lip bumpers are useful in increasing the arch length.

➤ Arch expansion procedures also can be carried out to alleviate crowding.

➤ Molar distalization is another method to gain space in minor crowding correction.

Extraction
Treatment planning should be aimed at the choice of extraction. After extraction,
treatment is done with preferably fixed appliance mechanotherapy. If there is any
unerupted tooth, it has to be brought into occlusion.
Aetiology and management of class I
malocclusion with spacing
Definition
Imperfections in the teeth alignment and distance, wherein there is a gap between two
teeth or many teeth.

Types of spacing
There are two types of spacing: (i) localized spacing and (ii) generalized spacing.

Localized spacing (fig. 29.2)

Localized spacing is a condition in which spacing is present in localized regions or
areas.

FIG. 29.2. Localized spacing.

Aetiology of localized spacing

1. Missing teeth:

a. Congenitally missing teeth: This causes localized spacing

but the problem may not be restricted to one particular
spot.

b. Unerupted teeth: Impacted or unerupted tooth causes

localized spacing; assess whether the tooth can be brought
 into normal position.

c. Premature loss of permanent teeth: In this situation, decision

has to be made whether to close the space or maintain the
space and replace it with an implant or bridge.
2. Prolonged retention of primary teeth: This results in (i) ectopic eruption of
permanent successor and (ii) when the primary tooth is exfoliated after ectopic eruption
of permanent successor space results.

3. Sucking habits: May cause localized spacing.

Generalized spacing (fig. 29.3)

The causes for generalized spacing are:

1. Microdontia: The presence of small teeth in the normal jaws will result in generalized
spacing. Such conditions are best treated by jacket crowns, composite build-ups or
consolidation of spaces and placement of bridges.

2. Macrognathia: This also manifests in the same way as small teeth. But here the teeth
sizes are normal, whereas the arch size is bigger.

a. Best method of treatment is to protract the posterior teeth

to close anterior spaces, if the profile is acceptable.

b. This eliminates chances for relapse.

c. Other methods will be jacket crowns, composite build-ups

or consolidation of spaces and placement of bridges.
3. Macroglossia: An unduly large tongue causes generalized spacing.

a. The lateral borders of the tongue show crenations or

indentations.

b. Treatment is not advisable, unless the malocclusion is

gross.
 c. If malocclusion is gross, partial glossectomy or excision of
wedge of tissue from tongue can be advised.
4. Sucking habits: May also cause generalized spacing.

5. Abnormal tongue posture: May also cause generalized spacing.

FIG. 29.3. Generalized spacing.

Management
Management of spacing can be done by orthodontic, or combined orthodontic and
prosthodontic treatment.

Orthodontic management
➤ Elimination of the habits by habit-breaking appliance.

➤ Localized spacing can be closed with removable appliances with springs.

➤ If there is proclination associated with spacing, Hawley’s appliances are used for
closing of spaces and retraction.

➤ Conditions where spaces are to be closed by protraction of posterior teeth can be

achieved only by fixed appliance mechanotherapy.

Retention: Cases treated orthodontically usually require long-term retention.

Prosthodontic management: Sometimes localized spaces are best treated by giving jacket
crowns or composite build-ups.

Combined orthodontic and prosthodontic management

➤ If the space is excess or severe, then the space is consolidated by using fixed
appliance therapy.

➤ In the consolidated space, either an implant is placed or a bridge is placed.

Median diastema
Median diastema (Fig. 29.4) is a form of localized spacing wherein there is space present
between two central incisors.

FIG. 29.4. Median diastema.

Causes of median diastema

The aetiology of median diastema is depicted in the flowchart.

Investigations
➤ Examine and confirm whether median diastema is localized or part of generalized
spacing.

➤ Measure the mesiodistal width of the teeth.

➤ Blanch test: Lift the upper lip and look for blanching of the soft tissues lingual to and
 between two central incisors. Presence of blanch indicates high frenal attachment as
cause of midline diastema.

➤ Assessment of deep overbite.

➤ Look for any pernicious oral habits.

➤ Periapical radiograph (V-shaped notching will be present between the central

incisors).

Approach to treatment and timing

1. Physiologic median diastema/ugly duckling stage:

• Spacing between central incisors is part of normal growth.

• This space becomes smaller as the lateral incisor erupts into

the arch.

• The appearance of the permanent canine brings about total

closure of the median diastema.

• This condition requires no treatment.

2. Ethnic and familial:

• Certain group of people, especially African populations,

exhibit median diastema as an ethnic norm.

• Median diastema is seen in some families also.

3. Imperfect fusion at the midline:

• Median diastema occurs due to imperfect fusion at the

midline of the premaxilla.

• A V-shaped or W-shaped osseous septum may be associated

with this condition.
• Treatment consists of excision of included interdental tissue
between the incisors.

• A flap is raised interdentally and fissure bur inserted gently

into the cleft.

• With the bur, the included tissues are removed and flap
sutured.

• An orthodontic appliance for closure of median diastema is

given during healing process.
4 and 5. Small teeth/microdontia and macrognathia: Such conditions can be treated
either by orthodontic means or by mean of jacket crowns or composite build-up.
Closure by jacket crown or composite build-up is the best method.

6 and 7. Missing teeth/extracted tooth: Space can be consolidated and replaced with
implant or bridge.

8. Peg lateral: After median diastema closure with orthodontic appliance, the peg-
shaped lateral incisors are reshaped either by jacket crowns or composite build-up.

9. Retained deciduous teeth: This will cause ectopic eruption of tooth and median
diastema.

• The retained deciduous tooth has to be extracted at the

earliest and allow for spontaneous closure of median
diastema.
10. Mesiodens: Mesiodens should be extracted and space closed.

11. Enlarged frenum: Frenectomy should be done after bringing the incisors together.
Scar tissue formed will help in retention.

12. Midline pathology: Midline pathology, like cysts, has to be treated first and then
closure attempted.

13. Deep bite: Along with closure of space, bite opening is done to achieve stable
results.
14. Elimination of habits: Median diastema due to pernicious habits requires
simultaneous discontinuation of the habit.

Orthodontic management of median diastema

Orthodontic management for median diastema can be divided into four main
categories:

1. Closure by mesial tipping movements

Appliances used are as follows:

• Removable appliance with two finger springs for mesial

movement of central incisors (Fig. 29.5).

• Removable appliance with split labial bow (Fig. 29.6).

• Ortho bands and elastics for the two central incisors.

2. Closure by bodily movement: This can be achieved with the use of:

• Edgewise appliance

• Preadjusted edgewise appliance (Fig. 29.7)

• Begg brackets with passive uprighting spring

3. Closure by reduction of overjet:

• In the case of patients, with increased overjet, reduction of

overjet will close the median diastema.

• Maxillary labial segment that exhibits median diastema is

drawn into smaller perimeter when the overjet is reduced.

• This causes spontaneous closure of diastema along with

overjet reduction.
• Removable Hawley appliance can be used for this purpose.

• Fixed appliances also are used.

4. Overall orthodontic treatment:

• When median diastema exists with other types of

malocclusion, closure of median diastema is carried out
along with other correction.

• This is best achieved by fixed appliance mechanotherapy.

FIG. 29.5. Finger springs used to close median diastema.

FIG. 29.6. Closure of median diastema by split labial bow.

 FIG. 29.7. Closure of median diastema by bodily movement.

Other methods of treatment

1. Restorative management: Very small median diastema is closed using composites.

2. Prosthetic management: If the diastema is big, closure by light-cure composite will

increase the mesiodistal width of the tooth to an unaesthetic level. In these cases, if the
arch is well aligned closure by giving an implant or a bridge is suggested.

3. Surgical management: Surgery is done in some cases where there is a median

diastema in otherwise normal occlusion.

ACCESSORY POINTS
➤ A midline diastema of 1.5 mm between the central incisors in a 9-year-old child
requires no treatment.

➤ Crowding due to disproportionately sized teeth and jaws is called as primary

crowding or hereditary crowding.

➤ Acquired crowding due to loss of arch length due to environmental cause is called
secondary crowding.

Advanced Learning
Transposition
Definition: A transposed tooth is that which is (i) changed in positional location to an
adjacent tooth or (ii) erupting into a position normally occupied by a non-adjacent
tooth.
There are two types of transposition: Incomplete transposition displays only crown
misplacement; complete transposition involves whole tooth.
Epidemiology
Sheldon Peck and Harvey Peck (1995) have quoted the most common transposition in
decreasing order of occurrence as follows:

➤ Maxillary canine with first premolar

➤ Maxillary canine with lateral incisor

➤ Maxillary canine with first molar

➤ Maxillary lateral with central incisor

➤ Maxillary canine with central incisor

➤ There is no definite evidence of sexual differences in transposition of canines

Classification
➤ Three part coding (Favot P, Attia Y and Garcias D, 1986)

➤ First part: Jaw of occurrence

➤ Second part: Transposed – tooth

➤ Third part: Site of transposition

For example, Mx C P1 means transposition of maxillary canine to first premolar

position.
Aetiology
➤ Retained primary canines are the best documented aetiologic factor (Shapiro Y, 1960)

➤ Roots of primary tooth deflect the permanent tooth

➤ Trauma in primary dentition

➤ Unknown aetiology

Management
➤ Early recognition might help to change the eruptive path.

➤ Leaving the transposed tooth is a prudent alternative sometimes, followed by

 occlusal equilibration.

➤ If associated with crowding, extraction and treatment with fixed appliance.

Rotation
Rotation is malposition due to abnormal turning of a tooth to its long axis (Fig. 29.8).

FIG. 29.8. Rotation.

Rotation can be defined as the spinning of the tooth around its long axis.
Types of rotation
1. Centric rotation – only rotation around the long axis.

2. Eccentric rotation – rotation with tipping of the tooth also.

• Derotation can be achieved by applying a couple.

• The forces get nullified and only moment exists which

causes rotation.

• Force required for rotation correction is 35–60 g.

• There is greater tendency for the rotation to relapse after

correction.

• Rotation can be achieved by two ways–by using a couple

force and by using a single force and a stop (Fig. 29.9).
FIG. 29.9. Methods of rotation. (A) Use of couple for correction and (B) use of single force and
stop.
CHAPTER 30
Management of transverse malocclusions

CHAPTER OUTLINE
❖ Define crossbite. What are the various types of crossbite?
❖ Aetiology, differential diagnosis and management of anterior crossbite
❖ Aetiology, differential diagnosis and management of posterior crossbite
❖ Accessory points
❖ Advanced learning
❖ Facial asymmetry
Definition and types of crossbites
‘Crossbite’ refers to a condition where one or more teeth may be abnormally malposed buccally or
lingually or labially with reference to the opposing tooth or teeth. (Graber TM)

Types of crossbite

Method 1

a. Anterior crossbite: (i) single tooth and (ii) multiple teeth

or segmental.

b. Posterior crossbite: (i) Unilateral, (ii) bilateral and (iii)

single tooth crossbite.

Method 2

a. Dental: (i) anterior and (ii) posterior

b. Skeletal: (i) anterior and (ii) posterior

c. Functional crossbite
Terminologies used

1. Anterior crossbite: This is a condition in which one or

more primary or permanent maxillary incisors are lingual
to the mandibular incisors.

2. Buccal crossbite: Condition in which the maxillary

posterior teeth is buccal to the mandibular antagonist.

3. Lingual crossbite: Condition in which the maxillary

posterior teeth are lingual to mandibular antagonist.
4. Scissors bite or telescopic bite: Mandibular teeth are
entirely lingual to the maxillary arch.
Aetiology, differential diagnosis and
management of anterior crossbite
I. Anterior crossbite

Anterior crossbite is a condition in which one or more primary or

permanent maxillary incisor is lingual to the mandibular incisor
(Fig. 30.1).

Synonyms: Reverse overjet, reverse bite, underbite.

II. Aetiology

Aetiology of anterior crossbite can be studied under dental,

skeletal and functional factors.

Dental factors:

• A dental anterior crossbite is because of abnormal axial

inclination of the maxillary incisors.

• The reasons for abnormal axial inclination:

• Trauma to primary teeth or to the permanent tooth bud

• Over-retained primary tooth

• Labially positioned supernumerary tooth

• Inadequate arch length which causes lingual eruption of

permanent tooth

• Lip biting habit

• Repaired cleft lip

Skeletal factors:

• Skeletal crossbite results due to excessive mandibular

growth.

• It is genetic or inherited malocclusion.

• In children with cleft palates where there is retrognathic

maxilla.

Functional factors:

• A dental crossbite also occurs due to functional interference

of the mandible during closure (Fig. 30.2).

• This is because of premature tooth contact.

• This results or leads to pseudo-class III malocclusion.

III. Unfavourable sequelae of anterior crossbite

• Loss of arch length as the adjacent teeth migrates.

• Excessive wear to the teeth.

• Traumatic occlusion of the unlocked tooth.

• Development of pseudo-class III.

• Hence, all anterior crossbites should be treated as early as

possible.
IV. Diagnosis/differential diagnosis
The factors to be considered in diagnosis:

Number of teeth involved: This gives an indication whether

the crossbite is dental or skeletal.

1. Single tooth crossbite – usually local origin and dental

crossbite or functional.

2. Segment crossbite – usually skeletal.

Locations of the tooth in crossbite: Permanent teeth are

usually deflected in their eruption path. Any deflection from
the original places indicates dental type of crossbite. In
skeletal crossbite, teeth are usually normally positioned.

Functional path of closure: Functional path of closure of

mandible and occlusal prematurities are important factors.
In initial or developing stages of crossbite, simple occlusal
grinding will eliminate the development of crossbite.

Molar and canine relationship: In dental crossbite, in centric

occlusion, molar and canine relationship will be class I. In
true skeletal crossbites, the molar and canine relationship
will be class III.

Radiographic findings: Lateral cephalography is useful:

• To find out skeletal discrepancy and axial inclination of the

incisors relation to the skeletal.
V. Treatment of anterior crossbite

Factors to be considered:
• Availability of mesiodistal space to correct the in-locked
tooth.

• Sufficient overbite.

• Position of the tooth.

• Occlusion – whether it is in class I or class III.

• Extents of root formation – light forces are advised for tooth

with incomplete root formation.

Methods of correction of anterior crossbite:

• Occlusal equilibration

• Tongue blade therapy

• Inclined planes

• Expansion appliances with either screws or cantilever

springs

• Fixed appliance

Occlusal equilibration for anterior crossbite:

• Anterior mandibular displacement (see Figs 26.2, 26.3 and

related text of Chapter 26 on Interceptive Orthodontics).

• Inclined plane: Refer to functional appliances for inclined

plane.

• Expansion appliances: Refer to Chapter 21 on Expansion

 Appliances

• Schwarz type expansion plate with posterior bite plane.

• Upper Hawley’s appliance with cantilever spring to move

the in-standing tooth. Posterior bite plane is added to the
Hawley’s appliance.

• Removable appliances with Z spring or double cantilever

spring.

• In class III cases, due to retrognathic maxilla, functional

appliances, like FR III, are used.

• Fixed appliance: The in-locked tooth or teeth is pulled into

correct labial position by fixed appliances.

FIG. 30.1. Anterior crossbite.

FIG. 30.2. Functional anterior crossbite.
Aetiology, differential diagnosis and
management of posterior crossbite
I. Definition

A posterior crossbite is an abnormal buccolingual relationship

of a tooth or teeth between maxilla and mandible when they
are brought into centric occlusion (Fig. 30.3).
II. Clinical presentation

Posterior crossbite presents as any one or combination of the

following ways:
either unilateral or bilateral
1. Lingual crossbite

2. Buccal crossbite

3. Complete lingual crossbite

III. Aetiologic factors

Aetiology of posterior crossbite can be studied under dental,

skeletal and functional factors.

a. Dental factors (dental crossbite)

The dental factors responsible for posterior crossbite:

• Faulty eruption pattern, where the tooth erupts out of

position.

• Insufficient arch length; this leads to lingual or buccal

deflection of teeth during eruption.
• Over-retained primary tooth; this leads to lateral shift of the
mandible.

• Ectopic eruption.

• Prolonged thumb or finger sucking: This causes narrowing of

the arches and lingual tipping of the posterior teeth.

b. Skeletal factors (skeletal crossbite)

Skeletal crossbite occurs due to two reasons:

1. Asymmetric growth of maxilla or mandible due to:

(a) Inherited growth pattern

(b) Trauma

(c) Long-standing functional problem.

2. Difference in basal width of the maxilla and mandible due

to:

a. Constricted maxilla

b. Cleft palate.

c. Functional or muscular crossbite

• This is due to functional adjustments to tooth interferences.

• In this condition, muscular adjustment is more when

compared to dental crossbites.
• Functional analysis has to be done.
IV. Unfavourable sequelae of posterior crossbite

• Abnormal wear of the dentition.

• Interference with normal growth and development of dental

arches.

• Pain due to muscle spasm.

• Possible damage to periodontium.

V. Differential diagnosis

• Study models using wax bite in centric relation is a useful

diagnostic aid.

• A dental crossbite will exhibit an abnormal buccal or lingual

axial inclination.

• A skeletal crossbite may not exhibit abnormal axial

inclination of teeth.

• Study models will show which tooth is at fault in the dental

crossbite whether maxillary tooth or mandibular tooth.

• Symmetry of the dental arches can be assessed using grids,

symmetroscope, Boley gauge or divider.

• This helps in diagnosing the arch at fault in skeletal

crossbite.

• Assessment of midlines by (posteroanterior) PA view

 radiographs or frontal cephalograms should be done.

• Midline should be assessed both in rest and centric

positions.

• Differential diagnosis of midline shift is as follows:

Possible combinations of crossbite are depicted in Fig. 30.4.

FIG. 30.3. Posterior crossbite.

 FIG. 30.4. Possible combinations of crossbite.

VI. Treatment of posterior crossbite

Factors to be considered:

• Availability of mesiodistal space to correct the crossbites.

• Position of the apical portion of tooth after treatment. This

should be in the same position as that of tooth in normal
occlusion.

• Types of tooth movement required, either tipping or bodily

movement.

1. Single tooth dental crossbite: Usually in single tooth

crossbite, both the antagonist teeth are tipped out of
position.
• Simple through the bite elastics are effective in the treatment
of such cases (Fig. 30.5).

• It is also called crossbite elastics.

• Disadvantages with this method:

i. Requires patient cooperation.

ii. Requires banding of the teeth.

2. Dentoalveolar contraction and crossbite: First any

functional interference present is eliminated by occlusal
equilibration.

Appliances given after occlusal equilibration:

a. Treatment of bilateral contraction of maxillary arch: (i) Quad

helix, (ii) W arch and (c) RME.

b. Treatment of unilateral contraction of maxillary arch: (i)

Removable plates, (ii) quad helix, (iii) W arch and (iv)
coffin spring.

c. Mandibular dentoalveolar contraction: (i) Quad helix spring.

3. Skeletal crossbite: This could be due to narrow maxilla or

narrow mandible.

a. Narrow maxilla: (a) Mild cases – quad helix or W arch; (b)

Severe cases – RME or Minnesota expander.

b. Narrow mandible – usually associated with retrognathic

mandible – functional appliances.
• Very severe cases are treated by surgery.

FIG. 30.5. Single tooth crossbite correction through the bite elastics.

ACCESSORY POINTS
➤ A crossbite is a dental malformation in transverse plane.

➤ An impending anterior crossbite should be treated as soon as it is noticed.

➤ Anterior crossbite causes localized gingival recession in children.

➤ Posterior crossbite is usually described in terms of position of upper molars.

➤ Laterognathia is true skeletal crossbite.

Advanced Learning
Facial asymmetry
Definition: ‘Dissimilarity of parts on either side of a straight line or plane or about a
centre or axis’. Although almost everyone has some facial asymmetry, this is usually
mild.
Aetiology
Samir E Bishara (1994) has classified into genetic/congenital and environmental causes
for facial asymmetry.
Genetic causes
➤ Craniofacial microsomia

➤ Unilateral cleft lip and palate

Environmental causes
➤ Intrauterine pressure

➤ Condylar hypertrophy

➤ Condylar fracture

➤ Pathologic conditions like infection, osteochondroma

➤ Habits

➤ Functional mandibular deviation, e.g. premature contacts

➤ Retained/missing teeth

Types
The facial asymmetry could be any one or combinations of the following types:

➤ Skeletal

➤ Muscular

➤ Functional

➤ Dental

Clinical assessment
Patient should be assessed in three planes:

➤ Skeletal assessment: Assess the facial proportion in all three planes (pitch, roll and
yaw).

➤ Soft tissue: Assess for bilateral symmetry and for deviation of dorsum and tip of
nose and the philtrum.

➤ Dental: Assess for functional displacement. Check occlusion in centric occlusion and
rest position. Look for open/deep bites, crossbite, rotations, midline and sagittal
relation.

Management
1. Skeletal asymmetry:
• Surgical intervention prior to adolescence is done with the
main goal to create an environment in which growth is
possible.

• Hence surgery is indicated only when abnormal growth is

making the problem worse.

• Hybrid functional appliances can be given.

• Surgical correction.
2. Dental/functional:

• Occlusal equilibration to correct functional disturbance

• Early correction of crossbite

• Space maintenance
CHAPTER 31
Management of vertical malocclusions

CHAPTER OUTLINE
❖ Aetiology, clinical features and management of deep bite
❖ Aetiology, clinical features and management of open bite
❖ Accessory points
❖ Advanced learning
❖ Short face/low-angle cases/hypodivergent face
❖ Long face/high-angle case /hyperdivergent face
Aetiology, clinical features and management of
deep bite
I. Deep Bite

Deep bite describes a condition of excessive overbite, where the

vertical measurement between the maxillary and mandibular
incisal margins is excessive when the mandible is brought into
habitual or centric occlusion. (Graber)
II. Concept of normal and excessive overbite

In normal overbite, the upper incisors slightly overlap the

lower incisors. It is usually expressed in millimetres.

Measure of overbite: Method 1

• The overbite is measured quickly by marking a short line on

the labial surface of the lower incisor with a sharpened lead
pencil.

• The distance from the incisal edges to the mark is then

measured with the use of Boley gauge or divider (Fig. 31.1).

• Normal value of overbite: 1–3 mm.

Method 2

• The overbite is also described as percentage of the

mandibular incisor crown length overlapped by maxillary
central incisors.

• Five to twenty per cent of overlap of the mandibular incisors

 is considered normal.
III. Unfavourable sequelae of deep bite

• Deep bite affects the facial aesthetics.

• Impairs the dental health of an individual.

• Excessive overbite where the lower incisors hit the lingual of

maxillary incisors or gingival tissues results in periodontal
destruction.

• There will be anterior migration of maxillary anterior teeth.

• Wear of mandibular incisors.

• Spacing in maxillary anterior region.

• Leads to problems in temporomandibular joint.

Diagnosis

Diagnostic aids required:

• Clinical examination

• Intraoral radiograph

• Study casts

• Lateral cephalogram.

Deep bite can be divided into dental and skeletal deep bite
following proper diagnosis.
Skeletal deep bite: May be due to malrelationship of alveolar
bones and/or underlying mandibular or maxillary bone.

Deep bite of dental origin: In this type of deep bite, the

problem lies in the dentition. The various causes for deep
bite are depicted in Table 31.1.

Table 31.1.
Causes of deep bite

Dental deep bite Skeletal deep bite

• Premature loss of permanent teeth causing lingual collapse of anterior teeth • Horizontal growth pattern
• Anterior tipping of posterior teeth • Short AFH
• Infraocclusion of posterior teeth due to tongue thrusting (Fig. 31.2) • PFH is long
• Supraocclusion of anterior teeth • UFH:LFH is reduced
• Occasionally deep bite is caused due to large-sized teeth • Interocclusal clearance is small
• Convergent rotation of skeletal jaw bases (Fig. 31.3)

Note: AFH, anterior facial height; PFH, posterior facial height; UFH, upper facial height; LFH, lower facial height

IV. Features of skeletal deep bite

• Deep curve of Spee in mandibular dentition.

• Reverse curve of Spee in maxillary dentition.

• When there is maxillary excess – gummy smile.

• Lower facial height is less.

V. Treatment planning

The primary determining factor in treatment planning is to

decide whether deep bite correction is achieved by intrusion
or extrusion. There are five important factors to obtain stable
relationship.

• Lip relationship

• Vertical facial relationship

• Occlusal plane

• Interocclusal space

• Age of patient and duration of treatment

1. Consideration of lip relationships

Incompetent lips Competent lips
1. Deep bite with large interlabial gap 1. Deep bite with less interlabial gap
2. Increased distance between incisal edge of incisors and upper lip (gummy 2. Normal or reduced distance between incisal edges of incisors and upper
smile) lip
↓ ↓
Bite opening by intrusion of anterior teeth Extrusion of posterior teeth

2. Consideration of vertical facial relationships

• Extrusion of 1 mm of posterior teeth results in increase in

anterior facial height by 2.5 mm.

• Therefore, extrusion mechanics has to be avoided in

patients with increased facial height or high mandibular
plane angle.

• In patients with class II division 2 malocclusion, extrusion

of posterior teeth may be the treatment of choice.

a. Increased anterior facial height (AFH) or increased FMA –

intrusion of anterior teeth.

b. Reduced AFH or reduced FMA – extrusion mechanism.

3. Consideration of occlusal plane

One of the objectives in correction of deep bite is to obtain a

flat occlusal plane. Flat occlusal plane or levelling of curve
of Spee can be obtained by intrusion, extrusion or relative
intrusion (see Fig. 23.2).

4. Consideration of interocclusal space

• Normal freeway space is 2–4 mm. This should be

maintained even after bite opening by extrusion. If the
interocclusal or freeway space is encroached upon, the
results will not be stable.

5. Age of patient

• In young patients, bite opening can be achieved through

orthodontic mechanism.

• In adults with skeletal problem, surgical approach is the

preferred method of treatment.

Treatment mechanics/appliances used

• This can be broadly classified into three types:

1. Intrusion mechanics

2. Relative intrusion technique

3. Extrusion mechanics

1. Intrusion mechanics

a. Burstone intrusion arch (Fig. 31.4): The intrusion arch is

made of 0.018 × 0.022 inches rectangular wires with helix
of approximately 3 mm in diameter. Helix is placed
anterior to the molar tube on both right and left sides.
Base arch is activated by placing bend at the wire near the
 helices. When the bend is given, the anterior part of the
wire lies gingivally. Wire is pulled down to the bracket
level, which causes intrusion force to the anterior.

b. Utility arches: Uses of utility arches were advocated by

Ricketts RM. There are four types of utility arches: (i)
Intrusion, (ii) retraction, (iii) protrusion and (iv) passive.
Intrusion utility arches are used for achieving intrusion of
anterior.

Utility arch with gable bend is a bypass type of arch wherein

the intrusion force is delivered directly to the incisors (Fig.
31.5). Intrusion can be achieved by two ways:

- First method: By placing an occlusally directed V-bend or

gable bend.

- Second method: By placing tip back bends in the molar

segment of the utility arch.

c. Reverse curve of Spee: Preformed archwires that are bent

in the direction opposite to curve of Spee are called reverse
curve wires. They are made from resilient wires. They are
used to flatten the curve of Spee.

d. Archwires with anchor bends or tip back bends: Tip

back bends or anchor bends are placed in continuous
archwire mesial to the molar tube. This causes intrusion of
the anterior and slight extrusion of posterior teeth.

2. Relative intrusion technique

Functional appliance: Functional appliances used during

 growth period cause relative intrusion. In this, the lower
incisors are prevented from erupting. The posteriors are
allowed to erupt. This causes opening of the bite (see Fig.
23.2).

3. Extrusion mechanics

Anterior bite plane: Both fixed and removable anterior bite

planes cause supra-eruption of posterior. When the
appliance is given, there should be posterior clearance by
1.5 mm. The bite opening by supraeruption of posterior
teeth should not encroach upon the normal freeway
space.

FIG. 31.1. Overbite–measurement.

FIG. 31.2. Dentoalveolar deep bite due to infraocclusion of molars and supraocclusion of
incisors.

FIG. 31.3. Skeletal deep bite due to convergent rotation of jaws.

 FIG. 31.4. Burstone intrusion arch.

FIG. 31.5. Utility arch with gable bend for intrusion.

Aetiology, clinical features and management of
open bite
Definition
1. ‘Open bite’ is descriptive of a condition where a space exists between the occlusal or incisal
surfaces of maxillary and mandibular teeth in the buccal or anterior segments, when the
mandible is brought into habitual or centric occlusion (Graber TM).

2. Open bite is a condition where there is localized absence of occlusion, while the remaining
teeth are in occlusion.

Incomplete overbite: In this condition, there is overjet present but not vertical overlap.
This is called incomplete overbite and is also called open bite tendency (Fig. 31.6).

FIG. 31.6. Open bite and incomplete overbite.

Aetiology of open bite

Aetiology can be classified under two headings (Fletcher BT, 1975):

1. Epigenetic factors

• Altered morphology and size of the tongue

• Disharmony in skeletal growth pattern of maxilla and
mandible

• Vertical relationship of jaw

• Tongue posture
2. Environmental factors

• Abnormal function like thumb-sucking habits

• Improper respiration (Linder-Aronson S, 1972)

• Tongue dysfunction

• Protracted tongue posture which is either:

• Endogenous – retained infantile swallow or

• Acquired adaptation – adaptation to inflamed tonsils

Diagnosis
Different forms of open bite may be observed:

1. Incomplete overbite: In this condition, there is overjet present but not vertical
overlap. This is called incomplete overbite and is also called open bite tendency.

2. Simple open bite: The problem is confined to the teeth and alveolar process. More
than 1 mm of space is seen between the incisors. The posterior teeth are in occlusion.

3. Complex open bite: There is disharmony in the skeletal components of the anterior
face height. Open bite extends from premolars or deciduous molars on one side to the
corresponding teeth in opposite side (Fig. 31.7).

4. Compound or infantile open bite: Compound or infantile open bite is completely

open up to the molars.

5. Iatrogenic open bite: Iatrogenic open bite is due to orthodontic treatment.

Treatment plan: The following factors are to be considered.

1. Balance between the nose, lip and chin.

2. Nasolabial angle:

• Acute – retraction of incisors will improve aesthetic

• Obtuse – proclination of incisors will improve aesthetic

3. Lip configuration

4. Length of the lower third of the face

5. Chin prominence

FIG. 31.7. Complex open bite. Disharmony of skeletal bases.

Treatment
1. Simple anterior open bite

• Most common reason for simple open bite is the digital

sucking.
• Habit breaking should be the primary objective of treatment
during mixed dentition.

• Along with habit breaking, open bite can be corrected.

• In mixed dentition, functional appliances like activator,

bionator or Frankel are indicated.

• Multibanded appliances are used to close the open bite

along with habit-breaking appliance in late mixed dentition
and early permanent dentition.

• Tongue spikes, either removable or fixed type is used to

prevent tongue thrusting or digit sucking.
2. Simple posterior open bite

Posterior open bites are relatively rare when compared to

anterior open bite. Causes for posterior open bite include
ankylosed primary molars, and lateral tongue thrust.

Early treatment: Bionator or activator with flanges is used to

prevent lateral tongue thrust.

Removal of ankylosed primary tooth; posterior open bite is

difficult to treat, if the tongue reflex gets fixed. A permanent
type of retention is required after correction.
3. Complex or skeletal open bite

Skeletal open bite is a symptom of serious skeletal dysplasia.

Early diagnosis of skeletal open bite is crucial – since it helps
to minimize the problem. Bionator or Frankel for open bite
correction is indicated for early management.
Features of skeletal open bite

• Palatal plane is tipped upward

• Steep mandibular plane

• Increased anterior facial height

• Obtuse gonial angle

• Narrow maxillary arch

• Excessive gingival display

• Decreased freeway space

Complex open bite is difficult to treat orthodontically.

Adult skeletal open bite: Adult skeletal open bite is best

treated by orthognathic surgery. The greater the skeletal
elements contribute to the aetiology, the poorer the
prognosis for treatment (Mizrahi E, 1978).

ACCESSORY POINTS
➤ ‘Deck biss’ – means ‘cover bite’ or closed bite or 100% deep bite.

➤ Apertognathia is the other name for open bite.

➤ Bite opening by relative intrusion is achieved during growth period.

➤ High mandibular plane angle cases are treated by high-pull headgears.

➤ Hawley appliance with anterior bite plane is used for correcting deep overbite.

➤ When upper incisors overlap the lower incisors completely it is called closed bite.

➤ Hypodivergent face means short face or low-angle case.

➤ Hyperdivergent face means long face or high-angle case.

➤ Extrusion of 1 mm of posterior teeth results in increase in anterior facial height by 2.5

mm.

Advanced Learning
Short face/low-angle case/hypodivergent face
Introduction
A type of vertical facial pattern can be described as hypodivergent. Hypodivergent
vertical dysplasia is clinically termed as short face. Generally facial pattern with
mandibular plane angle less than 20° is considered as hypodivergent. The following are
the features of low angle cases.
Extraoral features
➤ Brachycephalic head form

➤ Euryprosopic facial form

➤ Wide set eyes

➤ Prominent cheek bones

➤ Low mandibular plane angle

➤ Horizontal or orthognathic growth pattern

➤ Prominent chin

➤ Straight or dished in soft tissue profile

➤ Small gonial angle

➤ Large and broad ramus

➤ Reduced lower facial height

➤ Thin lips

➤ Strong masseter muscles

Intraoral features
➤ Flat palatal plane
➤ Broad arch

➤ Crowded mandibular incisors

➤ Deep overbite

Cephalometric features
➤ FMA <25°

➤ SN to MP <32°

Long face/high-angle case/hyperdivergent face

A type of vertical facial pattern can be described as hyperdivergent. Hyperdivergent
vertical dysplasia is clinically termed as long face syndrome. Generally facial pattern
with mandibular plane angle more than 30° is considered as hyperdivergent. The
features of high-angle case are as follows:
Extraoral features
➤ Dolichocephalic head

➤ Leptoprosopic face

➤ Long sloping forehead with heavy glabella

➤ Long and thin nose

➤ Large gonial angle

➤ Short ramus

➤ Long anterior face height

➤ Short posterior face height

➤ Downward and backward position of mandible

➤ Convex soft tissue profile

➤ Vertical mandibular growth

➤ Ectomorphy

➤ Weak temporal muscles

➤ Incompetent lip
Intraoral features
➤ Open bite relationship

➤ High and narrow-arched palate

➤ Arch length discrepancy

➤ Over-erupted incisors

➤ Impacted third molars

Cephalometric findings
➤ Prognathic maxilla

➤ Retrognathic mandible

➤ FMA >28°

➤ SN to MP >32°

➤ Small interincisal angle

➤ Vertical mandibular growth

CHAPTER 32
Management of sagittal malocclusions

CHAPTER OUTLINE
❖ Aetiology, clinical features and diagnostic features of class II division 1
malocclusion
❖ Management of class II division 1 in a growing child (mixed dentition period)
❖ Management of class II division 1 malocclusion in an adult
❖ Incisor edge–centroid relationship/edge–centroid relationship
❖ Class II division 2 malocclusion
❖ Class III malocclusion
❖ Differences between true class III and pseudo-class III
❖ Bimaxillary protrusion
❖ Accessory points
Aetiology, clinical features, and diagnostic
features of class II division 1 malocclusion
Introduction
Class II malocclusion is a condition in which the lower molar is positioned distal in
relation to upper molar.

Synonyms: Distocclusion/postnormal occlusion

➤ Class II malocclusion is divided into two types namely division 1 and division 2. If
the molar relation is class I on one side and class II on the other, it is called class II
subdivision malocclusion. The incidence of class II division 1 malocclusion is 20%
(Todd JE and Lader D, 1975).

Aetiology of class II division 1 malocclusion

1. Heredity: Heredity plays an important role as the aetiology of class II malocclusion.

• Inherited growth pattern of the jaw may manifest as

prognathic maxilla or retrognathic mandible.

• Sometimes both prognathic maxilla and retrognathic

mandible may be present.
2. Developmental defects: Micrognathia or small mandible may be due to congenital
defects like Pierre Robin syndrome, Treacher Collins syndrome.

3. Trauma: Birth injuries – mandible will become hypoplastic. Trauma to TMJ – causes
ankylosis and retarded growth of mandible (Vogelgesicht).

• Intrauterine pressure may lead to asymmetry and inhibited

growth of mandible.
4. Habits: Various pernicious habits like digit sucking, tongue thrusting, mouth
breathing can cause class II division 1 features.

5. Posture: Faulty body posture leads to undesirable mandibular posturing and

retruded mandible.
6. Diseases: Nasopharyngeal disease will cause increased proclination and class II
malocclusion.

Clinical features
The various clinical features can be analysed under the following headings:

1. Skeletal features:

The skeletal pattern is class II, the severity of condition depends on the degree of
skeletal discrepancy. The possible types of skeletal discrepancy are prognathic
maxilla, retrognathic mandible, combination of prognathic maxilla and retrognathic
mandible (Fig. 32.1). Some cases will be associated with receding chin.

2. Soft tissue features:

• Convex profile

• Posterior divergence

• Incompetent lips or potentially incompetent lips

• Due to increased overjet, there will be lip trap

• Hyperactive lower lip/mentalis activity

• Abnormal buccinator activity due to posterior placement of

tongue
3. Occlusal features (Fig. 32.2):

• Class II molar relation

• Class II incisor relationship due to increased overjet

• Overbite is frequently deep

• If associated with thumb sucking, incomplete overbite or

open bite
• Deep curve of Spee

• Canine relationship will be class II

• Crossbite and scissors bite may occasionally be present

4. Facial growth:

Varying types of growth pattern are seen.

• Cases with horizontal growth pattern respond well to

functional appliance therapy.

• Vertical growth patterns are difficult to treat.

5. Functional features:

• Abnormal swallowing pattern may be evident.

• Hyperactive mentalis.

• Path of closure will be deviated due to crossbite.

FIG. 32.1. (A) Class II due to prognathic maxilla, (B) class II due to retrognathic mandible and
(C) class II due to combination of prognathic maxilla and retrognathic mandible.
 FIG. 32.2. Class II division 1 dental features.

Investigations or diagnostic features

➤ Model analysis: Will show arch length discrepancy.

➤ Functional analysis: Will reveal aberrations in normal functions like respiration,

swallowing and path of closure.

Cephalometric findings
The usual possible cephalometric findings in class II division 1 malocclusion are
enumerated in Table 32.1.

Table 32.1.
Cephalometric findings in class II division 1 malocclusion

Increased SNA >84° Prognathic maxilla

Decreased SNB <78°
Increased ANB >4°
Increased upper 1 to NA angle
Reduced interincisal angle
Increased FMA >28°
Decreased FMA <23°
Increased IMPA >90°
Retrognathic mandible
Class II skeletal base
Proclined upper incisor
Proclined upper and lower incisors
Vertical growth
Horizontal growth
Proclined lower incisors
Management of class II division 1 in a growing
child (mixed dentition period)
1. Treatment objectives

The objectives of treatment planning in correcting a class II division 1 malocclusion in a

growing child are:

• Relieve crowding and irregularities of teeth

• Correction or improvement of skeletal discrepancy

• Establish stable class I incisor relationship

• Establish normal overbite

• Correction of molar and canine relation

• Improving facial aesthetics

2. Treatment plan for class II malocclusion in growing child

Flowchart depicts treatment plan for class II malocclusion in a growing child.

3. Correction of skeletal class II malocclusion

• A growing patient with skeletal class II malocclusion should

be treated by growth modulation.

• The skeletal age and growth potential can be assessed with

hand–wrist radiograph.

• Lateral cephalograms help to locate the skeletal problem.

Prognathic maxilla:

• Growth inhibition of the maxilla for prognathic maxilla, with

distalization of upper buccal segments is achieved by using
extraoral orthopaedic force.

• Headgears are used for orthopaedic force.

• Patient wears the appliance for 12–14 h a day.

• Orthopaedic force of 350–450 g/side is applied.

• High-pull or occipital-pull headgear is used for vertically

growing patients.

• Cervical-pull headgear is used for horizontal growing

patients.

• Maxillary intrusion splint is used in patients with vertical

maxillary excess.
Retrognathic mandible:

• Growth stimulation of the mandible is induced using

functional appliances.
• Functional appliances act by placing the mandible in
anterior position and also by eliminating functional
retrusion.

• Commonly used functional appliances for class II correction

are activator, Frankel, twin block and bionator.

• During late mixed dentition in children with residual

postpubertal growth, fixed functional appliances like Herbst
and Jasper jumpers are used.
Combination of prognathic maxilla and retrognathic mandible:

• Growth modification is done by combination of headgear

and functional appliances.

• Activator with headgear is commonly used.

4. Correction of dentoalveolar class II with class I skeletal base (Fig. 32.3)

• In dentoalveolar class II, the skeletal base is normal or

orthognathic. The defect lies in the dentoalveolar part.

• Establishment of normal incisor and molar relationship is

one of the aims of early correction.

• If this is achieved, the other teeth usually settle in normal

position and function.

• Correction of crowding is achieved by gaining space either

by distalization of molars or extraction.

• Deep bite correction is achieved by using anterior bite planes

in low-angle case.
• In high-angle cases, incisor intrusion is achieved using utility
arches.

• Retraction of incisors is achieved by using labial bows or

with fixed appliance mechanotherapy.

• Posterior crossbites are corrected using crossbite elastics.

• Any habit should be corrected simultaneously.

Retention after class II correction: Tweed’s type B retention plan is used.

FIG. 32.3. Dentoalveolar class II. Note the skeletal bases are in a normal relation.
Management of class II division 1 malocclusion
in an adult
1. Treatment objectives

• Relieve crowding and irregularities of teeth.

• Correction or improvement of skeletal discrepancy either by

surgery or camouflage.

• Establish stable class I incisor relationship.

• Establish normal overbite.

• Correction of molar and canine relation.

• Improving facial aesthetics.

2. Treatment plan for class II correction in adult

Treatment plan for class II malocclusion in adult is as follows:

3. Orthodontic camouflage

• Orthodontic camouflage implies repositioning the teeth

without correcting the skeletal problem.
• The objective of orthodontic camouflage is to correct the
malocclusion which makes the underlying skeletal problem
less apparent.

• Class II malocclusions often can be camouflaged.

• Indications for camouflage treatment:

• Patients too old for growth modulation

• Mild or moderate skeletal class II

• Good alignment of teeth

• Good vertical proportions

Extractions for camouflage are done in three possible ways: (i) Extraction of upper first
premolars, (ii) extraction of upper and lower first premolars and (iii) extraction of
upper first and lower second premolars.

• Extraction of upper first premolars alone is done when only

retraction of proclined incisors is required.

• If crowding correction or proclination correction is required

in the lower arch then extraction of both upper and lower
first premolars is done.

• Extraction of lower second premolar is done for molar

correction.

• Orthodontic camouflage is achieved through fixed

appliance.

• Camouflage is best performed in adolescents but it is also

done in adults.
4. Surgery

In severe class II skeletal malocclusion, surgery is the apt form of treatment.

• Envelope of discrepancy will act as a guideline in selecting

cases for orthognathic surgery.

• The various surgical procedures carried out are as follows:

1. Prognathic maxilla – (a) Le Fort I osteotomy, (b) anterior

maxillary osteotomy.

2. Retrognathic mandible – (a) sagittal split, (b) oblique

osteotomy – advancement procedure.

3. Combination – Bijaw surgery with genioplasty, if

required.
5. Orthodontic correction

• Establishment of normal incisor and molar relationship is one

of the aims of early correction.

• If this is achieved, the other teeth usually settle in normal

position and function.

• Correction of crowding is achieved by gaining space either

by distalization of molars or extraction.

• Deep bite correction is achieved by using anterior bite planes

in low-angle case.

• In high-angle cases, incisor intrusion is achieved using utility

arches.
• Retraction of incisors is achieved by using labial bows or
with fixed appliance mechanotherapy.

• Posterior crossbites are corrected using crossbite elastics.

• Any habit should be corrected simultaneously.

Incisor edge–centroid relationship/edge–centroid
relationship
The relationship between the incisal edges of the lower incisors and the centroid of the upper
incisor is called the incisor edge–centroid relationship (Fig. 32.4).

➤ For a stable occlusion, the lower incisor edge should be 2 mm in front of the centroid
of the upper incisor (Houston WJB, 1989).

➤ When the lower incisor edges lie behind the upper centroid, it should be corrected.

Correction of unfavourable edge–centroid relationship: Mild cases are treated with

removable appliances. Severe cases are treated with fixed appliance.

Upper anterior bite planes: These are effective in correcting the edge–centroid
relationship (Fig. 32.5).

Retraction of upper incisors by extraction of upper first premolar is the simplest way of
providing space to establish normal edge–centroid relationship. In severe cases,
normal edge–centroid relationship is achieved by both palatal movement of upper
incisors and labial movement of lower incisors.
 FIG. 32.4. Edge–centroid relationship.

FIG. 32.5. (A–C) Effects of anterior bite plane and (D) intrusion of molars cause deepening of
bite and unfavourable edge–centroid relationship.
Class II division 2 malocclusion
Class II division 2 malocclusion is generally the result of dentoalveolar compensation
for a class II skeletal pattern by retroclination of the upper central incisors. The overbite
also will be deep. The incidence of class II division 2 malocclusion is 5% (Todd and
Dodd, 1975).

I. Clinical features

Clinical features of class II division 2 can be studied under the following headings:

Skeletal features:

• The skeletal pattern may be class I or class II.

• Class II skeletal pattern is usually mild when compared to

division 1 pattern.

• In the vertical dimension, the lower anterior face height is

smaller.

• FMA is low.

• Deep bite will be moderate to severe. Lower facial height

will be reduced.

• Transversely, the maxillary arch may be broad relative to

mandibular arch.
Soft tissue features:

• The level of the lower lip is high relative to the upper incisor
crown.

• Because the lower lip is high, it causes the upper incisors to

retrocline since the skeletal pattern is not severe.
• If the skeletal pattern is severe, the upper teeth will lie
outside the lower lip, and this will cause proclination as in
class II division 1 malocclusion.

• Hyperactive lower lip.

• Deep mentolabial fold.

• Because of chin prominence, the profile may be straight.

• Competent lips.

• Strong musculature will be present.

• Trauma to the palatal gingiva due to closed bite of lower

incisor.
Occlusal features (Fig. 32.6):

• Class II molar relationship

• Class II division 2 incisor relationship

There are three types of incisor relationship. They are as follows:

• Type A: Retroclined upper central and lateral incisors

• Type B: Retroclined upper central incisors and proclined

lateral incisors

• Type C: Retroclination with crowding of upper anterior

teeth

• Retroclined lower anterior teeth

• Excessive deep overbite

• Increased curve of Spee

• Increased interocclusal clearance or increased freeway space

• Class II canine relation

• Lower anterior crowding

Facial growth:

• Anterior mandibular rotation or horizontal type of growth

pattern seen.

• Favourable for functional appliance therapy after alignment

of incisors.
Functional features:

• There will be posterior displacement of mandible due to

over closure (Fig. 32.7).

• This is called functional retrusion of mandible.

• The path of closure of mandible will be upwards and

backwards.

• Usually associated with large interocclusal distance.

 FIG. 32.6. Dental features of class II division 2 malocclusion.

FIG. 32.7. (1) Rest position, (2) abnormal contact, (3) closed position, (A+B) interocclusal
distance of patient.
II. Treatment of class II division 2 malocclusion

1. Child

a. Skeletal – functional appliances after alignment of incisors

b. Dental – orthodontic correction

2. Adult

a. Skeletal malocclusion – corrected by either (i) orthodontic

correction or (ii) surgery.

b. Dental malocclusion – corrected by orthodontics.

III. Objectives of treatment

• Correction of potentially traumatic deep bite.

• Alignment of upper incisors.

• Relieving the crowding in the lower arch.

• Elimination of functional retrusion.

• Establishing class I molar relation.

IV. Functional appliances

• Children seeking orthodontic correction due to class II

division 2 are less when compared to class II division 1.

• The reason is that the profile is not seriously affected in a

child with class II division 2 malocclusion.
• Functional appliances with modification for division 2
malocclusion are used.

• Usually the incisors are aligned before giving functional

appliances.
V. Removable appliances

• Removable appliances are usually used to assist in the

reduction of deep overbite.

• In mild cases, simple removable appliances alone will be

enough.

• Removable appliances are not used in conditions which

require premolar extraction.

• Removable appliances used:

• Hawley’s appliance with anterior bite plane.

• Hawley’s appliance with double cantilever springs.

VI. Fixed appliance in the upper arch

• Fixed appliance in the upper arch alone is indicated when

the overbite and incisor inclination is acceptable.

• Molar distalization is done and the space gained is used to

align teeth.
VII. Upper and lower arch fixed appliance

This appliance is indicated when the following objectives are to be achieved:

• Extraction and correction of crowding

• Overbite correction by active intrusion

• Achieve proper interincisal angle

• To torque the incisors

VIII. Orthognathic surgery

In the most severe form of class II division 2 malocclusion, combination of orthodontics

and jaw surgery is done.

• After alignment of incisors, the overjet will be increased in

presurgical phase.

• Mandibular advancement is done by orthognathic surgery.

• Postsurgical orthodontics for levelling and finishing will be

required.
IX. Retention

• Prolonged retention should be planned.

• Pericision is done for the incisors (Edwards JG, 1970).

• In cases treated after growth, fixed permanent retention is

advisable.
Class III malocclusion
Class III malocclusion is found in about 3% of the population. Class III malocclusion is a
condition in which the lower molar is positioned mesial to the upper molar.
Synonyms: Mesiocclusion, prenormal occlusion.

Aetiology
Environmental factors play small or negligible role in the genesis of class III
malocclusion.

1. Functional factors: These influence the development of class III malocclusion.

• Unfavourable anterior incisal guidance promotes class III

relationship.

• If functional cases are not treated, they can become a true

class III malocclusion.

• Premature loss of deciduous molars also may cause

mandibular displacement.

• Loss of posterior teeth results in loss of posterior

proprioceptive support in habitual occlusion.
2. Soft tissue factors: A flat anterior positioned tongue that lies low in mouth is said to
cause class III malocclusion.

• Lack of eruption of posterior teeth due to lateral tongue

thrust results in overclosure of mandible. This causes
autorotation which leads to class III formation.
3. Heredity: Heredity plays an important role in skeletal or true class III malocclusion.

4. Racial: Class III malocclusion is found commonly in certain races, e.g. Habsburg jaw
in German royal family.

Clinical features
Clinical features in class III malocclusion (Fig. 32.8) are studied under following
headings:

1. Occlusal features

• Class III molar relation: The lower dental arch is in anterior

relation to the maxillary arch. Mesiobuccal cusp of the upper
first permanent molar occludes with the interdental space
between the lower first and second permanent molars.

• Class III canine relation: Upper canine occludes with the

interdental space between lower first and second premolars.

• Severity of the incisor malrelationship varies greatly.

• It could be edge-to-edge or reverse overjet.

• Frequently, the lower incisors are retroclined.

• The overbite also varies between cases.

• Deep bite or open bite will be seen.

• Crowding will be present in some cases.

• Upper arch is narrow and lower arch broad. This could lead
to crossbite.
2. Skeletal features

a. Sagittal: Usually class III skeletal pattern exists as

(Edmund C Guyer, Edward E Ellis, James A McNamara
Jr. and Rolf G Behrents, 1986): retrognathic maxilla,
prognathic mandible or combination (Fig. 32.9).
• Sometimes the skeletal pattern will be class I with
dentoalveolar class III (Fig. 32.10).

b. Vertical: Class III malocclusion is associated with both

increased and reduced facial height or average facial
height. Accordingly, the Frankfort mandibular angles are
high, low or average.

c. Transverse: In many cases, maxilla is narrow and the

mandibular base wide.
3. Soft tissue features

Profile – concave

Divergence – anterior

Lips – frequently incompetent

Upper lip – may be short

Tongue pattern – more anteriorly placed

4. Functional features

• There is forward displacement of mandible.

• Lateral mandibular displacement is also found when there is

unilateral crossbite.

• In pseudo-class III, patients will have class I skeletal pattern,

the abnormality is due to tilting of the tooth.

• The path of closure is upwards forward and forwards.

5. Growth

• Facial growth is unfavourable in most of the class III cases.

• Vertical facial growth increases the tendency to open bite.

• Excessive horizontal growth causes the reverse overjet to

become worse.

FIG. 32.8. Dental features of class III malocclusion.

 FIG. 32.9. (A) Prognathic mandible, (B) retrognathic maxilla and (C) combination of
retrognathic maxilla and prognathic mandible.

FIG. 32.10. Dentoalveolar class III skeletal pattern.

Diagnostic features of class III

➤ Model analysis will show arch length discrepancy.

➤ Functional analysis will reveal aberrations in normal function like respiration,

swallowing and path of closure.
Cephalometric findings
The usual cephalometric findings are depicted in Table 32.2.

Table 32.2.
Cephalometric findings in class III malocclusion

Decreased SNA <78° Retrognathic maxilla

Increased SNB >82°
Decreased ANB <1° or negative
Increased upper 1 to NA
Reduced interincisal angle
Increased FMA >28°
Decreased FMA <23°
Increased IMPA >90°
Decreased IMPA <90°
Prognathic mandible
Class III skeletal base
Proclined upper incisors
Proclined upper and lower incisors
Vertical growth
Horizontal growth
Proclined lower incisors
Retroclined lower incisors

Management
Management flowchart for class III malocclusion is depicted in Fig. 32.11.

FIG. 32.11. Treatment plan for class III malocclusion.

Treatment objectives
➤ To achieve growth modulation in skeletal case

➤ To relieve crowding and produce alignment of teeth

➤ To correct incisor relationship to obtain normal overjet and overbite

➤ To eliminate anteroposterior and unilateral lateral crossbite

➤ Stable molar relationship

1. Skeletal class III in growing child

a. Midface deficiency (retrognathic maxilla)

• When midface deficiency is diagnosed, functional appliances

are indicated in primary dentition or early mixed dentition.

• FR III is widely used. Other functional appliances that can be

used are reverse activator, reverse bionator and twin block
for class III.

• Reverse-pull headgears are also used in cases with maxillary

deficiency.

b. Mandibular prognathism: Extraoral appliance, like chin

cap, is used as an early form of treatment.

c. Combinations: Devices which combine midface

protraction and chin cap are ideal for the cases. Reverse-
pull headgear can be used. FR III with chin cap can be
used.
2. Class III skeletal problem in adult

a. Camouflage: This can be used in mild skeletal class III

problems.

• But usually camouflage is less successful in class III when

compared to class II problems.

• Lower premolars are extracted and combined with class III

elastics and chin cap to produce good dental occlusion.

• The drawback with camouflage is that retraction of lower

 incisors makes the chin more prominent.

• The other extraction pattern for class III camouflage is

extraction of upper second premolars and lower first
premolars.

• This is followed by class III intermaxillary elastics which aid

in lower incisor retraction and molar correction (Fig. 32.12).
Surgical management: The maxilla may be advanced or mandible pushed back as the
condition demands. Sometimes a combination of upper and lower jaw surgery is
performed with reduction genioplasty.

3. Functional class III/postural class III/pseudo-class III

This is a postural malrelationship due to reflex functional mandibular protrusion.

• There is shift from class I to class III as the mandible closes.

• Early treatment consists of occlusal equilibration.

• Late treatment consists of correcting the anterior crossbite or

functional interference.
4. Dentoalveolar correction

a. Removable appliances: Removable appliances are

effective when one or two incisors are in crossbite
associated with functional displacement.

• Effective during mixed dentition period.

• Adequate overbite is essential.

• Appliances like anterior expansion plates and Z springs are

used to achieve labial movement of palatally placed incisors.
 b. Fixed appliances: In a suitable case, fixed appliance gives
excellent result.

• Case selection is critical.

• Cases are treated either by extraction or by nonextraction.

FIG. 32.12. Class III elastics.

Differences between true class III and pseudo-
class III
Pseudo-class III malocclusion is a positional malrelationship due to reflex functional
mandibular protractions.

Synonyms: Pseudo-class III, postural class III, compulsive prognathous occlusion,

functional class III.

Clinical features or differences between pseudo- and true class III malocclusion are
depicted in Table 32.3.

Table 32.3.
Pseudo and true class III malocclusion–differences

S.
Pseudo-class III True class III
no.
1. This has a normal class I skeletal base This has a class III skeletal base
2. Class I molar relationship in rest position Class III molar relationship in rest position
3. Associated with functional interference when mandible moves from rest position to May not be associated with functional interferences; not a
occlusion rule
4. There is shift from class I to class III molar relationship as the mandible closes in centric Class III in centric occlusion
occlusion
5. Patient can move mandible backwards to edge-to-edge or normal overbite Patient cannot move mandible backward to edge-to-edge
6. Path of closure is upwards and forwards up to initial contact and then forwards Path of closure is upwards and forwards
7. Usually associated with deep bite Varying overbite present
8. There is overclosure of mandible May or may not be associated with overclosure
9. Associated with large freeway space May not be associated with large freeway space
10. Maxillary arch may be constricted Well-developed maxillary arch
11. This is a postural malrelationship due to reflex mandibular protraction It is a skeletal dysplasia involving mandibular
hypertrophy
12. Profile of the patient improves as the mandible drops from centric to rest position No improvement in profile

Treatment of pseudo-class III

1. Occlusal equilibration: In the early stages, patients can be treated by equilibration
alone.

2. Inclined plane: Inclined planes act as extension of the lower incisal edges by
contacting the palatal surfaces of maxillary incisors. On closing, the mandible is forced
to be retruded. Maxillary teeth are tipped labially.

3. If the bite is shallow, then posterior bite blocks with Z spring to move the palatally
placed maxillary incisors can be given.
Bimaxillary protrusion
There are two types of bimaxillary protrusion. They are (i) bimaxillary prognathism and
(ii) bimaxillary dental protrusion.

1. Bimaxillary prognathism

• Bimaxillary prognathism is a skeletal problem in which both

maxilla and mandible are placed forward than normal in
relation to cranium.

• Because bimaxillary prognathism is a problem in the basic

morphology and growth pattern of the bony skeleton,
interception does not produce very satisfactory results.

• Bimaxillary prognathism is seen as ethnic type of

malocclusion.

• Bimaxillary prognathism may exist alone or in combination

with bimaxillary dental protrusion.
Treatment: Treatment consists of camouflage or combined orthodontics and surgery.

• Camouflage treatment consists of symmetric extraction of

premolars (mostly first premolar) and retraction of incisors.

• More severe cases are treated by combined orthodontics and

surgery.
2. Bimaxillary dental protrusion

• Bimaxillary dental protrusion is proclination of both upper

and lower dentitions on normal bony base.

• Diagnosis is confirmed by measuring the interincisal angle.

• Treatment consists of symmetric extraction of four first
premolars and treatment with fixed appliance
mechanotherapy.

• Results are more satisfactory than the treatment of

bimaxillary prognathism.

ACCESSORY POINTS
➤ In severe class II malocclusion, angle ANB is large.

➤ Wits cephalometric analysis assists in diagnosing sagittal malocclusion.

➤ In class III skeletal pattern, angle SNA is less than angle SNB.

➤ Pseudo-Class III is on account of deviated path of closure.

➤ Wash board appearance is seen in compensated class III malocclusion and class II division
2 malocclusion.

➤ Orthodontic camouflage implies repositioning the teeth without correcting the skeletal
problem.

➤ Relationship between the centroid of maxillary incisors and incisal edge of

mandibular incisor is termed as edge–centroid relationship.
CHAPTER 33
Management of problems in adult
patients

CHAPTER OUTLINE
❖ Adult orthodontics
❖ Adjunctive orthodontic treatment
❖ Comprehensive treatment of adult
❖ Accessory points
❖ Advanced learning
❖ Obstructive sleep apnoea (OSA)
❖ Management of medically compromised patients in
orthodontic practice
❖ Trauma and orthodontics
Adult orthodontics
The number of adults seeking orthodontic treatment is on the rise. Adults who seek
orthodontic treatment can be grouped as follows:

1. Younger adults less than 35 years of age who seek orthodontic correction of
malocclusion.

2. Older group of adults (40s) who require orthodontic treatment as part of larger
treatment plan.

The treatment for adults is broadly classified into two types–adjunctive and
comprehensive treatment.
Adjunctive orthodontic treatment: The orthodontic treatment procedures are carried
out to facilitate other dental procedures to control disease and to restore function.
Comprehensive orthodontic treatment: This is essential treatment procedure carried
out in children for correction of malocclusion. Important difference in adult is the
absence of growth, which means growth modification is not feasible. These treatment
procedures require complete fixed appliance and require more than 6 months for
completion of treatment.

Adjunctive orthodontic treatment

1. Goals of adjunctive orthodontic treatment

• To facilitate restorative treatment by proper positioning of

teeth so that ideal and conservative techniques can be
carried out.

• Improve periodontal health by eliminating plaque-prone

areas due to malocclusion.

• To establish favourable crown to root ratio.

• To place the tooth in proper position so that the occlusal

forces are transmitted through the long axis of the teeth.

• Typically adjunctive orthodontic treatment procedures

require only less time (usually less than 6 months). The
 appliances are required only for a part of the dental arch.

• Adjunctive orthodontic treatment requires proper

coordination with periodontist and conservative dentist.
2. Timing and sequence of comprehensive treatment

The first step is the control of the dental disease problems.

• Caries, pulpal pathology must be treated.

• Restorative and endodontic procedures are carried out.

• If there is any periodontal problem, that also has to be

treated before orthodontic treatment.

• Scaling, curettage and gingival grafts should be done prior

to orthodontics. Period of 6 months to be allowed for
healing and commencement of orthodontic treatment.

• Osseous surgery and surgical pocket elimination are done

after orthodontic treatment since during tooth movement
soft tissue and bone recontouring occurs. Fig. 33.1 depicts
sequence of comprehensive treatment.
3. Adjunctive treatment procedures

a. Uprighting of molars: Many adults will have loss of

posterior tooth, usually first permanent molars.

• When a first molar is lost, the adjacent teeth drift, tip and
rotate (Fig. 33.2).

• The gingival tissues get folded and there is formation of

 periodontal pocket and poor interproximal contact.

• Uprighting of molars eliminates the periodontal problems,

create space for pontic or close the space, if there is
negligible residual space.

Appliances used: Partial fixed appliance with uprighting

springs. As a guideline, prosthesis should be given within 6
weeks after completion of uprighting.

b. Forced eruption: Forced eruption or crown lengthening is

done to increase the crown-to-root ratio.

• Fracture tooth/teeth with defects in the cervical 3rd of roots,

tooth with one-walled periodontal defects are candidates for
forced eruption.

• Extrusion is done to cause eruption of the tooth.

• Endodontic therapy is carried out before orthodontic

extrusion.

• Crown-to-root ratio after treatment should be minimum 1:1

or better.

Appliances used (Fig. 33.3): Extrusion with and without

orthodontic bracket can be achieved.

c. Alignment of anterior teeth: The reasons for alignment of

anterior teeth in adults are:

• To improve access and to facilitate proper placement of

restorations.
• To facilitate placement of normally contoured crowns and
pontic.

• To reposition the roots; this helps in improving the

embrasure form and increase the amount of interradicular
bone.

• To facilitate proper placement of implants.

d. Positioning tooth for implants: In some cases, implants are

placed for replacement of teeth.

• The teeth have to be properly positioned for efficient

placement of implants.

• Usually implants for prosthesis are placed after the cessation

of vertical growth.

• In boys, it will be about early 20s and in girls 15–17 years of

age.

e. Crossbite correction: Crossbite in adults can be corrected

using removable and fixed appliances.

• Removable appliances are indicated when the correction

requires only tipping movements. With removable
appliances, there is reduction in overbite. This is a drawback
as establishing a good overbite relationship is the key to
maintain crossbite correction.

Fixed appliances: If vertical control is critical and if bodily

movement is required, then arch appliances are utilized.

f. Diastema closure: Closure of anterior space is easy. The

 problem is that it requires permanent retention.

• In adults for better aesthetics, partial closure of incisor space

and redistribution of the space is done. This is followed by
composite build-up.

FIG. 33.1. Flowchart showing sequence of comprehensive treatment.

FIG. 33.2. Effect of loss of first permanent molar.

 FIG. 33.3. Forced eruption with orthodontic brackets.

Comprehensive treatment of adults

There are not much of difference in orthodontic treatment between adults and children.
Response to orthodontic force may be slightly slower in adults when compared to
children. The special consideration for adults comes under three categories: (i)
Motivation for adult patient, (ii) periodontal aspects and (iii) lack of growth and special
aspects.

Motivation for adult patient

There are three reasons for the adult to seek orthodontic treatment.

1. Psychological aspects: Adults seek orthodontic treatment because they themselves

expect something out of treatment.

• Orthodontic treatment is sought as a last ditch effort to

improve personal appearance to overcome social problems.

• Since the adults seek treatment because of internal

motivation, they are likely to respond well.

• Few patients may present with unrealistic expectations. It is

the duty of the clinician to explain to the patient about the
possible outcome of the treatment.

• Another concern for the adults is the visibility of the

appliance. Patients must be made to understand that
treatment cannot be carried out without other people
knowing about it.
• Some adult patients expect treatment to be done in a
separate chamber rather than in an open treatment room.

• In treating adult patients, the orthodontist is working with

individuals who are interested in their own treatment unlike
adolescent patient.
2. Periodontal and restorative needs: Orthodontic treatment can be a part of overall
treatment plan for patients who already have periodontal and restorative problems.
Orthodontic treatment will not cure the existing periodontal and restorative problems,
but might reduce future attacks.

3. Temporomandibular pain/dysfunction: Temporomandibular dysfunction (TMD) is a

major motivating factor for adults to seek orthodontic treatment. Orthodontic treatment
sometimes solves TMD problems. TMD problems can be divided into two groups:

a. Those with internal joint pathology

(i) Disc displacement

(ii) Destruction of intra-articular disc

b. Symptoms of muscle origin

(i) Spasm

(ii) Fatigue of muscle

• Patients with TMD problems of muscle origin are likely to

benefit from orthodontic treatment.

• There are three methods to treat myofacial pain symptoms.

They are (i) reducing the amount of stress, (ii) reducing the
patient’s reaction to stress and (iii) improving occlusal
relationship.
Periodontal aspects of adult treatment

Periodontal problems are important in adult patients because orthodontic treatment

might aggravate periodontal problems, if oral hygiene is not maintained. Adult patients
seeking orthodontic treatment will be with minimal, moderate or marked periodontal
problem.
Minimal periodontal problem: In patients’ with minimal periodontal problem, extra
care must be taken to clean the teeth. Adequate care should be given to ensure that
there is no progression of periodontal problem.
Moderate periodontal problem: All the existing periodontal problems and dental
problems must be brought under control before commencement of orthodontic
treatment.
All aspects of periodontal treatment except osseous surgery should be carried out.
Endodontic treatment of any pulpally involved tooth should be carried out.
Endodontically treated tooth can be moved orthodontically. Attempting to move a
pulpally involved tooth without doing root canal treatment might cause a flare up of
the periapical problem. Any restorations, if required, are done before orthodontic
treatment. Cast restorations should be delayed until completion of treatment. Frequency
of cleaning and scaling should be increased when compared to normal orthodontic
patients.
Marked periodontal problem: Patients are seen more frequently for periodontal
maintenance as well as orthodontic adjustments. Minimum orthodontic goals are set to
keep the orthodontic forces to absolute minimum.
Missing teeth: (i) Prosthetic replacement and (ii) space closure are the two methods
in management of missing teeth.
Old extraction site: Closure of residual space in old extraction site will be difficult for
the following reasons:

➤ Resorption results in decrease in the vertical height of the bone.

➤ Remodelling produces buccolingual narrowing of the alveolar process.

➤ In adjunctive treatment, the mesially tipped posterior tooth is uprighted and

prosthesis placed.

➤ In comprehensive treatment, space is closed by mesial movement of posterior teeth.

➤ Temporary implants can be used as anchorage site to move lower molars forward
into an old first molar or second premolar extraction site (Fig. 33.4).

Tooth loss due to periodontal disease

➤ It is not advisable to move a tooth into an area where bone has been destroyed by
periodontal disease.

➤ Reason is that normal bone formation will not occur as the tooth moves into the
 defect.

➤ It is better to move the teeth away from this area and plan for prosthesis.

FIG. 33.4. Implant used to move molars forward.

But in conditions like aggressive periodontitis, where there is premature loss of first
molar and incisor, first molar space can be closed by mesial movement of second molar.
As the second molar moves, it brings its own investing tissues with it and the large
bony defect disappears.
Comprehensive orthodontics in patients planned for implants
Missing teeth: Prosthesis planned – implants, bridge.

➤ A successful implant requires adequate bone to support it. Loss of tooth or missing
tooth leads to loss of alveolar bone.

➤ In cases of missing permanent tooth, the deciduous tooth, if present, should be

retained to allow alveolar bone growth.

➤ Implants are placed usually after 16 or 17 years of age.

Special aspects of treatment for adults

➤ Due to lack of growth, extrusion mechanics are unstable in adults. Bite opening is
done by intrusion.

➤ The forces should be kept light since the periodontal support is compromised.

➤ Orthodontic space closure is contraindicated in teeth which are lost due to

periodontal disease.

➤ The extent of camouflage treatment possible should be assessed.

➤ Space closure is done in the same way as what is being done for adolescents.
➤ The retainers advised for adults:

• Suck down plastic wafer.

• Occlusal splint with positive indexing of the teeth which

extends buccally and lingually to maintain the position of
tooth.

ACCESSORY POINTS
➤ Orthodontic treatment is commenced 6 months after active periodontal therapy.

➤ Percentage of adults with an overjet of 7 mm or more is 6%.

➤ Percentage of adults with an anterior open bite (AOB) is 9%.

➤ The three main reasons for adults to seek orthodontic treatment are improvement of
aesthetics, relief of TMD and improvement of function.

➤ The slower rate of tooth movement in adults is compensated by good cooperation.

Advanced Learning
Obstructive sleep apnoea (OSA)
Definition: Battagel JM (1996) defines OSA as repeated collapse of upper airway
during sleep causing cessation of breathing despite the inspiratory effect.
It is a potentially life-threatening disorder.
Aetiology
Anatomical factors

➤ Reduced oropharyngeal dimensions between soft palate, tongue and pharyngeal

walls

➤ Short mandible leading to reduced functional space

➤ Shorter cranial base

Pathophysiologic factors
➤ Fatty deposits causing constriction of oropharynx

➤ Modifications of airway dimensions by posture

➤ Problems with muscle tonus

Clinical features
The clinical features are enumerated in Table 33.1.

Table 33.1.
Various diagnostic features of obstructive sleep apnoea

Medical symptoms Nocturnal symptoms Diurnal symptoms

Nocturnal hypoxaemia Choking Tiredness
Hypertension Restlessness Headache
Cardiac problems Nocturia Hypersomnolence
Nocturnal angina Snoring
Myocardial infarction

Diagnosis
➤ Patient’s history

➤ History from sleeping partner

➤ ENT examination

➤ Cephalometry

➤ Overnight polysomnography in sleep

➤ Laboratory measurement of heart, brain, respiratory activity, oral and nasal airflow,
sound and body posture

Management
➤ Multidisciplinary team comprising thoracic physician, ENT, maxillofacial surgeon
and orthodontist

➤ Elimination of aggravating factors like asthma, COAD (chronic obstructive airway

disease)

➤ Reduction of weight

➤ Surgical correction of nasal and nasopharyngeal obstructions like polyp, deviated

nasal septum

➤ Mandibular advancement splints

➤ Continuous position airway pressure (CPAP) delivers conditions on under pressure
through tight fitting nasal mask

➤ Mandibular advancement surgery

➤ Tape or otherwise affix a tennis ball to the back of pajamas before going to sleep at
night or posture alarm to encourage sleep on one side.

Management of medically compromised patients in orthodontic practice

The problems encountered during orthodontic treatment in different medically
compromised situations and their management are given in Table 33.2.

Table 33.2.
Medical disorders and orthodontic management

Medical disorder Anticipated or encountered problems Management

Congenital heart disease Bacteraemia during banding, separation of tooth, cleaning and Treatment to be initiated after consulting cardiologist or
polishing, exposure of tooth physician
Rheumatic fever

Bacterial endocarditis

High-risk groups

• Aortic valvular disease
• Prosthetic valves
• Patent ductus arteriosus
• Infective endocarditis
• Ventricular septal defect
• Coarctation of aorta
Intermediate-risk groups
• Mitral valve prolapsed
• Mitral stenosis
• Tricuspid valve disease
• Non - valvular intracardiac
prosthetic implants
Low-risk groups
• Atrial septal defect
• Coronary artery disease
Latex allergy
Nickel allergy
Bis-GMA allergy
Epilepsy
Juvenile rheumatoid arthritis
Haematological problems
Learning difficulties
• Use of calcium channel blockers like nifedipine might cause • Antibiotic prophylaxis as per the recommended
gingival overgrowth guidelines
• Good oral hygiene
• Daily use of chlorhexidine
• Change of drug
• Contact urticaria • Management of allergic reactions
• Rhinoconjunctivitis • Use of non-latex gloves and elastics
• Asthma
• Anaphylactic shock (very rarely)
• Relatively uncommon • Mild cases treated for allergy
• Delayed hypersensitivity • Severe cases, treatment plan to be modified
• Contact dermatitis
• Uncommon hypersensitivity • Material to be changed
• Gingival hyperplasia • Good oral hygiene is mandatory
• Gingivoplasty/ gingivectomy needed postorthodontic
treatment
• Removable appliance not indicated in uncontrolled
epilepsy
• Steroids interfere with orthodontic tooth movement • Simple treatment to be followed
• Destruction of condyles • Limited effect of functional appliance due to
destruction of condyles
• Bleeding and clotting problems • Treatment undertaken only in controlled patients
• Malignancies • Treatment in malignant conditions initiated, if there is
no relapse after 2 years
• Drooling • Keep treatment simple
• Manual dexterity is poor • Oral hygiene measures
• Oral hygiene will be poor • Behaviour management
• Motivation

Trauma and orthodontics

Severely proclined upper incisors seen in class II division 1 malocclusion can
predispose the child or adults to trauma.
Epidemiology
➤ The teeth most commonly affected are the maxillary incisors.

➤ Most common damage that occurs is enamel fracture.

➤ Incidence of trauma increases with age up to 13 years (Atack NE, 1999) and decreases
after 13 years.

➤ When the overjet is greater than 9 mm, there are 45% increased chances for trauma to
upper incisors.

Prevention
➤ Children with increased risk of trauma should be subjected to interceptive treatment.

➤ The drawbacks of early treatment include longer treatment time and poor patient
compliance.

Orthodontic treatment of traumatized tooth

Good history-taking is highly essential to find out previous trauma before start of
orthodontic treatment. Orthodontic treatment should be delayed in patients with
trauma. The recommended observation periods for different traumas, before the start
of active treatment are given in Table 33.3.

Table 33.3.
Observation period for different types of trauma (Andreasen FM, Andreasen JO
and Bayer T, 1989)

Nature of trauma Observation period

Crown fracture (with or without pulpal involvement) 3 months after radiographic evidence of hard tissue formation
Root fracture Minimum 12 months (depends on type of healing)
Granulation tissue healing Do not undertake treatment
Subluxation and lateral luxation 3 months
Extrusion, intrusion and re-implantation 12 months

Precautions (Crawford PJM et al, 1997)

➤ Avoid excessive pressure; light, short-acting forces recommended.

➤ Avoid moving roots into palatal plate.

➤ Monitor pulp health and root resorption during treatment.

➤ Radiographs should be taken; if it shows damage, reassess treatment plan.

Effects of orthodontic treatment on traumatized teeth
Evidence suggests (Linge BO and Linge L, 1983):

➤ Normal effects of orthodontic tooth movement

➤ Transient pulpitis

➤ Root resorption

➤ Loss of vitality
SECTION XI
Miscellaneous
OUTLINE

34. Retention, relapse and complications

35. Digital orthodontics

CHAPTER 34
Retention, relapse and complications

CHAPTER OUTLINE
❖ Definition of retention and relapse
❖ Causes for relapse in orthodontics/need for retention after orthodontic treatment
❖ Various schools of thought pertaining to retention in orthodontics
❖ Theorems on retention
❖ Classification and planning of retention in orthodontics
❖ Mechanical aids to retention/retention appliances/retainers
❖ Adjunctive procedures to aid retention and to prevent relapse
❖ Retention with regards to different types of malocclusion
❖ Active retention
❖ Accessory points
❖ Advanced learning
❖ Raleigh William’s keys to eliminate lower incisor
retention
❖ Tweed’s retention plan
❖ Complications/deleterious /iatrogenic effects of
orthodontic treatment
Definition of retention and relapse
Retention
Retention can be defined as holding of teeth in optimal aesthetic and functional
positions after active orthodontic therapy, long enough to aid in their stabilization.

Relapse
Relapse implies loss of any correction achieved by orthodontic treatment.
Causes for relapse in orthodontics/need for
retention after orthodontic treatment
Following the completion of active mechanical tooth movement, the teeth are in a state
of unstable position.
The various reasons for cause of relapse or need for retention can be studied under
the following headings as given in flowchart.

1. Soft tissue factors

• Teeth will be in unstable position after the orthodontic

treatment.

• Soft tissue pressures constantly on the teeth produce a

relapse tendency.

• Teeth have to be placed in a new position of balance.

Muscular factors:

• Teeth in their new position will take time to stabilize.

• Persistence of any abnormal habit will again alter the

equilibrium and cause relapse of the teeth.
2. Supporting tissues

The gingival and periodontal tissues are changed or altered,

subsequent to orthodontic tooth movement and require time
for reorganization.

Reorganization of periodontal fibres:

• During tooth movement, periodontal ligament (PDL) space

and collagen fibre bundles are altered.

• Restoration of normal periodontal architecture will occur

only after removal of fixed appliances. This is because
reorganization takes place when the tooth starts responding
individually to functional forces like masticatory force.

• PDL reorganization occurs over a 3–4 months’ period.

• Once the reorganization takes place, active stabilization of

the tooth due to PDL metabolism comes into effect.

Reorganization of gingival fibres:

• Gingival fibres are predominantly collagen and elastic fibres.

• Reorganization of gingival fibres occurs slowly.

• Collagenous fibres complete their reorganization in 4–6

months.

• Elastic supracrestal fibres remodel very slowly and

sometimes it takes nearly 1 year to reorganize.

• Therefore, pericision is recommended in teeth corrected for

 rotations.
3. Occlusal factors

Tooth size discrepancy:

Tooth size discrepancy between maxillary and mandibular

teeth leads to improper correction or relapse after correction.

Features of maxillary tooth material excess:

• Deeper overbite, greater overjet, combination of both

increased overbite and overjet, anterior crowding, improper
buccal occlusion.

Features of mandibular tooth material excess:

• End-to-end incisor relationship, spacing in maxillary

anterior region, lower anterior crowding, improper buccal
occlusion.

Proximal reduction is done in maxilla or mandible depending

on the area of excess tooth material.

Axial inclination:

• Excessive lingual tipping of the anterior teeth results in

deepening of bite.

• Proper angulations between upper and lower incisors are

functionally important.

Transverse discrepancy:
• Tendency for relapse associated with palatal expansion
techniques is more.

• Hence long-term retention is required.

Third molars:

• The role of third molars in causing late mandibular incisor

crowding is doubtful.

• But extraction of lower third is found to produce beneficial

effects in reducing lower anterior crowding.

• This is because; the late incisor crowding which is due to late

mandibular growth causes distal and lingual movement of
lower teeth.

• Extraction of third molars provides space for this distal and

lingual movement.
4. Facial growth and occlusal development

• Dentoalveolar adaptation tends to maintain occlusal

relationship even with skeletal malrelationship.

• But if the skeletal growth continues in a marked fashion,

occlusal changes occur.

For example:

1. Skeletal open bite worsens with growth in lower facial

height.

2. Deterioration of class III occlusion, if class III skeletal

relationship continues.
Various schools of thought pertaining to
retention in orthodontics
There are four schools of thought pertaining to retention.

1. Occlusion school of thought (Norman William Kingsley)

• According to this school of thought, proper occlusion of

teeth is a potent factor in maintaining the stability of the
teeth.

• At the end of active orthodontic treatment, there should be

proper intercuspation and interdigitation.

• There should be cusp to fossa relationship between

maxillary and mandibular teeth.
2. Apical base school of thought (Axel Lundstrom)

• As per this school of thought, apical base is one of the most

important factors in both correction of malocclusion as well
as maintenance of correct occlusion.

• Intercanine and intermolar width should not be altered to

prevent relapse.

• Nance advised to increase the arch length only to a minimal

extent.
3. Mandibular incisor school of thought (Grieve GW and Charles W Tweed)

• This theory postulated that the mandibular incisors should

be placed upright and over the basal bone.
4. Musculature school of thought (Roger’s)
• Establishing proper functional muscle balance is a must to
achieve stable occlusion.

• Improper muscle balance leads to relapse.

Theorems on retention
There are 10 theorems on retention. The first nine theorems were put forward by Riedel
RA Moyers, Robert E has included the 10th theorem.

Theorem 1
‘Teeth that have been moved tend to return to their former positions’.

➤ The reasons for the teeth to go back to their original position include apical base,
transseptal fibres and musculature.

➤ This theorem is true for rotations.

➤ Concept can be applied to incisors also.

Theorem 2
‘Elimination of the cause of malocclusion will prevent recurrence’.

➤ This theorem is true for malocclusions with known aetiologic factors like thumb
sucking, tongue thrusting and abnormal lip position.

➤ Many a times, reasons for malocclusion are not known.

➤ If the cause for malocclusion is known, every step should be taken to remove or
eliminate the aetiology for malocclusion.

➤ This helps in stability of the occlusion.

Theorem 3
‘Malocclusion should be overcorrected as a safety factor’.

➤ This is being practised by many orthodontists.

➤ The concept of overcorrecting is to allow or expect some amount of relapse so that

after relapse there is normal occlusion.

➤ Overcorrection is done when treating class II malocclusion, class III malocclusion,

rotations.

➤ There is little evidence to indicate that overcorrection is successful in preventing

return to the former position.
Theorem 4
‘Proper occlusion is a potent factor in holding teeth in their corrected positions’.

➤ Correct intercuspation is an essential factor in occlusal stabilization.

➤ Equally important is to obtain proper functional occlusion.

Theorem 5
‘Bone and adjacent tissues must be allowed to reorganize around newly positioned
teeth’.

➤ Retention appliances are based on this principle.

➤ The supporting tissue takes time to reorganize to the newly corrected position (refer
to previous question for exhaustive detail for this topic; role of supporting tissues in
relapse).

Theorem 6
‘If the lower incisors are placed upright over basal bone, they are more likely to remain
in good alignment’.

➤ Treatment should be aimed to place the lower incisor in proper angulation and
position.

➤ Stability is better, if the incisors are placed upright over basal bone.

Theorem 7
‘Corrections carried out during periods of growth are less likely to relapse’.

➤ Treatment carried out during growth allows the tissues to adjust better.

➤ Therefore, orthodontic treatment should be instituted at the earliest possible age.

➤ Early treatment planning offers greater advantage in long-term stability particularly

in skeletal malocclusion.

Theorem 8
‘The farther teeth have been moved, the less likelihood of relapse’.

➤ There is little evidence to support this concept.

➤ It is better to minimize extensive tooth movement by interceptive procedures like

 guidance of eruption, use of orthopaedic forces and functional appliances.

Theorem 9
‘Arch form particularly in the mandibular arch, cannot be altered permanently by
appliance therapy’.

➤ Treatment should be aimed at maintaining the arch form presented by the

malocclusion as much as possible.

➤ The intercanine width in the mandible represents muscular balance and dictates the
limits of dental expansion.

➤ Expansion of mandibular arch leads to relapse.

Theorem 10
‘Many treated malocclusions require permanent retaining devices’.

➤ Correction of malocclusion with specific occlusal goals and regard to the growth and
functional aspects requires no permanent retention.

➤ Some types of problems are retained for a very long period.

Classification and planning of retention in
orthodontics
General considerations
Teeth usually tend to move back to their original position, because of elastic recoil of
gingival fibres and also because of soft tissue pressures from lip and tongue.

➤ To prevent relapse, retention appliances are given.

➤ The routine time plan for retention is as follows:

1. Full-time retention appliance wear for the first 3–4

months.

i. Retainers should not be worn during eating.

ii. This allows the tooth to respond individually to

functional forces and allows for reorganization.

2. Retention continued on part time basis for 12 months.

i. This facilitates remodelling of gingival tissues.

3. If significant growth remains, part time wear of retention

appliance is continued till cessation of growth.

Retention planning
Retention planning is divided into four categories, depending on the duration of
retention treatment.

1. Self-retentive or no retention plan

The occlusion may be self-retentive as when an upper incisor

is moved over the bite. So, no retention is required in
corrected crossbite with adequate overbite established (Fig.
 34.1).
2. Short-term retention/limited retention (3–6 months)

a. Corrected crossbites

Anterior: When adequate overbite is not present.

Posterior: When axial inclinations of posterior teeth remain

reasonable after correction.

b. Dentitions that have been treated by serial extraction

procedures.

c. Highly placed canines treated by extraction.

d. Cases treated by maxillary retardation after completion of

growth period.

e. Corrections of blocked-out teeth.

3. Medium-term retention/moderate retention

• This is indicated where the supporting tissues will take

longer time to adapt.

Medium-term retention may extend between 1 and 5 years.

a. Class I nonextraction cases, with protrusion and spacing

of maxillary incisors.

b. Class I and class II extraction cases.

c. Corrected deep overbites in class I or class II

malocclusion.
 d. Early correction of rotated teeth to their normal positions.

e. Corrected class II division 2 malocclusion.

4. Permanent or semipermanent retention

a. Cases treated by expansion particularly in the mandibular

arch.

b. Generalized spacing with arch length excess.

c. Severe rotation.

d. Severe labiolingual malposition.

e. Midline diastema in otherwise normal occlusion.

f. Cleft palate cases.

g. Adult patients with periodontal problems.

FIG. 34.1. Corrected crossbite with adequate deep bite needs no retention.
Mechanical AIDS to retention/retention
appliances/retainers
I. Definition

Retention appliances are passive orthodontic appliances that are used

to hold the teeth moved by orthodontic treatment till the
supporting tissues are reorganized.
II. Ideal requirements of retention appliances

• It should restrain each tooth that has been moved into the
desired position.

• It should allow the functional forces to be transmitted to the

retained teeth, if worn.

• It should be easily cleanable.

• It should be self-cleansable.

• It should be inconspicuous.

• It should be strong enough to achieve the objectives of

retention.
III. Classification of retainers
Removable retainers
1. Hawley’s retainer and modifications
2. Wrap around retainer
3. Canine-to-canine clip-on
4. Tooth positioners
5. Essix retainers/invisible retainer
6. Functional appliances
Fixed retainers
1. Banded canine-to-canine retainer
2. Bonded canine-to-canine retainer
3. Diastema maintenance
4. Anti-rotation band
5. Band and spur
6. Pontic maintenance

IV. Removable retainers

• Removable retention appliances serve effectively for
retention against intra-arch stability.

• They are also effective in growth problems, wherein

functional appliances or headgears are used as retention
appliances.

a. Hawley retainer

• Hawley retainer is the most commonly used retentive

appliance (Fig. 34.2).

• It incorporates clasps on molar teeth and a labial bow, which

spans from canine-to-canine.

• The palatal or lingual portion is constructed of acrylic and

covers the palatal mucosa.

• Because of the palatal coverage, it acts as a potential bite

plane to control overbite.

• The drawback of standard Hawley retainer is when used in

first premolar extraction cases, it causes the space to open
because of the wedging effect.

Modifications:

1. Instead of short labial bow, a long labial bow can be used

in first premolar extraction cases. This prevents wedging
effect in extracted site (Fig. 34.3).

2. Alternative design for extraction cases is to wrap the

labial bow around the entire arch, without clasps. This is
useful to close residual spaces also. This is called Begg’s
 retainer or circumferential maxillary retainer (Fig. 34.4).

3. Another alternative in extraction case is to solder the

labial bow to the Adams clasp (Fig. 34.5). The action of
labial bow holds the extraction space closed.

Hawley retainer can be made for upper or lower arch.

FIG. 34.2. Hawley retainer.

FIG. 34.3. Hawley retainer with long labial bow.

 FIG. 34.4. Begg’s retainer.

FIG. 34.5. Labial bow soldered to Adams’ clasp.

b. Removable wrap around or clip-on retainer

• This consists of a wire reinforced plastic bar along the labial

and lingual surfaces of the teeth.

• Made with clear acrylic.

• This is used in cases where the periodontal support is

inadequate.

• This retainer splints the teeth together firmly.

• This is a disadvantage of the retainer as the functional
stimulus will not be transmitted to individual teeth.

c. Modified wrap around/canine-to-canine clip-on retainer

• This is widely used in lower anterior region.

• It has the advantage, it can be used to realign lower incisors.

• It is well tolerated by the patient.

d. Positioners as retainer

• Tooth positioner devised by Kesling HD is usually used as a

finishing appliance.

• Sometimes this positioner itself can be used as retaining

appliance.

Advantages of positioner:

• It maintains intra-arch tooth position.

• It maintains the occlusal relationships also.

Disadvantages:

• It is bulky.

• Pattern of wear of positioner is different from that of

retention appliance.

• They do not retain incisor irregularities and rotations as

efficient as standard retainers.
• Tendency for the bite to deepen.

e. Essix retainer/invisible retainer

• The standard Essix canine-to-canine retainers are made from

clear thermoplastics (Fig. 34.6).

• It incorporates all the advantages of canine-to-canine clip-on

retainer.

• In extraction cases, it is made to extend to cover the

extraction site.

• It is aesthetically acceptable.

f. Functional appliances

• Functional appliances are used in subjects who have still

growth left.

• Activators and oral screen are commonly used.

 FIG. 34.6. Essix retainer.

V. Fixed retention appliances

• Fixed retainers are used in conditions where long-term

retention is required.

• It is indicated in conditions where intra-arch instability is

anticipated.

a. Banded canine-to-canine retainer

• Banded canine-to-canine retainer is used for maintenance of

lower incisor position during growth (Fig. 34.7).

• The retainer consists of fixed lingual bar attached to the

canines or premolars in some cases.

• The fixed lingual bar is soldered to the canine bands on the

lingual aspect.

Disadvantages:
• Trapping of plaque against the bands.

• Predisposition to decalcification.

• Aesthetically unsightly.

b. Bonded canine-to-canine retainer

• A fixed lingual canine-to-canine retainer can be fabricated

without bands by bonding to the lingual surface.

• It is attached only to the canines, resting passively against

the lingual surface of central and lateral incisors (Fig. 34.8).

• Made from heavier wire to resist distortion.

• The ends of the wire is sandblasted to improve retention.

Modification:

In cases of rotation and crowding correction, the lingual wire

is bonded to one or more incisor teeth. In this situation, a
flexible braided steel archwire is used.

c. Maintenance after diastema closure

A fixed retainer is used to maintain diastema correction (Fig.

34.9).

d. Anti-rotation band

• This is used to maintain corrected single tooth rotation.

• The band on the rotated tooth has two spurs welded to it –

 labially and lingually (Fig. 34.10).

• The spurs rest on adjacent teeth and prevent relapse.

e. Band and spur

• Band and spur are used to hold incisor tooth that were
labially or lingually placed (Fig. 34.11).

• This prevents the tooth from returning to its original

position.

f. Maintenance of pontic or implant space

• A fixed retainer is used to maintain space for a pontic.

• A shallow preparation is made in the enamel of the marginal

ridges of the adjacent teeth to the extraction site.

• A section wire is bonded.

FIG. 34.7. Banded canine-to-canine retainer.

FIG. 34.8. Bonded canine-to-canine retainer with flexible braided wire.

FIG. 34.9. Maintenance after diastema closure.

FIG. 34.10. Anti-rotation band with spurs labially and lingually.

FIG. 34.11. Band and spur.
Adjunctive procedures to aid retention and to
prevent relapse
Certain minor surgical procedures are performed to aid retention. These include
frenectomy, pericision and papilla dividing procedures (refer to Chapter 27 for full
detail of the procedures).
Retention with regards to different types of
malocclusion
Retention with regards to different types of malocclusion can be studied under two
headings.

1. Retention after correction of skeletal problems (Table 34.1):

The conditions include:

• Class II

• Class III

• Deep bite

• Open bite

• Transverse problems
2. Retention after correction of dental problems (Table 34.2):

The conditions include:

• Arch length changes

• Rotations

• Changed axial inclination

• Mesiodistal relationship changes

• Incisor alignment

• Holding spaces
Table 34.1.
Retention after skeletal correction

Objective Problem Method of retention

Retention after class • 1–2 mm of anteroposterior change is likely to • Overcorrection is the first step
II correction occur • Continuation of headgear wear
• Results from forward movement in the upper • Use of functional appliances
arch and distal movement of lower arch • Worn for 12–24 months
• Continuation of growth
Retention after class • Relapse from continual growth • Mild cases – positioners are useful
III correction • Very difficult to control • Retrognathic maxilla – functional appliances are used (FR III, reverse activator or
bionator)
Retention after • Vertical growth continues into late teens • Control of vertical overlap is achieved by removable Hawley retainer
deep bite correction • The lower incisors encounter the bite plate so that the bite is maintained
Retention after • Relapse is due to extrusion of molars or • Control the eruption of molars
open bite correction intrusion of incisors • Use of high-pull headgears to upper molars
• Persistence of habits like thumb sucking, tongue • Appliance with posterior bite blocks (e.g. open bite activator or bionator) worn
thrusting, swallowing during night-time; conventional retainers worn during day time
Retention after • Overcorrection
expansion • Expansion appliance placed passively
• Removable appliance to aid in transverse retention

Table 34.2.
Retention following dental problems

Objectives Retention appliance used

Arch length changes Removable: Acrylic plate or lingual arch retainer with clasps and labial wire

Fixed: Molar-to-molar or canine-to-canine cemented bands with lingual wire adapted.

Elastoplastic positioner: Helps in minor corrections

Rotation correction Removable: Acrylic plate with lingual wire

Fixed: Cemented bands with antirotation spurs. Elastoplastic intermaxillary positioners

Changed axial inclination Anterior region: Acrylic plate and labial wire

Fixed: Labial or lingual retainer

Posterior region: Removable acrylic plate with labial wire

Fixed: Bands and spurs

Mesiodistal relationship changes Removable: Upper anterior inclined plane. Elastoplastic intermaxillary positioners;

Extraoral headgears

Fixed: Soldered inclined plane on maxillary lingual arch

Incisor alignment Removable: Removable Hawley retainer

Fixed: Banded lingual retainer; bonded lingual retainer

Holding spaces Removable: Acrylic plate with clasps and spurs in dentition areas

Fixed: Cemented band and cantilever type spur. Bonded pontic

maintenance
Active retention
In spite of utmost care in treatment and retention, sometimes relapse occurs. In these
conditions, retention appliances are used to correct the relapse. Hence, they are called
active retainers. The appliances used for active retention are as follows:

➤ Hawley retainers

➤ Spring retainers

➤ Modified functional appliances

1. Hawley retainers

• Hawley retainers are activated to close the residual

extraction space.

• To close small amount of band space.

2. Spring retainers

• Spring retainers are used for realignment of irregular

incisors.

• Development of late incisor crowding is an indication for the

spring retainers.

Steps in fabrication of spring retainer are as follows:

3. Modified functional appliance as active retainers

• This is used to correct class II relapse, when there is 2–3 mm

slipping into class II relation.

• Activator is used as active retainer.

• Improvement occurs not because of differential jaw growth

but because of tooth movement.

• Any tooth-borne active type of activator can be used as an

active retainer.

ACCESSORY POINTS
➤ Corrected anterior crossbite is an example for self-retaining malocclusion.

➤ Circumferential fibrotomy is done to minimize relapse of derotated tooth.

➤ During orthodontic treatment, the lower intercanine width should be maintained.

➤ Pericision should be performed after the tooth is fully derotated.

➤ Pericision involves elimination of the pull of elastic supracrestal gingival fibres by
sectioning these fibres.

➤ Teeth that have been moved tend to return to their former position due to transseptal
fibres.

➤ Reorganization of periodontal fibres occurs over 3–4 months.

➤ Collagenous fibres complete their reorganization in 4–6 months.

➤ Elastic supracrestal fibres remodel very slowly and sometimes it takes nearly 1 year to
reorganize.

➤ There are 10 theorems on retention. The first nine theorems were put forward by
Riedel. Moyer has included the 10th theorem.

➤ Begg’s retainer is the other name for circumferential maxillary retainer.

➤ Frenectomy should be done at the end of space closure.

➤ Spring retainers are used for realignment of irregular incisors.

➤ Six keys to eliminate lower incisor retention were given by Raleigh William.

➤ Retention appliances are generally recommended to be removed while eating.

Advanced Learning
Raleigh william’s keys to eliminate lower incisor retention
Raleigh William has outlined six keys to eliminate lower anterior retention and
improve post-treatment stability.
Key 1
The incisal edge of the lower incisor should be placed on the A–Pog line or 1 mm in
front of it (Fig. 34.12).
 FIG. 34.12. Key 1: position of lower incisal edge.

Key 2
➤ The lower incisor apices should be spread distally to the crowns (Fig. 34.13).
 FIG. 34.13. Key 2: Apices spread distally.

➤ Apices of lateral incisors must be spread more than those of central incisors.

Key 3
➤ The apex of the lower cuspid should be positioned distal to the crown. The occlusal
plane should be used as a positioning guide (Fig. 34.14).
 FIG. 34.14. Key 3: Lower cuspid apex is distal to crown.

➤ This reduces the tendency of the canine to tip forward into the incisor area.

Key 4
➤ All the four lower incisor apices must be in the same labiolingual plane (Fig. 34.15).

FIG. 34.15. Key 4: Positioning of lower incisors apices in the same labiolingual plane.

Key 5
➤ The lower cuspid root apex must be positioned slightly buccal to the crown apex.
Key 6
➤ Lower incisors should be slenderized.

➤ Flattening lower incisor contact points by slenderizing or stripping creates flat

contact surfaces (Fig. 34.16).

FIG. 34.16. Key 6: Creation of flat contact surface by slenderization.

➤ Flat contact surfaces help resist labiolingual crown displacement.

Tweed’s retention plan

Tweed has enumerated three types of growth trends-type A, type B and type C.
According to each growth trends, specific retention plan has been outlined.
Tweed’s growth trends
➤ Type A: Maxilla and mandible grow in unison both downwards and forwards. ANB
shows no change.

➤ Type B: Maxilla grows more rapidly than mandible. ANB angle increases.

➤ Type C: Mandible grows faster than maxilla. ANB angle decreases.

Retention for type A growth trend

➤ Upper and lower Hawley retainer for approximately 9–12 months.

➤ Then mandibular Hawley retainer is replaced with canine-to-canine lingual bar fixed
retainer.

➤ A new maxillary retainer with bite plane for night-time wear is given.

➤ After 18 months, maxillary Hawley retainer is worn 2 days a week and discontinued
after 24 months.

➤ Mandibular fixed retainer is worn till 16 years of age.

Retention for type B growth trend
➤ Maxillae are growing downward and forward at a greater amount than mandible in
type B growth trend.

➤ Kloehn type headgear is used as a retaining device.

Retention for type C growth trend

➤ In this, the lower face is growing forward and downward more than the middle face.

➤ Type C growth trends should be retained with fixed mandibular canine-to-canine

lingual bar.

➤ Maxillary Hawley retainer is advised.

Complications/deleterious/iatrogenic effects of orthodontic treatment

Any problem or condition developing in the course of treating a primary disease or
condition is called complication of treatment. There are a few deleterious damages to
the patient as a result of orthodontic treatment.
The deleterious or iatrogenic damages to the individual patient as a result of
orthodontic treatment can be studied under the headings given in Table 34.3.
Damage to crown: Decalcification occurs due to attack by acidic byproducts of plaque metabolism (Stirrups DR, 1995)
Trauma to enamel: Due to burs used, most common during debonding procedure
Root resorption: Refer to Chapter 15 on Biology of Tooth Movement

Intraoral effects
Pulp damage: Pulpitis is common but rarely leads to loss of vitality. Previous history of trauma to be assessed (Zachrisson BU, 1976)
Periodontal Gingivitis, periodontitis and burns due to etchant or during thermal bonding can happen
inflammation:
Alveolar bone Minimal crestal bone loss of about 0.5–1 mm occurs. Long-term effect also is minimal (Sharpe W, Reed B, Subtelny JD and Polson A, 1987)
loss:
Mucosal trauma: Ulcerations from distal ends or long spans of archwire. Initial ulcerations from brackets, acid burn following etching and injury due to
displacement of face bows have been reported (McGuiness NJ, 1992)
Allergy: Nickel hypersensitivity reactions have been reported, but they are rare. If established by patch testing, remove the sensitizing agent

Extraoral effects
TMJ: Temporomandibular joint (TMJ) problems are seen in adult patients. Evidence to support that orthodontic treatment causes TMJ symptoms is
weak. Soft diet, muscle exercise and analgesics to be advised as necessary. Class II elastics and headgear therapy to be discontinued (Rolf G
Behrents and Ralph A White, 1992)
Eye: Occular injuries due to face bow accidents have been reported
Skin: Bruising associated with neck straps; injuries due to displacement of headgear; pressure alopecia in scalp following headgear therapy
Allergy: Contact dermatitis due to nickel
Type IV sensitivity reactions have been reported. Patch test to be done to establish cause
Systemic Bacteraemia following banding and placement of separators
effects:
Cross-infection due to improper sterilization
Rarely, radiation hazard, if the patient is exposed for too many radiographs
Psychological
effects: Patients may not be satisfied with the treatment due to high expectations Teasing by peers also will be a problem Failed treatment
Table 34.3.
Classification of complications during orthodontic treatment
CHAPTER 35
Digital orthodontics

CHAPTER OUTLINE
❖ Digital orthodontics
❖ Digital panoramic images
❖ Digital cephalometrics
❖ Digital study models
❖ Digital photography
❖ Accessory points
❖ Advanced learning
❖ Paperless orthodontic practice
Digital orthodontics
Digital technologies used in orthodontic offices have dramatically changed patient data
collection and practice management.

➤ In many cases, the new technologies are significantly more expensive than the
technologies that they replace and modifications are frequently necessary.

➤ Although some orthodontists enjoy being on the cutting edge of technology, it

appears that not all orthodontists immediately incorporate new technologies into
their practice, as evidenced by a recent article (Keim, RG, Gottlieb, E, Nelson, AH,
and Vogels, DS, 2002). The various applications of computers in orthodontics are
given in Fig. 35.1.

FIG. 35.1. Various applications of computers in orthodontics.

Orthodontic practice management

➤ This refers to the applications that are used for the operation and the management of
orthodontic clinics.

➤ These applications include appointment arrangement, patient charting or

examination form handling, electronic patient recording and the use of electronic
patient identification cards.

➤ Most of the applications merely apply database techniques to computerize data that
serve as a basis for dental treatment.
➤ This is a pioneer group of applications that incorporates practical computer
techniques to traditional orthodontic treatment.

Digital recording applications

➤ This aspect refers to both computer hardware and software for recording and
visualizing patient information in an electronic form.

➤ The information can be recorded using different devices such as digital camera,
three-dimension measurement device, intraoral scanner or intraoral video camera,
digitizer and computerized tomography (CT) scanner.

➤ The applications in this group pave a way for computerized techniques to further
analyse dental data for better diagnosis and treatment planning.

Diagnosis and treatment planning applications

➤ This can be separated into two groups, those for dental model analysis and those for
cephalometric analysis.

➤ The techniques that are applied to these applications range from expert systems,
pattern recognition and image processing both in two-dimension and three-
dimension, and surgical simulation.

➤ The applications for diagnosis and treatment planning may require the information
on not only patient records but also treatment knowledge base, which can be a collection
of orthodontic treatment cases. Such an application of computer knowledge base and
data mining techniques will help to provide a better justification on treatment
planning based on past success or failure of treatment cases.

➤ The most valuable contribution of computers in orthodontics is the forecast of

growth from serial cephalograms.

➤ Computers are a valuable tool in treatment with invisalign braces and robotics are
being used for archwire fabrications.

Computer-assisted learning
From the limited number of studies available on this growing area of education
research in orthodontics, evidence indicates that computer-assisted learning (CAL),
when applied for teaching orthodontic topics related to diagnosis and treatment
planning, is more effective when compared to conventional modes of orthodontic
learning, and adds an additional and significant gain in student knowledge acquisition.

➤ Computers have revolutionized presentation of papers in conferences.

➤ A computer also helps in research purposes.
Digital panoramic images
Basic principles
➤ A digital panoramic image, the same as all digital images, is an image that is
composed of a large number of very small pieces of information known as ‘pixels’
(picture elements).

➤ The pixels forming the image are not randomly distributed throughout the image;
instead, they lie in specific cells formed by a layout of rows and columns, known as
the ‘digital image matrix’.

➤ The image matrix size corresponds to the number of rows by the number of columns.
An image of 10 × 10 in matrix size, for example, is made up of 10 columns and 10
rows.

➤ The size of the pixels directly affects the details of the digital image, and the smaller
the pixel size, the more detailed the digital image will be. Moreover, the size of pixels
is related to another very important factor in digital imaging–the image resolution.

➤ Resolution is the ability of an imaging system to distinguish between small objects

that lie very closely to another. The image acquisition process is the main factor
determining the resolution of the image.

➤ Each of the pixels in a digital image is represented by a specific number that

corresponds to the brightness with which the pixel will be displayed on screen
(computer monitor). This number is known as ‘pixel value’ or ‘pixel intensity’ and is
proportional to the brightness of the specific pixel–the higher the pixel intensity, the
brighter the pixel, and vice versa.

➤ In digital radiography, the pixel value corresponds to a specific shade of grey since
all the images encountered are ‘black and white’. The range of brightness levels (or
shades of grey in digital radiography) that can be displayed on screen is affected by
the digital bit depth. This is the number of bits (binary digits) that quantize each
pixel.

➤ A bit is a very small piece of data that, in the binary system (the system that most
computers operate with), can take only two values–either 0 or 1. As a result, the
baseline number for the calculation of the possible brightness values that a pixel can
take is 2.

➤ Eight bits grouped together form a ‘byte’. Digital systems typically process and store
information in byte increments (like kilobytes and megabytes). Since a pixel is
 represented by 8 bits in 8-bit systems, each pixel will require a storage capacity
(available memory) of 1 byte; 12-bit and 16-bit systems will require 2 bytes to store a
pixel.

Image acquisition
Acquisitions of digital panoramic images are done using two methods:

1. Direct method

• Charge-coupled devices

• Storage phosphor systems

2. Indirect method

• The digital conversion of an existing panoramic radiograph

is known as ‘indirect acquisition’ or ‘digitization’.
Charge-coupled device detectors
➤ In these panoramic systems, film and film holder (cassette) are replaced by an
electronic sensor that captures the panoramic radiographic image in an incremental
fashion and delivers the image to a computer for digital conversion, demonstration
and storage. This sensor is known as CCD (charge-coupled device) and is made up of
arrays of X-ray sensitive or light-sensitive cells or pixels that can generate voltage in
proportion to the amount of light or X-rays striking them.

➤ The pixels are arranged in lines in a rectangular base, and the more pixels packed
together, the higher the quality of the image that is captured. The individual CCD
pixel size currently used is in the range of 20–40 microns for intraoral sensors and
100–140 microns for sensors used in digital panoramic systems.

➤ The sensor is linked to the radiographic tube and moves in an opposite direction
during exposure, exactly as the radiographic film does in conventional panoramic
radiography. A scintillator (material that produces light energy when hit by X-rays) is
fibreoptically coupled with the sensor. As a result, the X-ray energy is converted to
light energy just before the sensor, so, light will excite the sensitive pixels of the
sensor. This process actually reduces the patient exposure because the presence of the
scintillator intensifies the X-ray energy when converting it to light (for each X-ray
photon striking the scintillator, several light photons are produced).

➤ The electrical charge that is generated in each of the pixels of the CCD is transferred
 from one pixel to another in a sequential fashion that is known as ‘charge coupling’
(hence, the name ‘charge-coupled device’).

➤ The final destination of the collected electrical charge is the read out amplifier, where
the voltage generated from each pixel is identified, stored and eliminated from the
sensor, so that it is rendered ready for new exposures. This part is very important,
since the digital panoramic image is built by increments of the sequential exposure of
a much smaller in-dimensions sensor. An analogue- to-digital converter (ADC) will
convert all these charges to digital by assigning a number to each one of them, in
proportion to the electrical energy. This number will eventually represent the pixel
intensity value (shade of grey) of the specific location of the digital image and its
range is limited by the output resolution of the ADC (8–16 bits).

➤ The very first report of digital panoramic radiography based on this form of
detectors is attributed to William D. McDavid and colleagues at the University of
Texas Health Science Centre, Texas.

Storage phosphor systems

➤ The process of acquiring a digital panoramic image with storage phosphor systems
lies very close to that of the film-based one. The difference is that, in this case, the
radiographic film is replaced by a reusable plate in an ordinary film holder (cassette)
without intensifying screens.

➤ The image is captured on the plate as analogue information and is converted to

digital format when the plate is processed (scanned) with a special laser scanner (Fig.
35.2).

➤ The way that this works is entirely based on the inherent properties of the emulsion
coating the plate (storage phosphors). Storage phosphors are materials that can store
X-ray energy when exposed to X-rays by means of a ‘latent image’.

➤ Later, when the phosphor is stimulated with light, the stored energy can be released
and readily detected in the presence of the stimulating light. The storage phosphor
plate (SPP) is made up of a polyester base that is coated with a layer of europium-
doped barium fluorohalide, the most commonly used phosphor compound. Some
protective coating is also added to prevent damage.

➤ When the SPP is exposed to radiation, the X-ray energy will be absorbed, causing a
series of electronic excitations in the emulsion (europium) with subsequent electron
entrapments in the crystal lattice of the storage phosphor. The number of the
excitation and entrapment events is proportional to the amount of X-rays striking the
plate. This metastable state of the emulsion due to its altered electronic status
constitutes the ‘latent image’.

➤ When the plate is stimulated by light emitted from a helium–neon laser scanner,
 most of the entrapped electrons will return to their previous state, releasing the
stored energy and, consequently, the electronic status of the emulsion will return
back to normal (stable).

➤ The released energy is in the form of light that is detected by a photomultiplier tube
(PMT). A PMT is a device designed to capture and enhance small amounts of light
energy and convert it to an electrical signal. The electrical signal generated is
proportional to the amount of light collected by the PMT. Lastly, the electrical signal
is converted to digital by an ADC.

➤ The ADC assigns a number to the resulting electrical signal provided by the PMT for
each site of the SPP. This number will eventually represent the pixel intensity value
(shade of grey) of the specific location of the digital image.

➤ After the completion of the scanning process, the SPP is flooded with light. This will
erase any remainder of the latent image and will render the plate ready for additional
exposures.

➤ Since exposure to light erases the latent image, care should be taken not to expose
unread SPPs to light. So, in accordance with the manufacturer’s recommendations,
the scanning hardware must be kept in a semi-dark environment to prevent any loss
of the latent image. The first application of SPPs as panoramic image receptors was
reported by Kashima I and colleagues.

FIG. 35.2. Diagrammatic representation of components used in digital radiography.

Indirect systems
➤ The digital conversion of an existing panoramic radiograph is known as ‘indirect
acquisition’ or ‘digitization’.

➤ This kind of conversion can be accomplished by laser scanners, flat-bed scanners

with a transparency adaptor or digital cameras/video cameras.

➤ Scanners use CCDs to detect light transmitted through a radiograph with subsequent
conversion to digital signals in proportion to the light intensity detected. The digital
signals will be transformed to shades of grey as discussed earlier.

➤ Digitization simply turns an analogue image into a form that can be further analysed
and manipulated by various computer tools.

➤ Although, in theory, the information obtained could be, at best, the same as in the
analogue image, some concerns have been expressed about possible distortions from
the lens system in digital cameras as well as contrast resolution with scanners.

Advantages of digital panoramic radiography

➤ Time saving is undoubtedly the dominant advantage of the digital panoramic
systems over the conventional ones. Automated film processors used in dental
practice range from 90 s to 4 min (depending on the type) for processing a panoramic
radiograph, whereas the CCD-based systems provide the captured image instantly.

➤ Moreover, digital systems need no darkroom facilities. Maintaining a darkroom

properly for film-based radiography is a demanding task that requires continuous
controls, a considerable amount of time spent by knowledgeable staff and it is costly
also.

➤ The digital detectors are more sensitive to X-rays, compared with film, and as a
result the patient exposure is reduced. Even though the radiation dose imparted with
a panoramic radiograph is small, the ALARA (as low as reasonably achievable)
concept encourages health care professionals to pursue diagnostic radiographs with
the least exposure to the patient. This is feasible with digital panoramic units.

➤ There is only one image available in a radiographic film for diagnosis, which can be
viewed only in one location, and if lost or misplaced it cannot be replaced. The
integration of digital radiography (panoramic and cephalometric) in the orthodontic
practice will reduce the need for storage of hundreds or thousands of radiographs,
and, if digital radiography is combined with electronic records, this need will be
completely eliminated.

➤ The digital radiographs in this case are stored in computer-based recording media.
From there, data can be retrieved at any time and distributed for demonstration in
one or more output devices (computer monitors) on request.
➤ Another factor that contributes considerably to the diagnosis is that higher resolution
digital images are provided.

➤ Image compression offers a solution to the increased need for electronic space, to
some extent. The goal of such an operation is to represent an image in a more
compact form by reducing its file size.

➤ The reduced image size will contribute not only to electronic space but also to a
faster data transmission. Teleradiology is the electronic transmission of radiographic
images from one location to another.

➤ Image magnification is considered a viewing enhancement, the application of which

will increase the size of the image, intending to make it more appealing to the
observer and improving the diagnostic efficacy.

➤ Density enhancement is the simplest operation that one can apply to restore a digital
image that appears to be either too light or too dark.

➤ The inversion grey scale is an operation that aims at producing an image that is the
negative form of an actual image. As a result, in the new image, all the blacks become
white, the whites become black and the intermediate grey shades take on their
respective negative qualities. The potential benefit is based on the fact that the human
eye is more sensitive to slight brightness changes in dark regions of an image than in
light regions.
Digital cephalometrics
Refer to Chapter 14 on Cephalometrics.
Digital study models
Study models provide a three-dimensional replica of malocclusion during any stage of
treatment, as well at the final outcome. Despite all associated benefits, these study
models have some disadvantages in terms of storage, durability and transferability.

➤ The procedures for taking dental impressions and forming study models have
progressed since their introduction in the early 1700s.

➤ Many attempts have been made to replace plaster study models. In the mid-1990s,
three-dimensional (3D) scanning technology was introduced, and study models were
transformed into a digital format. Recent technological breakthroughs have enhanced
the process of cast fabrication and manipulation. Software technology has refined this
approach, and digital orthodontic models have become commercially available.

Procedure
➤ This process still requires traditional alginate impressions to be taken in the
orthodontic office.

➤ Instead of being poured by the orthodontist, impressions are shipped overnight to

one of the companies offering digital models. There, a traditional plaster model is
fabricated and, using CAD-CAM technology is transformed into a digital, three-
dimensional (3D) image of the dentition.

➤ Within a few days, an electronic file is available to be downloaded from the internet
to a desired computer. Once downloaded, software enables the digital models to be
viewed and manipulated.

➤ Digital models are also an excellent tool for patient education. The younger
generations of patients currently in treatment are familiar with computers and are
comfortable with computer-generated images. They can relate to digital models and
probably expect to see this technology when they visit their orthodontists.
Digital photography
Digital imaging, one of the hot fields, is attracting more and more interest among
orthodontists. It is now possible, with a reasonable investment, to digitally acquire,
archive and easily retrieve clinical images of our patients.

➤ In digital photography, traditional film is replaced by a CCD. A CCD sensor has

thousands of light detectors, called ‘pixels’, on its surface.

➤ A high number of pixels (‘optical resolution’) increases the quality and detail of the
image, but also increases the size of the file in which the image will be saved. File
resolution can be increased by a software interpolation, which does not actually
improve the image quality. Therefore, when evaluating a camera’s optical resolution,
only the actual CCD optical resolution is considered and not the interpolation
resolution.

➤ The hardware involved includes flat-bed scanners, slide scanners, video cameras and
digital still cameras.

➤ Digital cameras can be divided into two main groups–compact digital cameras and
professional reflex cameras with digital interface.

➤ Once an image has been acquired by the CCD, it is stored in the camera’s memory as
a file. Image files can be of different formats and, more importantly, can be
compressed. Compression increases the number of images that can be stored in
memory, but it also causes a decay of the image quality; the higher the compression,
the greater the decay. A good feature is the ability to choose whether the images are
to be saved with or without compression, and at which compression level. This is
usually done by selecting the capture mode as ‘FINE’, ‘NORMAL’ or ‘ECONOMY’
(the terms may vary depending on the camera model). The file storage format is not
critical, but it is preferable to use digital cameras that save the acquired images as
JPEG or TIFF files, which can be read by virtually any imaging software. Proprietary
file formats will require special software.

➤ There are two types of image storage–built-in (internal) memory and removable
memory. Digital cameras with only internal memory should be avoided. Removable
memory is like a conventional roll of film that can be used over and over again. All
images stored in the digital camera’s memory are eventually transferred to a
computer for archiving. The time needed to transfer the images depends on two
factors: the size of the image files and the transfer speed (in kb/s). Since the file
dimension is determined by the resolution and compression of the image, a reduction
in size will have a negative impact on image quality. Therefore, transfer speed is the
key variable.
There are two different ways to transfer the images from the camera to the computer:

1. Cable connection: Most digital cameras can be connected

to a PC or Macintosh computer through a serial or parallel
port. This kind of connection is extremely slow, however,
and serial transfer is slower than parallel. Some cameras
can use a small computer system interface (SCSI) port,
which is much faster, but not available on all PCs.

2. Transfer from removable memory through a computer

drive: This is probably the most convenient way to
transfer the images to the computer.

ACCESSORY POINTS
➤ CT scan is a technique that blends the concept of thin layer radiography with computer
synthesis of image.

➤ Orascanner is a hand-held scanning device that directly captures a three-dimensional

image of the dentition.

➤ The process by which analogue information is converted into a digital form is called
digitization.

➤ A recent application of computers in orthodontic practice is computer-generated

telephone reminder system on appointments.

➤ Pixels are the short form for ‘picture elements’.

➤ Philipp Pfaff first described an impression-taking technique by using heated sealing

wax to obtain a negative representation of the dental arches that was then used to
pour a cast in plaster of Paris.

Advanced Learning
Paperless orthodontic practice
A paperless orthodontic office is a significant change. It increases practice efficiency,
enhances patient communication and reduces stress in the practice. The computer
system actually elevates the level of personal contact with patients, instead of reducing
it.
Technological considerations
➤ The first requirement for paperless operation is that the orthodontist must be willing
to change his/her practice into a high-tech operation.

➤ All paper records and manual systems must be replaced by a central, computerized
practice management programme. Thus, all patient records will be available at every
work station, to everyone with access to the computer system.

➤ These records include:

• Demographic (patient information forms)

• Diagnostic (health histories, photographs, models,

radiographs)

• Treatment (charts, plans, notes)

• Scheduling (appointment book)

• Financial (ledger cards)

➤ Ancillary tools may include imaging, cephalometrics, insurance-benefit data bases,
credit reporting, scanning, inventory and electronic ordering, and CD-ROM systems
for patient education, case presentations and staff training. All operations, including
treatment delivery, are centralized around the primary computer programme.

Physical considerations
An axiom in office design is that ‘work patterns determine the floor plan’. Therefore,
the first step in designing a perfect floor plan – whether the practice is paperless or not
– is for the doctor and staff to step back and analyse the way they work. It is important
to recognize and build on efficient work patterns, but to be willing to substitute new
methods in areas of weakness.
The sketch for conversion to a paperless orthodontic office is given in Fig. 35.3 (based
on Warren Hamula’s design). Switching to a paperless mode can be gradual, or with
the right system and proper preparation, can be done immediately. When establishing
a new facility, it is usually advisable to make a complete change before moving into the
new office.

➤ Many specific needs of the practice must be determined when making a transition
within an existing facility:
• Number and location of work stations

FIG. 35.3. Warren Hamula’s sketch plan for paperless orthodontic practice.

• Location of the file server

• Operating system requirements

• Present and future software requirements

➤ The number and location of work stations become important in the determination of
the computer hardware and the capacity required. Automated records should be
available for access at the following locations:

• Front desk

• Financial/business areas

• Key areas throughout the operatory

• Chair side units

• Satellite offices

• Doctor’s home
When practical, the main server should be located near the centre of the office, thus
reducing the distance to the work stations (Fig. 35.2).
A number of practice management software programmes are available, including
everything from electronic scheduling to computerized time clocks and payroll
systems. The management system should have the ability to link branch offices, if
necessary. In addition, if the doctor has access to patient information at home, it will
eliminate the need to take patient charts out of the office, with the potential of lost or
misplaced records. Office work can then be done at home on a laptop computer.
Financial considerations
➤ The initial investment in hardware and software is a factor to be considered in
developing a paperless office. Ongoing expenses will depend on the system selected
and the size of the practice.

➤ Operating a paperless practice should cost 2–5% of the gross income, but many
orthodontists can justify the investment based on increased efficiency alone.

Patient flow
➤ The floor plan should indicate the primary location and territory of each staff
member (Fig. 35.2). Good traffic flow promotes efficiency while allowing staff to
interact as necessary.

➤ An effective paperless practice carefully controls patient flow and keeps doctors and
staff fully informed of each patient’s location and treatment status.
➤ Upon arrival, the patient checks in at a station in the reception area. This information
is instantly relayed to the on-deck screen, which displays patients in the order they
are normally taken – first by appointment time, and second by check-in time. The
patient may be seated in the reception room, as is often done with adults, or may
proceed to an on-deck area in view of the assistants in the operatory.

➤ Any screen can be checked to determine whether a patient is early or late, or to find
out who is seated in which chair. Thus, the doctor always knows which chairs require
his or her presence, and in what order.

Records’ storage
➤ Traditional office designs allot considerable space to paper product storage and filing
cabinets, increasing the practice’s rental costs. As storage space fills up, many large
practices have to purge their files 2–3 years into retention. With more practices
prescribing long-term retention, however, records must legally be kept longer than in
the past. State laws may also require keeping patient records indefinitely.

➤ In a paperless office, the scanning system stores all patient records in the computer.
The storage problem is eliminated, and long-term retention information can be
instantly retrieved. Scanned records can be transferred to off-site storage on a regular
schedule, or whenever computer disc capacity is reached.

➤ The doctor or a designated staff member can leave the office each day with a back-up
copy of all the patient records in the practice – an important security advantage. In
case of a disaster such as fire or flood, the complete practice records can be available
for use within hours.

➤ Orthodontists using paperless systems should back up their patient records every
month and store them off-site at archiving services.

Reducing stress
➤ As with any major change, a few problems will arise during the transition to a
paperless operation, and a learning curve will be experienced. Nevertheless, those
who have made this transition, report that any initial apprehension is quickly
overcome by the reduced stress of treating patients.

➤ When doctors or staffs are tense or irritable due to breakdowns in routine, their
attitude is picked up by patients and parents: This is not the kind of atmosphere to be
created. In the paperless office, there is no such thing as a lost chart – once a constant
cause of frustration and lost time. Instant access to patient data by any staff member,
at work stations throughout the office, will be a welcome improvement over past
routines.

Methods of conversion to paperless clinic

➤ Conversion to a paperless clinic can be accomplished in two ways:

1. Jumping with a total conversion, scanning any and all

existing records and charting everything: This will require a
fast, high-quality scanner and a good amount of time up
front from either staff, or from temporary personnel brought
on specifically for this purpose.

2. Going into it gradually, charting only new patients: The

second method takes more time, but may be more practical
for most offices, given available staff time and learning
curves.
Index

A
Abnormal eruption of tooth, 566
Absolute anchorage, 282–285
Abstraction, 133, 134t
Accommodation in cognitive development, 102
Achondroplasia, 33, 143t, 159t
Ackerman–Proffit,
classification, 135
Acromegaly, 142, 148t
Acrylic, 391, 396–398, 422, 494–495, 626t
cold cure, 347, 357
heat cure, 347, 355
Acrylic partial denture, 494–495
Activator, 377–385
construction of, 380
contraindications, 379
effects of, 380
history, 377–378
indications, 378
modifications of, 385–389
trimming of, 380, 382
Adams clasp, 324–325
advantages, 324–325
design, 324
disadvantages, 325
parts, 324
 synonyms, 324
Adams pliers, 346
Adenoid facies, 149f, 173, 517
Adhesive precoated brackets, 308
Adjunctive orthodontic treatment, 605
Adolescence, 40, 81, 94–100, 458
Adult growth, 72
Adult occlusal equilibrium, 92
Adult orthodontics, 605–614
Advanced diagnostic aids, 191–192
Aesthetics, 177–178
macro, 177–178
micro, 177–178
mini, 177–178
Aetiology of malocclusion, 145, 170
developmental, 148–149
environmental, 148
functional causes, 149–151
postnatal causes, 148–157
prenatal, 143–145
Airrotor stripping (ARS) technique, 469
Alginate, 197, 300–301
Alizarin dye for vital staining, 35
ANB angle, 218, 218f
Anchorage, 268
classification, 274–275
definition, 274–275
extraoral, 346
factors affecting, 277–278
loss, 519
planning, 278
 sites of, 275–277
types, 278–282
values, 275
Andrew, 103
keys of occlusion, 103–108
straight wire appliance, 435–436
Angle of convexity, 234–235
Angle’s classification of malocclusion, 128–131
validity of, 131
Animism, 82
Ankylosis of primary tooth, 155
Annealing, 287–288
definition, 295
stages, 288
Anodontia, 139, 145, 153f, 522
Anterior bite plane, 348, 477, 483
Anterior crossbite, 575
aetiology, 577–581
definition, 577
diagnosis, 577–581
management, 577–581
Anterior nasal spine, 215, 228
Anterior open bite, 9-10t, 12, 118t, 136, 509f, 510, 587
Anthropoid space, 96
Anthropometry, 34, 34t
Antiflux, 296
Appliances, orthodontic, 310–312
definition, 310
fixed, 311
ideal requirements, 312–313
passive, 311
 removable, 311
types of, 315
Apron spring, 328, 339
Arch length, 461–462
deficiency, 461–462
definition, 461
excess, 461
Arch perimeter analysis, 200, 208, 462, 491
Arch wires, 432–433
classification, 434
different cross-sections, 433
metallic wires, 286
non-metallic wires, 286
Arrowhead clasp, 322–323
Arrow pin clasp, 317
Articulare, 215
Ashley Howe’s analysis, 202–203
Assimilation in cognitive development, 82–83
Attachments to bands in fixed, 434
Attraction, 79, 81, 133, 134t
Austenitic steel, 290

B
Baker’s anchorage, 281
Balancing extractions, 475f, 476
Ball end clasp, 318, 319–320, 403
Balters Wilhelm, See Bionator
Bandage for sucking prevention, 511
Band and bar space maintainer, 496
Band and loop space maintainer, 496f
Mayne’s modification, 497
Band material, 434t
Banded inclined plane, 372
Bandura’s observational learning, 83
Barrier techniques, 303
Base plate, 347–348
dimensions of, 348
functions of, 347
materials used, 347–348
Basion, 223
Begg technique, 436
Behaviour learning theories, 83–87
Behaviour management, 88
Behaviour rating, 87
Frankel, 87
Lampshire, 88
Wright’s, 87
Benjamin theory, 509
Bennett angle, movement, 125
Bennett classification, 123–125
Benninghoff’s lines, 111–113
Beta titanium wires, 286
Bimaxillary protrusion, 129
Biochemical feedback, 363
Bioelectric potential, 249
Bioelectric theory, 247–249
Biomechanics, definition, 269
Bionator, 389–392
Bite-plane, 368–369
horizontal, 368–369
inclined, 370
Bite-registration, 381–383, 390
Bite-wing radiograph, 183–184
Bjork,
implant radiography, 35–36
rotation of mandible, 68
sum of value, 235
Blanch test, 157, 174, 570
Blood flow theory, 249–251
Blue grass appliance, 512
Body ostectomy, 539–540, 540f
Bolton plane, 216t
Bolton ratio, 200–201
Bonded space maintainer, 490–491, 495
Bonding adhesives, 302t
Bony joints, 38
Boxing of appliance, 333–334
Branchial arches, 55
Brazing, 295–296
Broadbent, Holly, 212
cephalometry, 212
phenomenon, See Ugly duckling stage
registration point, 235
Bruckl’s appliance, 371
Bruxism, 515–516
Buccal canine retractor, 330–331
Buccal shield, 396
Buccinator mechanism, 113–114
Bulk technique, 357
Burstone, 315, 585f
intrusion arch, 487
spring characteristics, 315
TMA wire, 294
Butler’s field theory, 147–148
Butterfly test, 173t, 518t

C
Camouflage treatment, 476
in class II malocclusion, 473, 476
in class III malocclusion, 473, 476
C and L osteotomy, 540
Canine guidance, 125
Canine loop, 398
Canine retractors, 340
Cantilever springs, 328, 333
cranked, 335–338
double, 333, 335
paired, 336
single, 339
Cantilever type space maintainer, See Distal shoe
Capsular matrix, 48
Carey’s analysis, 208–211
Caries prevention, 487
primary, 26
secondary, 26
Cartilaginous theory of growth, 46, 73–74
Cements, 298
Centre of resistance (C res), 412
Centre of rotation (C rot), 270
Centric occlusion, 123
Centric relation, 123
Cephalic anomaly, 137
Cephalocaudal growth, 22–23
Cephalogram, 213
drawbacks, 213–214
in diagnosis and treatment, 231–233
 technique of, 214–215
types of, 213
uses of, 233
Cephalometrics, 212
defined, 213
landmarks, 215–216
reference planes, 216
Cephalometric, radiography, 212–215, 231
and growth, 240–242
Cephalostat, 214–215
Ceramics, 297–298
definition, 297
Cervical pull headgear, 411, 593
Cervical vertebrae maturation, 30
Chin cup, 415
Chromatic adhesives, 307–308
Circumferential clasp, 316t
Circumferential supracrestal fibrotomy, 532
Clasp,
classification of, 317
definition, 316
designing, 316–317
free ended, 317
ideal requirements, 317
Class I malocclusion, 5, 378
Angle’s classification, 129
Class II division 1 malocclusion, 129
aetiology, 590–592
Angle’s classification, 129
clinical features, 591–592
Class II division 2 malocclusion, 596–598
Classical conditioning, 83–85
Cleft lip and palate, 553–554
aetiology and pathogenesis, 555–561
classification of, 554
clinical features, 555–561
management, 555–561
orthodontic management, 561–564
prenatal diagnosis of, 564
Cleidocranial dysplasia, 153
Clinical FMA, 169–170
Clip on retainer, 622
Closed dentition, 96, 98
Coffin spring, 332–333
Cognitive theory, 82–83
Coil, 329
Coil springs, 433
Combination pull headgear, 411
Compensating extractions, 475
Complex tongue thrusting, 513–514
Complications of orthodontic treatment, 630–631
Compression theory in mouth breathing, 517
Computerized cephalometric system, 242–244
Concave profile, 135, 472
Condyle,
development, 61
postnatal growth, 68f
Congenital syphilis, 144
Contraction, 122, 172, 386t, 580
Controlling factors in growth, 27
Moyer’s classification, 27
Von Limborgh’s classification, 27
Convex profile, 168, 591
Cortical anchorage, 276
Corticotomy, 533
Couple, 270
Cranial index, 34
Craniometry, 34
Cretinism, 148t
Crossbite,
definition, 575
types, 135, 575
Crowding, 457
Crown and bar space maintainer, 495
Crown angulation, 104f
Crown inclination, 104f
Crozat appliance, 302, 311
Crystal growth, 439
CT scan, 191, 193
Curve of Spee, 105, 466, 537t, 538
Cyanoacrylates, 307
Cyclic AMP, 252, 253f

D
Deciduous teeth, early loss of, 413, 507
Decompensation, 496f, 538
Deep bite, 96, 97, 103t, 129, 136, 456–457
definition, 582
diagnosis, 583
measurement of, 582f
treatment, 584–586
Deglutition and stages, 117
Delta clasp, 325–327
Denholtz appliance, 376, 405
Dental arch, 133, 134t, 225f, 473
symmetry, 578
Dental groove, 94–95
Dentitio tarda/delayed eruption, 154–155
Dentofacial deformity, 534–535
Dentofacial planner, 243
Derotation, 472
Developmental causes of malocclusion, 148–149
Dewel technique of serial extraction, 521–527
Dewey’s modification of Angle’s classification, 132
Diagnostic aids, 162–163
classification, 162–163
essential, 162
supplemental, 163
Diagnostic set up, 204–205
Diastema, See Median diastema
Differential growth, 24–25
Digigraph, 244
Digital orthodontics, 632–633
digital photographs, 638–643
digital study models, 638
Digit sucking, See Thumb sucking
Dinaric individuals, 166
Discrimination of conditioned behaviour, 84f, 84–85
Disinfection, 303–306
Disking, 489
Displacement,
definition, 19
primary, 19f
secondary, 19f
Distal jet, 481–482
Distal shoe space maintainer, 490f, 493
fixed type, 495–500
removable type, 494, 500
Distraction, 134, 134t
Distraction osteogenesis, 546–547
Double oral screen, 375
Down’s analysis, 236–240
Driftodontics, 476
Dual cured bonding adhesive, 301–309
Dunlap beta hypothesis, 511
Duyzing clasp, 317
Dysfunctional movements, 118

E
Ectomorphic individuals, 165, 517
Ectopic eruption, 155
Edge–centroid relationship, 595
Edgewise appliances, 560, 562
Ego, 77
Egocentrism, 82f
Elastic limit, 314, 351
Elastics, 345–346
Electra complex, 78
Electromyography, 189–190
Elgiloy wires, 292
Endochondral ossification, different zones, 17
Endomorphic individuals, 165
Endosteal implant, 549
Enlow,
counterpart analysis, 235
V principle, 65–66
Envelope of discrepancy, 535
Epidemiology of malocclusion, 7–8
E plane, 217
Equilibrium theory, 160–161
Erikson’s stages of emotional development, 79–81
Eruption of teeth, 90–92
chronology of, 92
definition, 90–91
sequence of, 95
permanent, 91
primary, 91
stages of, 91–92
theories of, 90–91
Essix retainer, 623
Etching, 438–439, 441
Exercise device, 395
Expanding V, 21
Expansion, 419–420
appliances, 419–431
orthodontic, 419
passive, 419
screws, 430
mandibular, 420
maxillary, 420
rapid and slow, 420
Experimental approaches of measuring growth, 33, 35
Extinction of conditioned behaviour, 85, 89
Extractions in orthodontics, 473–484
Extraoral anchorage, 281
Extrusion, 273, 383, 456, 586
Eyelet clasp, 318

F
Face,
divergence, 168–169
form, 166
photographs, 186
profile, 167–168
proportions, 167
symmetry, 167
Face bow, parts, 409–410
Face mask,
Delaire type, 415
Hickham, 415
Petit type, 415
Turbinger type, 169
Facial index, 34
Facial profile analysis, 170, 176
Facial structures, growth of, 53–75
Fatigue, 315, 325
Feeding,
bottle-feeding, 115f
infant feeding, 115
Fetal moulding, 142t, 144
Finger springs, 336
First order bends, 435, 437t
Fixed appliances, 432–453
advantages and limitations, 450–453
evolution of, 435–437
parts of, 432
problems encountered during, 444–449
Fixed functional appliances (FFA), 405–407
flexible, 405–407
rigid, 406–407
Fluoride application, 470
Flux, 296
Force,
definition, 258
ideal orthodontic, 258–259
orthopaedic, 261–267
types, 258–261
continuous, 258–259
intermittent, 259
interrupted, 259
values for different types of tooth movement, 413
Forces of occlusion, 107
Formability, 289, 307t, 315
Frankfort horizontal plane, 133, 220, 221, 229
Frankfort mandibular incisor angle, 221
Frankfort mandibular plane angle (FMA), 221
Freeway space, 122, 584, 586, 588
Frenectomy, 529–530
Freud, Sigmund, 77, 89
Friction, 277–278
definition, 283
factors affecting, 284
Frontal resorption, 253
Frontonasal process, 54–55
Full clasp, 321
Functional appliances, 360–408
advantages, 367
and functional matrix theory, 407–408
and servo system theory, 408
classification of, 360–361
craniofacial response to, 364–365
 criteria for case selection, 366–367
definition, 360–408
disadvantages, 367
history, 361
ideal requirements of, 365
mechanism of action, 368
principles of, 362–363
Functional causes of malocclusion, 149–151
Functional class II malocclusion, See Pseudo-class III
Functional examination of, 170–173, 175-176t
path of closure, 176
respiration, 176
rest position, 176
TMJ, 176
tongue, 176
Functional matrix, and functional appliances, 407–408
Functional matrix theory, 46–49
Functional movements, 118, 403
Functional regulator, 392–393
clinical management, 401
indications, 393–394
philosophy of, 394–396
types, 392–393

G
Gable bend, 585
Gemination, 153
Generalization of conditioned behaviour, 83–87
Genetic theory of growth, 44
Genetics, 145–147
and malocclusion, 145–147
methods of transmission, 146
 modes of inheritance, 146
recent advances, 147
Gerber space regainer, 520
Gingival groove, 94–95
Gnathion, 215, 223
Gnathostatic casts, 209
Gold alloys, 286, 550
Golden proportions, 177
Gonion, 215, 237
Gothic arch, 125
Grainger’s treatment priority index, 8
Grain growth, 287, 288
Group function, 172
Growth and development, 14–15
amount of, 25
clinical implications of, 33
controlling factors of growth, 27
definition, 14–15
differences between growth and development, 15
hard tissue growth, 16t
methods of measuring growth, 33
nature of skeletal growth, 16
of facial structures, 53–75
pattern, 21–23
soft tissue growth, 16
theories of growth, 44–52
timing, 25
variability, 23–25
Growth axis, 220–221
Growth centre, 19
Growth equivalents concept, 52
Growth modification principles, 462–465
in maxillary transverse deficiency, 463
in prognathic mandible, 464
in prognathic maxilla, 463
in retrognathic mandible, 464
in retrognathic maxilla, 463–464
Growth sites, 19
Growth spurts, 25
clinical implications, 25
types, 25t
Guidance of eruption, 521–527
Gum pads, 94–95

H
Habit breaking appliance, 512, 514
Habits, 507
classification, 507–508
definition, 507
interception, 519
pernicious habits, 491, 492, 571, 590
types, 507
Hand-wrist,
anatomy of, 29–30
radiographs, 29, 186–189
Hand wrought roach clasp, 317
Hawley appliance, 348–349
Hawley retainer, 348–349
Headgears, 409–414
biomechanics, 411–413
components, 409–410
history of, 409b
instructions to patients, 413–414
 types, 410–411
uses, 413
Head types, 165, 175
Heat treatment of orthodontic alloys, 91–92
Helical loop canine retractor, 327, 330, 331
Hellmann standards, 39
Herbst appliance, 406, 477f
Heredity and malocclusions, 141-142t, 142t, 590
High frenal attachment, 157
Holdaway, 235–236
lip analysis, 235–236
ratio, 236
Hollow chop pliers, 347
Hotz modification of oral screen, 374
Hyalinization, 253–254
definition, 253–254
microscopic features, 255
reasons, 254–255
Hyperodontia, 153
Hyperparathyroidism, 148t
Hyperplasia, 16
Hyperthyroidism, 148t, 535t
Hypertrophy, 16
Hypodontia, 10-11b, 20f
Hypoparathyroidism, 148t
Hypopituitary dwarfism, 148t

I
Id, 77
Imaginary audience, 82f, 83
Imbrication, 474t
Impacted tooth management, 530–532
Implant radiography, 35–36
Implants in orthodontics, 549
Incisor classification, 134–135
Incisor liability, 98
Incisor mandibular plane angle, 221, 239
Indices of malocclusion, 8
definition, 8
ideal requirements, 8
types, 8
Indirect bonding, 451–452
Infant orthopaedics, 557–558, 561
Infantile swallow, 116
Inoculation, 303
In-out bends, 451
Interceptive orthodontics, 503
definition, 503
various procedures of, 503
Interincisal angle, 219, 225, 239
Intermaxillary anchorage, 280
Intermittent force, 259
Interproximal reduction, 469, 627f
Interrupted force, 259
Intramaxillary anchorage, 280
Intraoral anchorage, 279–281
Intraoral radiographs, 181, 182–184
Intrusion, 272–273
IOTN, 10–12
advantages of, 12
aesthetic component of, 11–12
dental health component of, 10-11b
disadvantages of, 12
Irreversible hydrocolloids, 300–301
Isometric contractions, 379, 386t
Isotonic contractions, 386t

J
Jackson’s clasp, 321–322
Jackson’s triad, 3–4
Jarabak’s ratio, 234
Jasper Jumper, 312, 406
Jones jig, 471, 480
Juvenile occlusal equilibrium, 91–92

K
Keles slider, 483–484
Kesling,
diagnostic set-up, 204–205
separators, 432
Key ridge, 107, 138
Keys of occlusion, 103–108
Andrews static occlusion, 103–105
Roth’s functional occlusion, 105–108
Kingsley, Norman, 361t
Kjellgren, See Serial extraction
K-loop distalizer, 483

L
Labial bows, 340–344
extended, 344, 348
fitted, 343
long, 341
reverse, 342–343
short, 340
 split, 341–342
Lag phase of tooth movement, 257
Laser etching, 439
Laser holography, 195
Late incisor crowding, 74
Late mandibular growth, 75
Lateral pterygoid muscle, 363
Latex elastics, 443
Law of canine, 134
Learning theory, 509
Leeway space of Nance, 100
Ligature wire, 435
Linderhearth analysis, 204
Line of occlusion, 107
mandible, 489
maxilla, 107
Lingual extension clasp, 320–321
Lingual orthodontics, 451
Lingual shield, 397–398
Lip,
competency, 169
posture, 169
tonicity, 169, 373, 373f
Lip biting, 514–515
Lip bumper, design construction, 376–377, 376f
Lip pads, 397, 399
Lischer’s modification, of Angle’s classification, 131
Load deflection rate, 315
Locked first permanent molar, 489
Lock pins, 434
Lokar molar distalizer, 483
Long face, 465
principles in correction of, 464
Loop forming pliers, 347
Lower inclined plane, 370
Lower lingual holding arch, 518–519

M
Macrodontia, 145, 461, 556
Magnetic resonance imaging (MRI), 192–193
Magnets, 308–309
Malformed teeth, 153–154
Malocclusion,
aetiology of, 141–142
classification of, 126–127, 141–142
definition, 126–127
developmental causes of, 148–149
incipient, 506
unfavourable sequelae of, 2–3
Mandible,
postnatal growth, 66–69
prenatal growth, 59–61
role of genetic and epigenetic factors in growth of, 145–147
rotations of, 41–43
trajectories of, 113
with regard to various theories of growth, 73–74
Martensite steel, 290
Mastication, adult and stages, 114
Maternal infection, 143, 555
Maxilla,
growth of, 73f
ossification centres of, 56
postnatal growth, 61–65
 prenatal growth, 53–57
trajectories of forces, 110
with regard to various theories of growth, 72–73
Maxillary process, 72–73
Maximal elastic moment, 283, 315
McNamara analysis, 217, 227t, 231
Mechanochemical hypothesis, 247
Medial pterygoid muscle, 74, 120
Median diastema, causes and management, 570
Medically compromised patients, 611
Membranous ossification, 17
Mershon’s modification, 498f
Mesial shift,
early, 94–100
late, 100
Mesiocclusion, 130–131
Mesomorphic individuals, 165
Messengers of tooth movement,
first, 250
second and third, 252
Microdontia, 461, 556, 568, 570
Mills retractor, 344
Minimum anchorage, 285
Mixed dentition model analysis, 207, 567
Model analysis, 196–211
classification, 200
Modelling, 86–87, 89
Model surgery, 539
Moderate anchorage, 285
Module, 305t, 407, 414
Molar clasp, 321
Molar distalization,
appliances used for, 477–484
complications, 547
contraindications, 544
indications, 378
Moment, 269–270
Moment to force ratio, 270
Monson’s curve, 102
Moss, Melvin, see also Functional matrix theory, 44
Motivation,
achievement, 88
affiliation, 88
attribution, 88
external, 88
internal, 88
Most retruded position of mandible, 123
Mouth breathing,
aetiology, 517
classification, 516
clinical features, 517–518
definition, 521
investigations, 518
pathogenesis, 517
treatment, 518–519
Mouth protectors/mouth guards, 500–502
Moyer’s analysis, 221, 567
radiographic methods, 207
Tanaka-Johnston analysis, 206–207
Mucosal barrier to eruption, 155
Muscle exercises, 525–526
Muscles,
 changes during growth, 121
function and malocclusion, 122
inframandibular, 119
supramandibular, 119
Myodynamic appliances, 361
Myotonic appliances, 361

N
Nance,
father of serial extraction, 476, 521
leeway space of, 100
space holding appliance, 498
Nasal septum, postnatal development, 36–37
Nasion, 215, 216t, 226–227
Nasoalveolar moulding, 563
Need for orthodontic treatment, 2–3
Negative reinforcement, 86
Neural crest cells, 53
Neuroepithelial trophism, 49
Neurotrophism,
definition, 49
types, 49
Neurovisceral trophism, 49
Newton’s laws of motion, 268
Nitinol wires, 292–294
Nolla’s stages of tooth development, 92
Normal occlusion, 90–108
Norwegian appliance, See Activator

O
Obstructive sleep apnoea, 610
Occipital headgear, 410–411
Occlusal equilibration, 488
Occlusal feature index, 9-10t, 127t
Occlusal index, Summers, 9-10t, 127t
Occlusion,
keys of, 103–108
line of, 107
normal, 107–108
Occlusogram,
definition, 190–191
disadvantages, 191
norms, 191
technique, 190
uses of, 191
Oedipus complex, 78
Oligodontia, 145, 153f
Omission, 86
Onlays, 542
Open bite, 586–589
Open dentition, 95–97
Optiflex wire, 286
Oral drive theory, 509
Oral hygiene, 487
during active treatment, 401
Oral screen, 372
Orbitale, 215, 221
Orbital plane, 133
Ormocers, 307
Orthodontic appliances,
expansion, 420
fixed, 432
functional, 360–408
 orthopaedic, 409
removable, 310–359
Orthodontic pliers, 346–347
Orthodontics,
aims and objectives of, 3–4
definition, 4
divisions of, 1
goals, 3–4
history, 4–5, 6
interceptive, 1
preventive, 1
surgical, 1
treatment planning in, 454–461
Orthognathic surgery,
contraindications, 535
indications, 534–535
Orthopaedic appliances, 409–418
Orthopaedic force, 258
definition, 258
for mandibular growth restriction, 262
for maxillary growth restriction, 261
for maxillary growth stimulation, 262
Ossification,
endochondral, 16
intramembranous, 17
Overbite, deep, 582
aetiology of, 582–586
definition, 582
diagnosis, 587

P
Palatal bow (pabo), 398
Palatal canine retractor, 328, 333, 337
Palate, 125, 174, 276, 553–554
Panoramic radiography, 184–186
Paperless orthodontic office, 640
Papilla dividing procedure, 533
Parafunctional movement of mandible, 118
Parent education, 487
Passivating effect, 290–291
Pavlov, Ivan, see also Classical conditioning, 89, 85
Peck and Peck ratio, 209
Peer assessment rate (PAR), 13
Pelots, 397
Pendulum appliance, 478–479
Pericision, 532–533
Periodontal aspects of orthodontic treatment, 608
Periodontal ligament, 246–247
response to physiologic forces, 247
structure, 246–247
Periosteal matrix, 47, 396, 407
Permanent retention, 598, 607, 619
Photocephalometry, 194
Photographs, facial, 186
Physiologic median diastema, 98, 570
Physiologic tooth movement, 245–246
Piaget, Jean, see also Cognitive theory, 76, 89
Pierre Robin syndrome, 159t, 377, 556, 557
Piezoelectricity, 248–249
Pitch, 178
Placodes, 54f
Plasma arc light, 308t
Pogonion, 215, 220
Point A, 215, 216t, 223, 224
Point B, 215, 216t, 223
Poor man’s cephalometric analysis, 170, 176
Pordios, 243
Porion, 215, 221
Positioner, 622, 625t
Positive reinforcement, 85, 86
Post-emergent eruption of teeth, 91–92
Posterior bite plane, 348
Posterior crossbite,
aetiologic factors, 577–579
definition, 577
treatment, 579–580
Posterior nasal spine, 216t
Postnatal causes of malocclusion, 148–157
Post-surgical orthodontics, 536, 538f
Postural rest position, 170–171
Preadjusted edgewise appliance, 312, 435–436, 538
Predental procedures in preventive orthodontics, 485–486
Pre-emergent eruption of teeth, 91
Prenatal causes of malocclusion, 143–145
Pressure tension theory, 249–251
Presurgical orthodontics, 563, 598
Preventive orthodontics, 485–486
definition, 485–486
rationale and principle of, 486–487
various procedures, 539–540
Primate space, 94–100
Primers, 441b
Proportional limit, 314, 315
Prostaglandins, 266
Proximal caries, 158f, 486, 488
Proximal slicing, 468
Pseudo-class III malocclusion, 603
Psychoanalytical theory, Sigmund Freud, 76–83
Psychology, child, 76
definition, 76
need to study, 76
Psychosocial theory, Erikson, 79–81
Pterygoid pillar, in trajectories, 111
Pterygoid response, 404
Puberty,
biological control of, 40–41
definition, 40
stages, 40–41
Punishment, 86

Q
Quad helix, 428
fixed, 425, 428–430
removable, 428
Qualitative methods of classification of malocclusion, 127
Quantitative measurement of growth, 15, 33
Quantitative methods of classification of malocclusion, 26
Quick ceph image, 243
Quick decay rate, 248

R
Radiograph, 181–182
bisecting angle technique, 182
bite-wing, 183–184
extraoral, 181
intraoral, 181
 panoramic, 184–186
paralleling technique, 182
Raphe median plane, 133–134
Rapid maxillary expansion, 419
history, 420
indications, 421
principles of, 432
Reciprocal anchorage, 279
Recovery heat treatment, 287–288
Recrystallization, annealing, 288
Registration point, Broadbent, 235
Reinforced anchorage, 281
Relapse, 615
causes, 615–617
definition, 615
Reminder appliance, therapy, 512
Remodeling, 18
definition, 18
types, 18
Removable appliances, 310–359
advantages, 313
clinical management, 347–348
designing of, 353–355
fabrication, 355–357
failures of, 350–358
limitations, 313
mechanical principles involved, 313–315
parts, 315–316
trimming, 357
uses in different types of malocclusion, 358
Removable space maintainer, 493–495
Repositioning of tooth, 533–534
Resilience, 314f, 315
Retained infantile swallow, 514
Retainers, 621–624
banded/bonded, 623
Essix, 623
fixed, 623–624
ideal requirements, 621
removable, 621–623
Retention, 615
definition, 615
in different types of malocclusion, 625–626
need for, 615–617
planning of, 619–620
schools of thought, 617
theorems on, 618–619
Retrodiscal pad, 51, 363f, 364f
Reverse loop canine retractor, 331–332
Reverse piezoelectricity, 248–249
Reverse pull headgear, 414–417
biomechanics, 416–417
components, 414–416
effects of, 416
history, 414
indications, 414
types, 415
Ricketts analysis, 223–225
Roberts’ retractor, 358-359t
Roche’s appliance, 499
Roll, 178
Rooting and placing reflexes, See Benjamin theory
Root movement, 271f, 273
Root resorption, 265–266, 630t
types, 263
Rotations of jaw, 41
clockwise and counterclockwise, 42
internal and external, 42f
matrix and intramatrix, 42f
Roth, keys of functional occlusion, 105–108
Rubella, 145, 303, 555

S
Safety valve mechanism, 26
Sagittal split osteotomy, 540
Scammon’s growth curves, 23f
Schwarz,
clasp, 322–323
degree of forces, 263
expansion plate, 425–427
Scissors bite, 575, 591
Scott’s hypothesis, See Cartilaginous theory
Screws, 345
Sealants, 439
Second messengers, 252
Self-correcting malocclusions, 102
Self-ligating brackets, 451
Sella, 215, 216t, 220, 235
Sella-nasion plane, 216t
Sensitization, 291–292
Separators, 432
types, 432
Serial extraction, 475–476, 521–527
benefits of, 522
 contraindications, 522
definition, 521
disadvantages, 524–527
indications, 522
rationale, 522
technique, 521, 524
Servo system theory, 49–52
and functional appliances, 407–408
Shape memory, 292–294
Sheldon’s classification of body build, 165b
Short face, 588–589
clinical features, 463
principle in growth modification, 462–465
surgical management, 572, 602
Sicher’s sutural theory, 45
Simian space, 96
Simon’s classification of malocclusion, 134
Simple anchorage, 509–510
Simple tongue thrust, 512
Skeletal classification, 139
Skeletal malocclusion, 131, 140, 414, 526
Skeletal maturity indicators, 29
cervical vertebrae maturation, 30
hand-wrist radiographs, 29
Skeletal open bite, 587–588
Skeletal unit, 47
macro, 48t
micro, 48t
Skinner BF, operant conditioning, 83
Sliding genioplasty, 542, 543
Slow expansion appliance, 424–425
Smile analysis, 178–180
SNA angle, 217
SNB angle, 217–218
Soft tissue paradigm, 14
Soldering, 295–296
definition, 295
technical procedure, 296
South end clasp, 323
Space age wires, 292–294
Space gaining procedures, 460t, 468
Space maintainers, 485
active, 490–491
classification, 565–566
contraindications, 493
definition, 490
functional, 490–491, 495
ideal requirements, 493
indications, 493
non-functional, 490–491, 491f, 495
removable type, 493–495
Space maintenance, 491–493
definition, 491
planning, 491–492
Space regainers, 519–521
Spacing, 568–569
aetiology, 568–569
generalized, 568–569
localized, 568
management, 569
Speech types and malocclusion, 118–120
Spring characteristics, 315
Springiness, 315
Spring retainers, 626–627
Springs, 327
auxiliary, 328
basic properties, 328–339
definition, 327–328
free-ended, 328
guided, 328
ideal requirements, 328
self-supported, 327–328
Sprinkle on technique, 357
Squeeze film effect, 263
Stability ratio, 329
Stainless steel, 289–292
18-8 type, 289–292
definition, 289
properties, 290–291
Stationary anchorage, 278
Steiner’s analysis, 217–220
Sterilization, 303–306
definition, 303
monitoring of, 304–306
of orthodontic materials, 304
Stomatognathics, 109
components, 109
definition, 109
Straight wire appliance, See Preadjusted appliance
Strain, 287, 314
Strain hardening, 287
Streaming potential, 249
Stress, 250f, 272, 283, 288, 293, 314
Study models, 196–200
advantages, 199
fabrication, 197
parts, 196–197
uses, 199
Superego, 77
Superelasticity, 293
Supernumerary tooth, 153
Supplemental diagnostic aids, 163
Supplemental tooth, 153
Surgical orthodontics, 528
definition, 287
procedures, 529–530
major, 529t
minor, 529t
Surgically assisted rapid palatal expansion (SARPE), 420, 423
Sved bite plane, 369
Swallowing,
adult, 115, 117
infantile, 116
Swallowing exercises, 513, 526
Synchondroses, 31–33
definition, 32t
intersphenoidal, 32t
intraoccipital, 32t
Syndromes causing malocclusion, 159t

T
Tanaka-Johnston analysis, 206–207
Temporomandibular dysfunction, 608
Terminal plane relationships, 97
distal step, 97
 flush, 97
mesial step, 97
Terrible two’s stage, 99
Therapeutic aids, 545–548
Therapeutic extractions, 529
Third molars, 75, 106, 472, 617
Third order bends, 435–436
Through the bite elastics, 280, 445t, 579
Thumb sucking, 508
aetiology, 508–509
definition, 521
methods of approach and treatment, 511
pathogenesis, 509
Timing of treatment, 416, 457
Tip edge, 437
Tipping, 271f, 472
controlled, 272
uncontrolled, 271
Titanium-molybdenum alloy (TMA), 294
Tongue blade therapy, 506–507
Tongue development, 70–75
Tongue thrusting, 512–514
classification, 512–513
definition, 512–514
treatment, 513
Tooth material, 202, 461, 570
Tooth movement,
biology of, 245–246
biomechanics of, 269
changes in other tissues,
histological changes, 252
 stages, 257–258
theories of, 247–252
types, 271–274
Torque, 104, 273
Total space analysis, 465
Trajectorial theory of bone formation, 110–111
Trajectories of forces, 111–113
mandible, 113
maxilla, 111–113
Transduction, 247, 364
Transient malocclusions, 102
Translation, 63
Transpalatal arch, 499
Transplantation, 534
Transposition of tooth, 566
Trauma, and orthodontics, 613
Treatment planning, 454–461
establishing goals of treatment, 455
for mixed dentition, 458
for primary dentition, 459
in adolescents, 460t
in orthodontics, 454–461
timing of treatment, 457
Treatment priority index, 12–13
Triangular clasp, 319
Trident of habit factors, 151
T spring, 352t
Tube shift technique, 163, 530
Tweed, 221–222
analysis, 221–222
diagnostic triangle, 221–222
 growth trends, 39
retention plan, 629–630
technique of serial extraction, 524–527
Twin block, 402–408
clinical management, 404
components, 403–404
construction bite, 403–404
design, 403–404
Twinning, 153
Twins, 146
dizygotic, 146
monozygotic, 146
Twin study, 146

U
Ugly duckling stage, 98–99
U-loop canine retractor, 332
Ultimate tensile strength, 314
Undermining resorption, 255–256
Unfavourable sequelae of malocclusion, 2–3
Universal pliers, 346
Unloaded nerve concept, 68
Upper anterior inclined plane, 347
Uprighting, 472
Utility arches, 585

V
Variability in growth, 23–25
Veau’s classification of cleft lip and palate, 554
Venn diagram, 135, 136, 138
Vestibular screen, 372–375
Visick clasp, 317
Visualized treatment objective (VTO), 365–366
cephalometric, 244
Vital staining, 35
Vitamin D excess, 144t
V principle, 21

W
W arch expansion, 464
Wash board appearance, 604b
Wassmund procedure, 543
Water holding test, 173t
Welding, 297
WHO classification of malocclusion, 139–140
Wilkinson extraction, 474
Wires, 288
braided or twisted, 306
composition and properties of metallic, 306–307
ideal requirements, 289
non-metallic, 306
used in orthodontics, 289
Wits analysis, 222–223
Wolff’s law of transformation of bone, 110–111
Working side, 123
Wrap around retainer, 621
Wrought alloys, 287

X
Xenon, 308t
Xeroradiography, 191
X rays, See Radiographs

Y
Yaw, 178
Y axis, 220–221
Yield strength, 314

Z
Zinc phosphate cement, 298
Zinc polycarboxylate cement, 298
Z spring, 320–321
Zygomatic pillar, 111f