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Aetiology of Malocclusion II

Dana Qatamin

Emad Maayta


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The Aetiology Of Malocclusion II

We said last lecture malocclusion is multi factorial , it could be : 1 genetic 2- environmental 3- developmental 4- congenital 5- functional Today we will talk about local factors causing malocclusion :
- Abnormalities in tooth size - Abnormalities in number of teeth and the form of teeth - Premature loss of primary teeth - Loss of permanent teeth due to caries - Prolonged retention of primary teeth - Trauma , facture and direct displacement of permanent teeth - Abnormal development in the position of tooth germs (ectopic eruption) - Sucking habit - Large persistent labial frenum

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1- Abnormalities in tooth size , number and form : * According to the size it could be : - Small teeth (microdontia) will cause spacing - Large teeth (macrodontia) will cause crowding * about the number : - Extra teeth (Supernumerary teeth) - Missing teeth ( hypodontia ) 6%, will cause spacing Supernumerary teeth : -prevalence in general 1% ( M:F=2:1) -consequences of supernumerary teeth on occlusion are ( crowding, spacing, impaction ) -The etiology of supernumerary: excessive but organized growth of dental lamina, because if it wasnt organized it well be a tumor. Types of supernumerary : 1-supplemental 2-conical (mesiodense) 3-tuberculate 4-odontoms can be complex or compound
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Supplemental: It's an erupted identical tooth, similar to the last tooth in series (in incisors its similar to lateral incisor and in premolars its similar to second premolar), it will cause crowding because it occupies more space. Conical (mesiodense): usually it is located in the premaxilla between central incisors (midline) and usually its inverted, it formed early and may erupt between the centrals causing displacement, mesiodense could be within the bone or erupted. Tuberculate: it usually comes in pairs of teeth more than one, it formed late, and prevent eruption of the incisors . - root formation in tuberculate is delayed compared to that of the permanent incisors. Odontomes: Complex a mass of tooth structure of enamel, dentine and cementum that doesn't look like normal teeth. Compound multiple supernumerary teeth that look like small teeth grouped together. "Wiki" Consequences of supernumerary :: -midline diastema caused by mesiodense -crowding. -delayed eruption of central incisors. -malposition of central incisors -root resorption of central incisors, if it is inside the bone close to the root of incisor -Cystic formation, any impacted dental tissue in bone with time can develop cyst (dentogensis cyst) Hypodontia : -It accounts for 6% -its most common in the mand. 2nd premolar to be missing around 2.8% in population , ( in Jordan 3.7% ) followed by maxillary lateral incisor: ~1.6% , (in Jordan 2.3%) then Max.2nd premolar : ~1.4% lastly Mand. Incisor : ~0.1 (originally,, Hypodontia is most common in third molar but we don't include it so we follow the previous order) Consequences of missing the lat. Incisor ::
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-Spacing - Unilateral missing of lateral incisor is more common than bilateral -Affects the eruption of canine (so malformed or missed lateral incisor can cause palatally impacted Max. canine ) In the case of missing lateral incisor we're talking about guidance teeth: the distal aspect of the lateral incisor root acts as a guide for the canine to erupt if this guide is no more available the canine fails to erupt, This is one theory of the impacted Max. canine the other theory is genetic theory. Consequences of missing man. Second premolar :: -retained deciduous 2nd molar (retained E) and in some cases its retained and ankylosed so when the alveolar bone grows it'll cause eruption of the teeth , but ankylosed tooth can't erupt so the adjacent teeth will keep erupting ,However the ankylosed tooth will look submerged (infraoccluded) . -spacing if the 2nd deciduous molar prematurely lost there'll be spacing because there's no 5 , and this space either closed or replaced. sometimes this space may not enough for prosthetic txt. So we do orthodontic txt. -over eruption of the opposing tooth nothing in contact prevent it from eruption so this is a problem because we can't put a prosthesis while we've over erupted tooth ( some dentists may cut over erupted tooth and do RCT) .

*Abnormal form : - Dens in dentine - Dilacerations - Gemination / fusion Gemination : development of two teeth from a single tooth bud, it can affects any tooth but commonly it affects Incisors (Usually it causes crowding ). Fusion : union of two teeth buds.

we can differentiate between them by: 1- counting the teeth, in gemination number of teeth will be normal, but if less its fusion. 2- Radiographs, one root for germination and two roots for fusion.
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2- Premature loss of primary teeth

The effect of premature loss of primary teeth is space loss . -premature loss of primary 2nd molar (E):before the eruption of the permanent 1st molar then the 6 will erupt in the space of E causing impaction and crowding of the 5 if it's not missing, so we need to put space maintainer for unerupted 6 to contact the mesial surface of 6 . if the loss of E is after eruption of 6 and the 5 is there so we'll have a Mesial tipping (mesial drifting) for the upper 6 and also we need to make space maintainer to keep the space for the 5. -primary 1st molars loss(D): 6s and Es will drift mesially Premature loss of Ds will cause mesial shift of Es and 6s, so space loss and crowding, also we may make space maintainer unilateral loss could cause midline shift If D is lost unilaterally it may affect the Midline, however the midline is shifted more when the unilateral loss is more anterior So the effect in Midline from premature loss of D is lesser than premature loss of C (Txt. either by space maintainer or balanced extraction "extraction of contra-lateral tooth" ) ,but in some cases the midline not shifted. in upper arch: 4s erupt before 3s: Upper permanent 1st premolar usually erupts before upper canine so when D is lost prematurely 4 will erupt and this may cause crowding of canine. in lower arch: 3s erupt before 4s: when D is lost prematurely 3 will erupt and this may cause crowding of 4 -Premature loss of primary canine (C) : - in the case of Ds and Es the most common cause of premature loss is caries . - In case of Cs is mostly as a result of root resorption by crowded lateral incisor - may result in canine crowding - if unilateral loss most likely cause midline shift and so the inter septic treatment would be to extract the contra-lateral one to the midline or space maintainer

3- Loss of permanent teeth :

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-Most common is 1st permanent molar loss because its the first erupted permanent tooth - cause mesial drifting of adjacent teeth (loss of 4 cause mesial drifting to 5 and close the space of 4) -over eruption of opposing tooth -centerline shift if the loss is more anterior -in case of adequate spaces, replace lost tooth ASAP -in case of crowding , dont replace the lost tooth and extract the contralateral one and relive the crowding . e.g. let's say the upper right 4 was lost due to caries now if the occlusal is normal and the space is adequate try to replace this 4 as soon as you can to prevent the space loss and mesial drifting and tilting of 5 and 6 . However if there is already crowding in the upper and in the orthodontist decided to extract teeth then use this lost tooth and extract the contra-lateral 4 to relieve the crowding so dont replace it .

4-Prolonged retention of primary teeth

-If the primary tooth is retained this will prevent the permanent tooth from eruption so may cause impaction or ectopic eruption . For example a 15 yr's patient with retained lower Es , you expect the 5s already there , but he came without 5s , 1st thing you do take x-ray to make sure that there is no 5s or there is but cannot erupt, if you decide to extract the retained E and there is no 5 you need to put implant or prosthesis ,in this case we dont extract it we keep it if there's no crowding , for esthetic reason or functional reason , but if the 5s does exist we extract the Es and allow the 5s to erupt . -Retained primary tooth may become submerged (infra occluded), in severe cases its totally covered by gingiva we make prosthesis but if the tooth not fully covered by gingiva we may put composite buildup to reach opposing tooth.

5- Impacted teeth
impacted incisors (the cause is supernumerary) , impacted or ectopic lower canines , impacted or ectopic max. 1st molar Impacted incisors -mesiodense is not necessarily associated with impaction it can erupt between incisors, the incisors can erupt with mesiodense still inside however tuberculate most likely cause impaction for the incisor.
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- It could be as result of supernumerary , and very early loss of primary teeth Impacted canine or displaced canine - prevalence 2.5% - Palatal impaction usually more than buccal impaction ( 85%of the impacted Max. canine is palatal and 15% is buccal) - Unilateral is more common than bilateral = 4:1 - Should be palpable at the area of buccal sulcus by the age of 8-10 yrs THE AETIOLOGIES : -disturbed path of eruption (lack of guidance by the root of lateral incisor ), usually palatal impaction -it can be as result of crowding, not enough space and in this case its impacted buccally -Hereditary (genetic theory ):points to genetic factors as a primary origin of palatally displaced canine . -long path of eruption because the canine has the longest path of eruption (the tooth germ of canine is near the infra orbital foramen) The position of impaction should be determined ,you need to determine whether this Max.canine is impacted palatally or buccally : -1st, you need to palpate the buccal sulcus in the area of canine to know if there's bulge or not (if you palpate a bulge this means the canine is buccally impacted) . - 2nd , if you can't feel the bulge and the canine is there so in this case you'll use (SLOB or Parallax technique in orthodontics ) .
SLOB : Two periapical films are taken of the same area, with the horizontal angulations of the cone changed when the second film is taken. If the object in question moves in the same direction as the cone, it is lingually positioned. If the object moves in the opposite direction, it is situated closer to the source of radiation and therefore buccally located .

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Ectopic erupted 1st molar - ectopic means it changes the path of eruption -the most common ectopic tooth is Max.1st molar - when 1st molar erupts mesially it will hit the root of upper Es and so it will damage root of E and erupt in E space , so it will cause crowding of 5 ectopic eruption of Max. 1 molar could be: 1- jump or reversible ectopic eruption: 6 will change its path of eruption from mesially to its normal eruption. 2- hold or irreversible ectopic : it keeps in the same direction (mesially)
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6- Local soft tissue factor

High labial frenum will cause midline diastema , treatment would be frenectomy.

you can refer to the pictures in the slides

Done by: DANA AL-QATAMIN

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