Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Malocclusion
-most often is hereditary
-less frequently is caused by thumb-sucking/tongue-thrusting, or trauma
“Sunday Bite”
-occurs when ppl w/ class II profile try to adopt forward postural position of mandible to improve
esthetics
Growth of Maxilla
-maxilla grows intramembranously
-growth occurs at sutures posterior and superior to maxilla at its connections to cranium and cranial base
-maxilla migrates downward and forward away from cranial base and undergoes significant surface
remodeling
-remodeling includes resorption of bone anteriorly and apposition of bone inferiorly
-much of anterior movement of maxilla is negated by anterior resorption, while downward migration is
helped by inferior apposition of bone
-addition of new bone can only occur at the surfaces and not interstitially
-thus, increased space for eruption of posterior teeth occurs by addition of bone posteriorly at
tuberosity as maxilla migrates downward and forward
Growth of Mandible
-growth of mandible is both endochondral and intramembranous
-major site of growth is condylar cartilage
-cartilage is transformed into bone at condyle as mandible grows downward and forward, away from
cranial base
-most growth of mandible occurs by new bone forming at condyle and by resorption of anterior part of
ramus w/ apposition posteriorly
Embryonic Development of Mandible
-mandible develops in the same area as cartilage of 1st pharyngeal arch (Meckel’s cartilage), but
development of mand. itself proceeds lateral to Meckel’s cartilage and is entirely intramembranous in
nature
-Meckel’s cartilage disintegrates and its remnants are transformed into a portion of inner ear (malleus and
incus)
-condylar cartilage develops independently and is initially separated by a gap from body of mandible
-it later fuses w/ developing mandibular ramus
Sex Differences
-girls reach growth peak around 2 yrs earlier than boys
-avg growth peak for girls in 12 yrs, boys is 14 yrs
-there is considerable individual variation in this
-generally, earlier the growth peak, the shorter the duration of growth spurt will be and less overall
growth that will occur
-girls will generally start growth sooner, grow for shorter amt of time, and grow less than boys
Predictors of Growth
1) Chronological age: not perfect predictor of when peak growth will occur
2) Dental age: even less reliable
-children whose teeth erupt early don’t necessarily grow early
3) Skeletal age: physical growth correlates well
a) hand-wrist radiograph is standard for assessing skeletal development
-ulnar sesamoid and hamate bones used as landmarks for timing adolescent growth
spurt
b) evaluate vertebral bones from Ceph radiograph
c) plot increases in body height over time
d) successive Cephs can be superimposed to determine when growth spurt has started/ended
4) Sexual development: sexual development and growth in height are very well correlated
-sex hormones have direct effect on endochondral ossification
Leeway Space
-difference in mesiodistal size btw primary canine to primary 2nd molar and their permt replacements
(permt canine to permt 2nd premolar)
-leeway space larger in mand. arch (2.5-4mm per side) where max. arch is around 1.5-2.5 mm per side
-leeway space can affect eventual permt molar relationship or may aid in resolution of crowding
Sequence of Eruption
1) Primary dentition
-begin calcification btw 3-4 months in utero
-mand. teeth start calcification before max.
-eruption of first primary tooth occurs at about 6-7 months and continue to erupt until 2-3 yrs old
-typical sequence: CI, LI, 1M, C, 2M
2) Permt dentition
-permt teeth begin calcification shortly after birth
-1st permt molar: calcification begins at 2 months
-3rd molars calcify at 8-9 yrs old
-max. sequence: 1M, CI, LI, 1PM, 2PM, C, 2M, 3M
-mand sequence: 1M, CI, LI, C, 1PM, 2PM, 2M, 3M
3) Gender: females have eruption around 5 months earlier than males
Eruption Patterns
1) Incisors: permt tooth buds lie lingual and apical to primary incisors
2) Canines: permt canine is more facially than primary but usually right in line
3) Permt teeth move occlusally and buccally during eruption
4) Maxillary arch is slightly longer (128mm) than mandibular arch (126mm)
Ectopic Eruption
-tooth erupts in wrong place
-most likely to occur in max. 1st molars and mand. incisors
-treated by placing brass wire btw primary 2nd molar and permt 1st molar
-more common in maxilla and assoc. w/ skeletal class II pattern
Crossbite
-teeth are on wrong side of opposing dentition
-types”
a) skeletal: has smooth closure to centric occlusion
b) functional: has deviation as pt closes
-causes: hereditary, jaw-size discrepancy, oral habit (thumb-sucking, not tongue-thrusting),
supernumerary teeth, or trauma
Posterior Crossbite
1) Normal: max. lingual cusps fit into mand. central fossa
2) Crossbite (Lingual crossbite): max. buccal cusps fit in mand. central fossa
-if bilateral, is called a “scissor bite”
3) Complete lingual crossbite: whole maxillary tooth lingual to mandibular tooth
4) Complete buccal crossbite: whole max. tooth buccal to mand. tooth
Crossbite Treatment
-crossbites treated in 1st stage of txt as transverse dimension is first to stop growing
-posterior crossbites corrected w/ palatal expansion (rapid palatal expander)
1) expander activated 2x/day (0.25mm per turn)
2) after activation completed, expander remains in place for 3-6 months for bone to form
-after expansion, diastema usually forms btw central incisors which closes spontaneously
-nasal floor expansion also occurs
Open Bite
-should be diagnosed early b/c it is not self-correcting and worsens w/ time
Facial Proportions
1) Lip posture/competence: with teeth together and lips at rest, the lips should lightly touch or be slightly
apart
-a gap of more than 3-4mm indicates lip incompetence b/c of long lower face, protruding
incisors, large overjet, or short lips
2) Incisors at rest (Lip-to-tooth): amt of upper incisor showing below upper lip
-2-4mm is considered esthetically pleasing
3) Gingiva at smile: up to 1-2mm of gingiva showing on smiling is esthetically pleasing, w/ any more
being excessive
Profile Examination
1) Facial convexity
a) Convex: indicates class II (retrognathic)
b) Straight: indicates class I (orthognathic)
c) Concave: indicates class III (prognathic) or midface deficiency
2) Lip prominence: evaluated by Rickett’s Esthetic Line (E-line) which extends from tip of nose to chin
-lips should be slightly behind this line for esthetics
-anterior-posterior position of incisors affects lip prominence
a) Full: protrusive
b) Average
c) Flat: retrusive
3) Nasolabial angle: angle btw base of nose and upper lip
-should be perpendicular or slightly obtuse
Molar Uprighting
-long-term loss of mand. 1st molar causes tipping, migration, and rotation of adjacent teeth into
edentulous space
-txt done by tipping 2nd molar distally and opening up space for pontic to replace missing tooth
-should band 2nd molar to prevent shearing of brackets
-timetable is 6-12 months
-stabilization should last until lamina dura and PDL reorganize
-slow progress in adult pt most likely caused by occlusal interferences
Impacted Canines
-can be brought into arch through ortho traction after being surgically exposed
-retained primary tooth should be extracted
-during exposure, flaps should be reflected so tooth is pulled through keratinized tissue, not alveolar
mucosa
-adequate space in arch should be created before attempting to pull impacted canine into position
Heavy Force
-use of heavy ortho forces does not make tooth movement more efficient and actually delays tooth
movement by causing a lag period after initial movement of tooth within PDL
1) Initial period of tooth movement
-bone bending and creation of piezoelectric signal occurs in less than 1 second
-pizoelectric signal characterized by quick decay rate and production of equivalent
signal of opposite direction when force is released
-PDL then compressed and fluid is expressed from area of compression, resulting from instant
movement of tooth within PDL in 1-2 seconds
-as fluids expressed from PDL, pain is felt as result of pressure applied within 5 seconds
-tooth is now compressed against bone surface and no further movement will occur until
resorption takes place
-resorption occurs within alveolar bone in marrow spaces and moves toward PDL area
-appearance of osteoclastic cells in marrow spaces is first indicator of resorption
-resorption can last a few weeks and no movement will occur until resorption is
completed when heavy ortho forces are applied
-compressed PDL undergoes significant tissue changes
-on compression side of PDL, hyalinized zone starts to develop (PDL lost all
organization and necrosis seen)
-cells from surrounding bone marrow start to migrate into area from marrow spaces within days
and resorption simultaneously starts within marrow spaces
2) Secondary period of tooth movement (after resorption)
-hyalinized PDL is in process of healing
-secondary movement occurs after a lag period during which resorption takes places
Light Force
-use of light force causes a smooth, continuous tooth movement without formation of significant
hyalinized zone in PDL
-teeth subjected to light forces start to move earlier and in more physiological way
-initial rxn include partial compression of blood vessels and distortion of PDL
-within minutes, blood flow altered, oxygen tension changes, and prostaglandins and cytokines
released within PDL
-metabolic changes start to appear in this area of PDL after a few hours of initial movement
-PTH, calcitonin, fibroblast distortion, substance P, prostaglandins, and neurotransmitters
-within a few hours, a signal transduction starts in PDL and c-AMP levels increase
-cellular differentiation takes place in PDL and coupling btw osteoclast/osteoblasts activities results in
frontal resorption of bone
4) Pulpal effects
-mild pulpitis or loss of vitality are rare
-loss of vitality seen in teeth that had trauma, restorations, or moved with heavy forces over long
distances
-if apex is moved out of alveolar bone, blood supply may be severed and tooth loses vitality
5) Root resorption
-as PDL experiences hyalinization, the adjacent cementum shows signs of resorption as well
-heavy continuous forces have more potential for root resorption
-resorptive defect can repair depending on size of defect created
-risk factors for root resorption include:
a) genetic factors (family hx of root resorption)
b) heavier forces
c) single rooted teeth
d) trauma, bruxism, heavy mastication
e) tooth already had signs of resorption prior to ortho
f) movement of roots into cortical plate
-teeth with substantial root resorption but intact marginal periodontium will not experience any
more mobility than unresorbed teeth
Moments
-moment is defined as a tendency to rotate and may refer to rotation, tipping, and torque in ortho
-moment of force is equal to magnitude of force x distance of force from center of resistance (M=Fd)
-3 orders of tooth movement:
1) First order: rotation
2) Second order: tipping
3) Third order: torque
-if force is applied at any point other than center of resistance, a moment is created
-the center of rotation is the mathematical point about which the tooth appears to have rotated after
movement is complete
-increasing magnitude of force or applying the same force farther from center of resistance will increase
tendency for rotation
Couples
-a couple is two equal and opposite forces
-a couple applied to a tooth produces pure rotation without translation
-tooth rotates about its center of resistance regardless of point of application of couple
-magnitude of moment created by couple depends on magnitude of force x distance btw forces (M=Fd)
-couples usually applied by engaging a wire in an edgewise bracket slot
Types of Tooth Movement
1) Pure rotation
-when a couple is applied to a tooth, it rotates around its center of resistance
-center of rotation is at center of resistance
2) Tipping
-when force is applied at bracket, center of resistance moves in direction of force and crown tips
in direction of force (apex moves in opposite direction)
-center of rotation is apical to center of resistance
-this is easiest and fastest tooth movement, but least desirable
3) Crown Movement
-force is applied at bracket and small couple is also applied to partially negate tipping of crown
caused by the force
-center of rotation is at root apex
-is a slightly difficult tooth movement and occurs slowly
4) Pure Translation
-force applied at bracket and larger couple also applied to exactly negate tipping of crown
-center of rotation is so far apical to tooth that tooth translates w/o tipping
-is difficult and slow type of tooth movement
5) Root Movement
-force applied at bracket and an even larger couple is applied to more than negate tipping of
crown so only root moves in direction of force
-center of rotation is at crown of tooth
-is most difficult and slowest tooth movement
Static Equilibrium
-all ortho appliances obey Newton’s 3rd law (for every action there is an equal and opposite rxn)
-for each appliance, the sum of forces and sum of moments acting on it equal zero
-it is impossible to design an appliance that defies this law of physics
Anchorage
-defined as resistance to movement
-anchorage value of any tooth is equal to its root surface area
1) Reciprocal tooth movement: 2 equal anchorage value teeth are moved against each other and
move same amt toward/away from each other
2) Reinforced anchorage: adding additional teeth to a unit to distribute force over greater area
slows movement of anchor unit
-ex. Headgear or interarch elastics
3) Stationary anchorage: teeth meant to be the anchor are activated to undergo difficult, slow
movements which distribute forces over large areas of PDL
4) Cortical anchorage: anchor teeth roots are moved into cortical bone which resorbs more
slowly than medullary bone
5) Implants for anchorage: implants, including palatal implants and miniscrews, can serve as
absolute anchorage for holding or moving teeth
-a stable implant will not move since it has no PDL
Brackets
1) Metal brackets: made of stainless steel
-disadvantage is poor esthetics
2) Ceramic brackets: made of monocrystalline/polycrystalline ceramics
-highly esthetics, but prone to fracture
-also have high frictional resistance to sliding mechanics so can cause abrasion of opposing teeth
3) Self-ligating brackets: special locking mechanism incorporated into bracket system to engage archwire
to eliminate need for ligatures
-shorten txt time by reducing friction b/c wire is kept engaged in bracket slot
Bands
-all of teeth, including molars, can be bonded but it is still preferred to band the molars
-prior to banding, separators are placed btw teeth to create space for band fitting and cementation
-types of separators: 1) elastomeric 2) metal
-glass ionomer cement used b/c fluoride-releasing properties
Bonding
-brackets attached to enamel using bonding resins
1) Direct bonding: direct attachment of ortho appliances to teeth using chemical or light-cured
adhesives
2) Indirect bonding: brackets first positioned on study casts and then transferred to mouth using
custom tray
-more technique-sensitive but less chairside time needed and more precise
-principles mechanism of attachment btw tooth and resin is mechanical interlocking of bonding agent and
etched enamel
-bonding procedure:
1) enamel prophylaxis to remove pellicle and enhance wettability of enamel for acid etching
2) enamel etching w/ 37% phosphoric acid
3) bracket positioning and secured w/ resin adhesive and light-cured
Headgear
-uses: 1) modify growth of maxilla (restrain growth to allow mand. to catch up)
2) retract (distalize) or protract maxillary teeth
3) reinforce anchorage
-usually used in skeletal class II growing pts
-headgear should be worn at least 8 hrs per day (preferable 14 hrs)
-for orthopedic/skeletal changes, force of 250-500 g/side recommended
-for dental changes, force of 100-200 g/side recommended
High-Pull Headgear
-used in pts w/ class II malocclusion, increased VDO, minimal overbite, and gummy smiles
-consists of high-pull headstrap and facebow which inserts into headgear tubes of max.1st molar
attachments
-objectives of appliance: restrict downward and anterior max. growth
-places distal and intrusive (upward) force on maxilla
Cervical-Pull Headgear
-used to correct class II malocclusion w/ deep bite
-consists of cervical neckstrap and facebow which inserts into tubes of max 1st molar attachments
-objectives: 1) restrict anterior growth of maxilla
2) distalize and erupt maxillary molars
-places distal and extrusive (downward) force on maxilla
Chin Cup/Cap
-can be used to correct class III malocclusions from excessive mandibular growth
-works by restraining mandibular condylar growth
-consists of headstrap and cup that fits on chin
-designed to deliver forces in superior and posterior direction to condyles via chin
Functional Appliances
-hold mandible in protrusive position and transmit forces created by stretch of muscles and soft tissues to
dental and skeletal components to produce movement of teeth and modification of growth
-designed to modify growth during mixed dentition
-have dental AND Skeletal effect
-used to correct class II malocclusion by restraining maxilla and displacing mandible while still allowing
normal mandibular growth
-appliances:
A. Tooth-borne
1) Herbst 3) Bionator
2) Activator 4) Twin block
B. Tissue-borne
1) Frankel appliance (only tissue-borne appliance)
-alters mand. posture and contour of facial tissue
-removable appliance
Herbst Appliance
-consists of piston and tube device that places mandible in forward position as pt closes mouth
-holds mandible forward to induce growth
-usually cemented or bonded to max. and mand. dental arches
-max. and mand. frameworks splinted together via pin and tube device
-shows increased tendency for mand. incisors to flare due to forces indirectly delivered to these teeth
-can be fixed (most often) or removable
Activator
-consists of acrylic body that coverts part of palate and lingual aspect of mand. ridge and labial bow that
fits anterior to max. incisors
-on acrylic adjacent to max. posterior teeth, facets are cut to allow occlusal, distal, and buccal
movement of teeth
-on lingual aspect of mand. posterior teeth, facets allows occlusal and mesial movement
-objectives: 1) activates mandibular growth to correct class II malocclusion
2) tip anterior teeth
3) control eruption of teeth vertically
-is first removable fxnal appliance
Bionator
-advances mand. to edge-to-edge position to stimulate mand. growth for correcting class II malocclusion
-similar design to activator but less bulky and less impedent to speech
-consists of lingual horseshoe-shaped acrylic w/ wire in palatal area
-facets placed in acrylic to guide posterior teeth and hold mandible in forward position
-labial bow presents anterior to maxillary incisors to eliminate pressure from buccal musculature
-is a removable appliance
Pendulum Appliance
-used to correct class II malocclusion by distalizing max. molar teeth
-can also fxn to expand maxilla by incorporating expansion screw into appliance
-if expanding screw used, it is called a Pendex appliance
Hyrax Appliance
-most common type of rapid palatal expander for skeletal expansion
-screw activated by at least 0.25mm/day for rapid expansion
-max. arch width increased by opening midpalatal suture
-expansion continued until lingual cusps of max. posteriors contact lingual inclines of buccal cusps of
mand. posteriors
-usually results in diastema formation btw max. central incisors, which closes on its own from
pull of supracrestal fibers
-retention needed for 3-6 months after active expansion completed w/ device remaining in place
Haas Appliance
-causes skeletal expansion of palate by use of acrylic pads placed in contact w/ palatal mucosa which
allows forces from appliance to apply to underlying hard tissues to minimize dental tipping
-disadvantages are inflammation of palate and difficult hygiene
Quad Helix/W-Arch
-mostly used for dental expansion
-should be used when only small amt of expansion needed
Transpalatal Arch
-used for dental expansion
-extends from one max. 1st molar to contralateral 1st molar along contour of palate 2-3mm away from
tissue
-can be used for expansion or restriction of palatal growth
Elastics
-elastomeric bands used to produce forces for tooth movements
1) Class I elastics (intramaxillary): used for traction btw teeth in same arch
2) Class II elastics (intermaxillary): worn from tooth in anterior maxilla (canine) to tooth in
posterior mandible (1st molar)
-used to correct class II malocclusion, reduce overbite, and restrict max. anteriors
3) Class III elastics (intermaxillary): worn from tooth in posterior maxilla (1st molar) to tooth in
anterior mandible (canine)
-used to protract max. posterior teeth or improve overjet in edge-to-edge bites or
anterior crossbite
4) Crossbite elastics: worn from palatal portion of max. teeth to buccal portion of mand. teeth
-corrects crossbite
-also causes extrusion of teeth so use caution in pts w/ open bite tendency
5) Anterior diagonal elastics: run from one side of max. teeth to other side of mand. teeth
crossing midline
-used to correct unaligned midlines
Part 10: Early Treatment
Early Treatment
-designed to alleviate or prevent moderate-severe ortho problems before permt dentition has fully erupted
-often further comprehensive txt will be needed once full permt dentition has erupted
Anterior Spacing
1) Max. midline diastema (less than 2mm)
-usually is self-correcting but txt indicated if esthetics are concern or if central incisors are
inhibiting eruption of lateral incisors and canines
-large space may indicate supernumerary tooth (mesiodens) or missing lateral incisors
2) Large max. midline diastema (over 2mm)
-not likely to close on its own
-fixed ortho appliances may be needed
-frenectomy after txt may be indicated if space re-opens or tissue bunches after txt
3) Generalized anterior spacing
-postpone txt until there is an esthetic complaint
-if spacing is accompanied by protrusion, a fixed ortho appliance usually required
Eruption Problems
1) Over-retained primary teeth: remove primary tooth to encourage eruption of permt tooth
2) Ankylosed primary teeth: usually resorb on their own but can be removed if causing delay in permt
tooth eruption
-if permt successor is missing, ankylosed primary tooth should be removed to prevent vertical
alveolar defect
3) Ectopic eruption: eruption of tooth into unexpected location or into adjacent tooth location
a) Lateral incisors: may cause loss of adjacent primary canine or midline shift
-usually indicates lack of sufficient space
-treat by extracting primary canines or space regaining
b) Max. 1st molars: may erupt into primary 2nd molar
-treat by uprighting the erupting 1st molar
c) Max. canines: may lead to canine impaction or resorption of adjacent lateral incisor
-extraction of primary canine indicated
Missing Teeth
1) Mandibular 2nd premolars
a) maintaining primary 2nd molars may be option
b) some reduction in width of primary 2nd molar may be needed to attain good posterior
interdigitation
c) early extraction of primary 2nd molars (age 7-9) can be done to encourage closure of space
2) Maxillary lateral incisors
a) substitute canine in lateral incisor position is option
b) retaining space for later replacement is option
c) best choice may depend on occlusion and esthetic demands
Removable Retainers
1) Hawley retainer
-incorporates clasps for retention and an outer bow w/ adjustment loops
-acrylic on palate can act as potential biteplate to control overbite
-outer bow retains incisor position and rotations
-clasps or wires that cross the occlusion may wedge space open or prevent closure of spaces that
remain (disadvantage)
2) Wrap-around retainer
-similar to Hawley retainer but w/o wires that cross the occlusion
3) Positioner
-may be used as finishing device and then as retainer
-are bulky and therefore not well tolerated
-not worn full-time and therefore may not retain rotations well
-maintains intra-arch and inter-arch relationships
4) Essex appliance: vacuum formed
-rapid, economical, and esthetic
Fixed Retainers
-bonded flexible lingual wires attached to individual teeth or bonded rigid wires bonded to 2 teeth
(especially btw lower canines)
-maintain mand. incisor position, hold diastemas closed, maintain space for pontic/implant, and keep
extraction spaces closed
Active Retainers
-used for realignment of irregular teeth
-irregular teeth are reset on a model and retainer is made to new tooth setup
-retainer needs to have some flexibility to fit over irregular teeth
-interproximal reduction may be required to allow space for teeth to rotate
Vertical Corrections
1) Maxillary surgery
a) Superior repositioning (to correct open bite): LeForte I used to move maxilla superiorly which
allows mandible to autorotate and correct open bite and long face
b) Inferior repositioning (to correct deep bite): Positioning maxilla downward would rotate
mandible open to reduce overbite and lengthen face
-this is one of least stable surgical procedures
2) Mandibular surgery
-anterior and downward rotation of mandible to correct deep bite can be done w/ sagittal split
osteotomy
-surgical procedures to move mandible superiorly to correct open bite aren’t recommended b/c
cause downward rotation at gonial angle and stretch muscles of pterygomandibular sling
Transverse Corrections
-for correction of crossbites, maxilla can be expanded or constricted during LeForte I osteotomy
-changes in mandibular width are more difficult
1) Maxillary expansion: positioning of lateral segments in ideal position or by use of surgically-assisted
rapid expansion
-expansion proceeds w/ a jackscrew device
2) Maxillary constriction: bone removed to allow for constriction of lateral segments
Genioplasty
-chin can be augmented to improve esthetics by osteotomy or adding implant material
-sliding osteotomy is preferred method and can be used to move chin in all 3 dimensions
-reduction is least predictable method
Timing of Surgery
-surgery rarely performed before adolescent growth spurt except in cases of facial deformity
1) Growth excess cases (class III w/ excess mand. growth): surgery should be delayed until mand. growth
is complete
2) Growth deficiency cases (class II w/ small mandible): surgery can be performed earlier in maturation