Orthodontics

The Art and Science

S.I. Bhalajhi
The Art and Science
 The Art and Science

Dr. Bhalajhi Ssmdaresa lyyer

Orthodontist Ministry of Health, State of Kuwait Formerly Assistant Professor,
Department of Orthodontics College of Dental Surgery, Kasturba Medical College,
Mangalore (A unit of Manipal Academy of Higher Education}

Third Edition
(With over 1250 illustrations)

fH
ARYA (NIEDI) PUBLISHING HOUSE
4805/24, Bharat Ram Road, Darya Ganj, New Delhi 110 002
Orthodontics - The Art and Science
 1st Edition : June 1997
2nd Edition : June 1999
3rd Edition : October 2003
Reprint : February 2004
© Reserved with publisher.

Exclusive rights reserved by Arya (MEDI) Publishing House, New Delhi for publication,
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All rights reserved. No part of this publication in general and the diagrams in particular
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there are errors, they are inspite of our best efforts. The author or the publisher will not
be responsible for these unintended errors.

ISBN 81-86809-16-3

Published by:
Mr. Sudhir Kumar Arya
for Arya (MEDI) Publishing House,
4805/24, Bharat Ram Road,
Darya Ganj, New Delhi - 110 002.
7
Authors

Dr. Bhalajhi Sundaresa Ivyer

Orthodontist, Ministry of Health,
State of Kuwait
Formerly
Assistant Professor
Department of Orthodontics
College of Dental Surgery, Mangalore
(A unit of Manipal Academy of Higher Education)

Dr. Seenia Iyyer Bhalajhi

Orthodontist, Ministry of Health,
State of Kuwait
Formerly
Assistant Professor
Department of Orthodontics
College of Dental Surgery, Mangalore
(A unit of Manipal Academy of Higher Education)
^Contributors
Dr. V. Surendra Shelty i.u.s KOS. Dean,
Professor and Head Department of
Cr.hodontes College of Dental Surgery
Mangalore
Dr. Ashima Valiathan a.o.s. o.o.s., vs
IUSA> P'ofesscr and Hoad Depar.menl of
Orthcdo-tics College of Dental Surgery
Manipal
Dr. Mohan Bal iga B.;-S., M.D.S Associate
Dean, Professo' and Head Department of
OralSurcery College of Dental Su-ge-y
Mangalore
Dr. Akhter Hussain s.c.s m.o.5. Professor
of Ort-oiontics Yenopoya Dental Co'ece
Mangalore
Dr.Anil.S.Malik3.D.S,. MOS. Professor of
Orthodontics Yenopoya Dental College
Ma-oa'ore
Dr. H.S.Divakar j.n.s >.os.. v.orw&Rcs
Assistant Professes Department of
Orthodontics Univo'sity of Trinidad
Dr. Rohan Mascarenhas BDS.. M.D.S.
Assistant Professor of Olhcdcntics
Yenopoya Denta Colfege Manga ore
Dr. Binnoy Kurian a.D.s.. MDS. Associate
Professor Department of Cr.hodontics
KA'.G.Dentel Co.e-go Sullia
Dr. Shaheer Malik 2.D.S >.OS
Olhcdcntisl
Dental Speciality Center
Ministry1 of Health,
State of Kuwait
Dr. Soben Peter BOS., M.D.S.
Professor
Department of Community
Dentistry College of Dental
Surgery Mangalore
Dr. Rajiv Ahluwalia 3D S MAS. Ass
slant Professor. Maulana Azad
Medical College Dental Wing, New
Delhi
Dr. Gurkeorat Singh 8.D.S.. MDS.
Consultant Orthccontist N ew
Delhi
Dr. Menaka Chona BOS.. V.D.S
Consultant Ortrodontist
New Delhi
Dr. Elbe Peter &c S M.D& Forrrerly
Assistant Professor Department of
Orthodontics College of De-tal
Surgery Mangalore
it Work
Raul Aguirre Brizuela
Lab Work
Henry Sudario Sumagpao
Orthodontic Technician,
Ministry of Health, Slate of
Kuwait
Dental Technicsn, Dr. Anand K.S. tc<s Dental
Ministry of Health. Surgeon
State of Kuwait

Dr Namilha Kama ^ns Dental Surgeo*

A
-
The eagerness on /he part of rhe graduating den/isJs /o .know more aboi/J Orthodontics and
the lack of an a i/ encompassing book vvos /he driving force /ha/ /ed me to author the first
edition of this text book of Orthodontics. Six years, two editions and numerous reprints,
.have encouraged me to come up v/tffo fb/s third edition.

Orthodontics is a dynamic field with changes occurring at a rapid pace.

Or/bodon/tos Js much more rhan o cosmetic field of Den/is fry. tfecen/ i'n/eres/ in /he
bio-cbemica/ and cellular aspects of tooth movement have proved beyond doubt that
Orthodontics is a specialization thai applies the principles of biology as well as
engineering. Orthodontics is also keen to adopt new technology to aid in imaging,
diagnosis ond treatment delivery. The new Technologies and a broader understanding of
the biological and mechanical aspects of tooth movement hove removed many of the
limitations of orthodontic treatment. The rapid improvements and advances place a
tremendous pressure on /he oufhors 'o frequently update and review the book, it has been
my endeavor to bn'ng to you some of fhese advances.

The third edition of this book adopts a friendly two color format followed
internationally by most publishers. An effort has been mode to improve /be overall quality
of the illustrations which have been pains/aki'ngJy redrawn and enhanced using the latest
available software. We hove aJso added a number of clinical photographs to enable easy
understanding of the subject.

I remain ever grateful to my /eocher Dr. VSurendra Shetty for his valuable
guidance over the years. I would a/so like to /bonk Mr Suc/biY Kumar Arya, /be pub/isber of/his
book for his whole hearted support in this endeavor. I hope this book is accepted ond
appreciated by the dental community.

TZhalafhl.S.

*->£>
j i <\\y \ jiywl
 jU^-nV' w^a

Contents
^
^
Section 1 Introduction

1 Introduction to Orthodontics 1 Section 2

Growth and development

s Growth and Development - - General

Principles and Concepts '
w

8 Growth and Development of Cranial 55NjSs

and Facial Structures 21
Hf
BUI Development of Dentition and 37
Occlusion
SSs-t SS is? •sv'.-^;^ -y -y-•*-y-y-y -v -.yy-y-y
^-yy-y -y

■
Functional Development

Section 3 Occlusion & Malocclusion

6 Occlusion - Basic Concepts 55

W Classification of Malocclusion 63

M
s 81
Si.-^,; Etiology of Malocclusion Habits txsvsss
9 97

10 Epidemiology of Malocclusion 109

•.•-.•■•.•■•.
Section 4 Diagnosis ^V..•/-•.•".•.•;.-..-'i-.".-'.-'/.-

ll. Orthodontic Diagnosis 115

12 Gephalometrics 143

13 Skeletal Maturity Indicators 161

SfeSSSS S S S i ^ ^ ^ i i S ^ S S S :
 ,«,IAI -,
A C

14 Model Analysis 175

Section 5 Biomechanics

15 Biology of Tooth Movement 13 •)

The Mechanics of Tooth Movement 195 W
Anchorage 203
Is Age Factor in Orthodontic^^^fe^l 1

Section 6 Preventive & Interceptlve Orthodontics

Section 7 Space Gaining

21 Methods of Gaining Space J||8l§i239

22 Arch Expansion

259 BSSSS
y/.^-v-vvy.v.;-
SSSSSSSWSSSS
23 Extractions

Section 8 Orthodontic Appliances

Orthodontic Appliances |f|§ |jjjj271

llll General Principles ||§||||

(Bill
;i ' 25 : Removable Appliances

26 Fixed Appliances

mm Myofunctional Appliances (|||S29

28 Orthopaedic Appliances 365
Section 9 Corrective Orthodontics

29 Treatment Planning 377

30 Management of Some Common 385

Malocclusions
31 Management of Class II . 397
Malocclusion
32 Management of Class III 407
Malocclusion
33 Management of Open Bite 415

34 Management of Crossbite 423

35 Management of Deep Bite 433

36 Cleft Lip and Palate 439

Section 10 Surgical Orthodontics & Retention and relapse

Lab Procedures

Genetics in Orthodontics

41 Computers in Orthodontics

42 Adult Orthodontics

Section 11 Miscellaneous
O
rthodontics is t not branch of dentistry Malocclusion is capable of adversely affecting the
concerned with prevention, interception facial appcarance of an individual.
and correction of malocclusion and other
Risk of caries
abnormalities ol the dento-facial region. The word
orthodontics is derived from the Greek words o/ihos
meaning correct and odonios meaning teeth. The term
Orthodontics was first coined by le Felon.
In 1922, the British Society for the Study of
Orthodontics has defined the speciality as,
Orthodontics includes the study ol the growth end
development of the jaws and face particularly, and the
body generally as influencing the postion 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 perverled development.'
Man has recognised the presence of dentofaciol
deformities and the need for its Treatment centuries
back. Crude appliances that were seemingly designed
to regulate the teeth have been excavated by
archeologistsfrom round the world including Egypt,
Greece and Mexico.
Normal alignment of teeth not only contributes to
the oral health but also goes a long way in the overall
well being and personality of an individual. Correct
tooth position is an important factor for esthetics,
function and for overall preservation or restoration ol
dental health. While most malocclusions may not
adversely affect the health of an individual, they
nevertheless are ccipoblc of producing undesirable
functional and esthetic imbalances. The following are
some of the unfavourable sequelae of malocclusion.

Poor facial appearance

Malalignment of teeth makes oral hygiene c. Esthetic harmony
maintenance a difficult task, thereby increasing the risk The orthodontist should strive to acheive these
of caries (fig 1). three main objedis'es of treatment.

Fig 1 I regu lor -eet-i aid crowding m eke ore I hygene maintenance f-ig 2 Tech that are severely proc hed are at a high risk of irjjry
difficult ond predispose to caries besides bfiing esthetically unpleasant.

Predisposition to periodontal diseases Functional efficiency

Malocclusion associated with poo-'oral hygiene is a Many malocclusions affect normal functioning of the
frequent cause of periodontal diseoses. Ir addition, stomatognathic system. The orthodontic treatment
teeth that are placed in abnormal positions can be a should thus aim at improving the functioning of the
cause for traumatic occlusion with resultant periodontal oro-facial apporatus.
t:ssuc damage.
Structural balance
Psychological disturbances
The oro-facial region consists of the dento-alveolar
Malocclusion that adversely affects the appearance of system, the skeletal tissue and the soft tissue
person leads to psychological disturbances. Unsightly
appearonce of teeth makes a person highly
self-conscious and turns him into an introvert. Thus
treatment of malocclusion in such patients helps in
improving the mental well being and confidence.

Risk of trauma
Teeth that arc severely proclined are at a high risk of
injury especially during play or by an accidental fall (fig
2).

Abnormalities of function
Many malocclusions cause abnormality in the
functioning of the stomotognathic system such as
improper deglutition, defects in speech, improper
respiration, etc.,.
Temperomandlbular Joint problems
Malocclusion associated with occlusal prematurities
and deep bite are believed to be a cause of TMJ
problems such as pain and dysfunction.

AIMS OF ORTHODONTIC TREATMENT

The aims and objectives of orthodontic therapy have

been summarised by Jackson as the Jackson's triad.
The three main objectives of orthodontic treatment are:
a. Functional efficiency
b. Structure! bal o nee
rig 3 Aims ore objectives of orhodonlic trectmonl ortnedontist can bring about changes in all the three
planes of spoce i.e. sagittal, transverse and vertical.
including musculature. Stable orthodontic treatment is
best achieved by maintaining a balance between these
Introduction
Alteration intosoft
Orthodontics 3
tissue pattern
The soft tissues that envelop the dentition are greatiy
influenced by the placement of the dentition. It is
possible to bring about favourable changes in the soft
tissue pattern by ortnodontic treatment.

Functional efficiency SERVICES OFFERED BY THE

three tissue systems. ORTHODONTIST

Esthetic harmony The sen/ices offered by an orthodontist can be broadly

classified as :
a. Preventive orthodontics
b. Interceptive orthodontics
Structural balance
c. Corrective orthodontics
d. Surgical orthodontics
Esthetic harmony
Preventive orthodontics
By far the most common reason for seeking
"Prevention"', they say, "is better than cure."
orthodontic care is to improve the appearance ot the
Preventive orthodontics includes procedures
teeth and face. Many malocclusions are associated
undertaken prior to the onset of a malocclusion in
with unsightly appearance of teeth and can thus offect
anticipation of a developing malocclusion. Preventive
the individual's self image, well being and success in
orthodontics can be defined as,
society. Thus tne orthodontic •reatment should aim at
improving the esthetics ci the individual.

THE SCOPE OF ORTHODONTtC

TREATMENT

Orthodontic treatment involves the three main tissue

systems concerned in dentofacial development,
namely the dentition, the skeleton and the facial and
jaw musculature. Orthodontic treatment can bring
about changes in the dentition, the skeletal system and
the enveloping soft tissue.

Alteration in tooth position

Orthodontic treatment is made possible by the fad that
teeth can be moved through the bone to ideal locations
by applying appropriate force on them. Most
malocclusions involving the dental system can be
effectively treated by moving teeth so as to normolise
tnc occlusion.

Alteration in skeletal pattern

Malocclusion may be associated with skeletal
disharmony involving the jaw bones (i.e. maxilla and
mandible). Deviation* from the normal can arise in
size, position and relationship between these skeletal

i
components. It is within the scopc of an orthodontist to
apply appropriate orthopaedic forces that are capable
of restraining, promoting or redirecting skeletal growth
so as to normalise the skeletal system. The
'Actions taken to preserve the integrity of what appears
normal for that age.'
Interceptlve Orthodontics
Interceptive orthodontics includes procedures that are
undertaken at an early stage of a malocclusion to
eliminate or reduce the severity of the same. By
undertaking appropriate interceptive procedures, it is
oossible to prevent establishment of a full fledged
malocclusion 'hat may require long term orthodontic
treatment at a later age.
Corrective Orthodontics
Orthodontic procedures undertaken to correct c fully
established malocclusion.
Surgical Orthodontics
They are surgical procedures that are undertaken in
conjunction with or as an adjunct to orthodontic
treatment.The surgical orthodontic procedures are
usually carried our to remove on etiologic factor or to
treat very severe dento-facial deformities that cannot
be treated by orthodontic therapy alone.
philosopher who gave medical science the first system
of comparative anatomy. Aristotfe was the first writer
who studied human teerh and compared them with
those of various other species.
The first recorded suggestion for active treatment
of malocclusion was by Aulius Cornelius Celsus (25
B.C.-A.D. 50) who advocated the use of finger
pressure to align irregu'artee'h.
Pierre Faucnard o French dentist is considered
the founder of modern dentistry. As early as I 723, he
developed whet is probably the first orthodontic
appliance co'led c Bandelette, that was designed to
expand the dental arch.
Norman Kingsley an American dentist, was the
first to use extra-orai force to correct protruding Aeeth.
He is considered os the oioneer in cleft palate
treatment.
Emerson C. Angeil (1823 - 1903) first advocated
the open'ng of t.ne mid-polatal suture, a procedure
which later came to be known as rapid maxillary
expansion.

BRIEF HISTORY OF ORTHODONTICS

Orthodontics is considered the oldest speciality of

dentistry. Evidences suggest that attempts were made
to treat malocclusion as early as 1000 B.C. Primitive
applionces to move teeth have been found in Greek
and Etruscan excavations.
The Greek physician Hippocrates (460 - 377
B.C.) is believed to be the pioneer in medical science.
He was the first person to establish medicol tradition
based or facts rather than religion or fancy. A number
of references on teeth and jaws are found in his
writings.
Aristotle (384 - 322 B.C.) was a Greek

Fig 4 Edward -o-tlov Angle - ^o'lier of 'v'iooorr CMbodon* cs

 F g 5 Calvin C c so Fig 6 Martin Dewey

Williom E. Mag ill (1823 - 1896) was the "irst In 1931, Holly Broadbent and Hoforoth
person lo band teeth for active toorh movement. independently developed cephalometric radiography
Henn^ A. Baker in 1 893 introduced what is cclled which standardised the positioning of the head in
Baker's anchorage or the use of intermaxillary e asl'cs relation to the film and X ray source. These
lo trect malocclusion. radiographs made it possible to visualise tne cranial
Edward H. Angle [1855 -1930} is considered :ne and facial skeleton. This can be considered a major
Father of Modern Ortnodontics' for his numerous advancement in orthodontic diagnosis and treatment
contributions to this speciality {fig 4). Through his planning.
leadership, orthodontics was separated from other Buonocore in 1955 introduced tneocid etch
branches of dentistry to establish itself as e speciality. technique. This enabled direct bonding of orthodontic
Ang.e's contributions include a classification of attachments to tne enamel which greatly enhanced
malocclusion and orthodontic appliances such as Pin esthetics.
and tube and the Edgewise appliance. Angle also Raymond Begg of Australia introduced a light
started a School of Orthodontics at 5?. Louis, New
London, Connecticut in which many c? the pioneer
American orthodontists were -'cined. Angle believed
tnatthe whole complement ct teeth could be retained
and yeT good occlusion could be ach'eved. He thus
advocated arch expansion for most patients.
Calvin Case (1847 - 1923} believed that ■racial
improvement was a guide to orthodontic treatment.
Case (fig 5) oiso claims to be the first orthodontist to
use intermaxillary elastics. Calvin Case was a critic of
Angle and opposed Angle's philosopny of arch
expansion to treat most cases. He advocated the
removal of certain teeth to achieve stable treatment
results and to improve facial esthetics.
Martin Dewey (1881 - 1933} was an ardent
champion of no n-extraction. Dewey (fig 6}also

i
modified Angle's classification of malocclusion.
wire fixed appliance technique that was based on the
concept of d ifferentia I force. He also advocated the
need for extraction of some teeth to achieve stable
results.
While the American orthodontists were showing
keen interest in improving fixed orthodontic
appliances, their European counterparts continued to
develop removable and functional appliances for
guidance of growth. Pierre Robin in 1902 introduced a
Monobloc which protruded the mandible forward in
patients with glossoptosis. Viggo Anderson in 1910
developed the activator which made use of the facial
musculature to guide the growth of the jaws. Rolf
Frankel in 1969 - 1973 proposed the Function
Regulator to treat a variety of skeletal malocclusions.
Lawrence Andrews introduced the Straight Wire
Appliance in the early seventies. This was a
preadjusted appliance in which the brackets were
pre-programmed to accomplish the desired tooth
movements in all the three planes of space. This is
considered a major advancement in improving
orthodontic treatment results with minimal possible
wire bending.
This discussion on the history and evolution of
orthodontics is by no means complete. There have
been numerous people whose contributions have
gone a long way in the improvement of this speciality.
For a more complete review the readers are adviced to
refer other relevant literature.

References

1. Asbcll : A brief history of orthodontics. Am J Orlhod 1990;

206-213
2. Moorees, Bu'slone, Chrsticinsen, H'txonaid Wei ostein :
Research relaled to malocclusion. Arr J Orthod 1971 ;1-1B
3. Sa zrron JA : Prac'icc of Orthodontics, JB lippincotf corn
pony, 1966
A. Graber TV. : Ortnodontics : Principles end Practice.
WB Sounder,! 988

Growth and Development - General

Principles and Concepts
The practice of orthodontics has two basic
requirements. The first and foremost is to possess an
intimate knowledge of the anatomy and growth of the
head. The second is to master the techniques for
regulating tooth position. In the past, the interaction
between these two sets of information was considered
to be only minimal. It is now established that a sound
knowledge of growth and development is essential for
successful orthodontic treatment. There are a number
of treatment modalities that can regulate the growing
dentition and the jaw bones. Understanding the growth
of the oro-facial region is vitally important when
planning such treatment procedures.
This chapter will present a comprehensive
review of the basic concepts of growth and
development as understood today. It would be our
endeavor to stimulate the young student's mind so that
he at a later date can contribute to solve the
complexities of cranio-facial development.

DEFINITIONS RELATED TO

GROWTH Growth

There is no universally accepted definition of growth.

Various clinicians have defined growth in different
ways.
"The self multiplication of living substance." (J.S.
Huxley)
"Increase in size, change in proportion and progressive
complexity." (Krogman) "An increase in size." (Todd)
"Entire series of sequential anatomic ond physiologic
changes taking place from the beginning of prenatal life
to senility." (Meridith) "Quantitative ospect of biologic
development per unit of time." (Moyers)
"Change in any morphological parameter which is
measurable." (Moss)
 Though growth is generally associated with environmental fcctors, there seems to be some
an increase in size, yet some conditions involving evidence that race does play a role i r growth process.
regression are also considered to take place during For example in American blacks, calcification and
growth. For example, the atrophy of the thymus gland. eruption of teeth occurs almost a year ecrlier than their
white counterparts.
Development
"Development," according to Todd," is progress Socio- economic factors
towards maturity". According to iVioyers, develoo- ment Children brought up in affluent and favorable
refers to all the naturally occurring unidirectional socio-economic conditions snow earlier onset of
changes in the life of an individual from its existence as growth events. They also grow to a larger size than
a single cell to its elaboration as a multifunctional unit children living in unfavorable socioeconomic
terminating in death. Thus it encompasses the normal environment.
sequential events between fertilization and death.
Family size and birth order
Differentiation
Studies have shown thef *he first born babies tend to
Differentiation is the change from a generalized cell or weigh less at birth ard have smaller stature but higher
tissue to one that is more specialized. Thus I.Q. The smaller the family size, the better would be the
differ-entiation is a change in quality or kind. nutrition ond other favorable conditions.

FACTORS AFFECTING Secu/ar trends

PHYSICAL GROWTH
Changes in size and maturation in a lorge population

A number of factors affect the rate, timing and can be shown to occur with time. For example, fifteen

character of growth. They include : year old boys are approximately 5 inches taller than the
same age group 50 years back. Although there is no
Heredity satisfactory explanation offered regarding this finding,

There seems to be a considerable genetic influence on it could possibly be due to changes in socio- economic

the size of parts, rate of growth and the onset of growth. conditions and food habits.

The genes hence play a major role in the overall growth

of a person.

Nutrition
Malnutrition may affect size of parts, body proportions,
quality and texture of tissues, and onset of groteh
events. The effects of malnutrition are reversible to a
certain extent as children have fine recuperative
powers. If the adverse effects are not too severe, the
growth process occelerates when proper nutrition is
provided. This is called catch-up growth.
illness
The usual minor childhood illness ordinarily cannot be
shown to have much effect on ohys'cal growth.
Prolonged and debilitating illness however can hove a
marked effect on all aspects of growth.

Race
Although the differences in growl1*! among different
roces con be attributed to other nutritional and
 siiiii

which is completed in girls

Growth and Development - General Principles and Concepts \ S
Climatic and seasonal effects
Seasonal variation have been shown to affect adipose
tissue content and the weight of new born babies.
Climatic changes seem to have little direct effect on
rale of growth.
Psychological disturbances
It is seen that children experiencing stressfull
between tne fourteenth and sixteenth year, but
extends in boys tnrough the sixteenth or eighteenth
year. Following this, a final period of slow growrh is
seen which ends between the eighteenth and twentieth
years in females but goes on in boys until about the
twenty fifth year.
Growth spurts

conditions display an inhio'tion of growtn hormone Growth does not take place uniformly at all times.
secretion. Psycnological disturbances of prolonged There seems to be periods when a sudden
duration can hence markedly retard growth. acceleration of growth occurs. This sudden increose in
growth is termed growth spurt1.
Exercise The physiological alteration in hormonal
Although exercises may be essential fora healthy secretion is believed to be the cause for such
body, strenuous and regular exercises nave not seen accentuated growth. The timing of the growth spurts
associated with more favorable growth. Certain differ in boys and girls.
aspects of growth such as developmenr of some mo'or Tne following are the timings of growth
skills and increase in muscle mass is found to be spurts.
influenced by exercise. a. Just before birth
b. One year after birth
SOME CONCEPTS OF GROWTH c. Mixed dentition growth spurt
Boys : 8-1 1 years
Concept of normality Girls : 7-9 years

Normal re-'ers to thai which is usually expected, is d. Pre- p u be rta I g rowlh s pu rl

ordinarily seen or is typical. The concept of normality Boys : 14-16 years

must not oe equated with thai of tne deal. While ideal Giris : 11-13 years
Growth modification by means of
denotes the central tendency for the group, normal
refers to a range.
Another aspect of cranio-fccio! growth is that
normality charges with age. Thus what is normally
seen or is expected for one age group may not be
necessarily normel for a different age group.

Rhythm of growth
According 1o Noolon, Human growth is not c steody
and uniform process wherein all parts of the body
enlarge at tne same rate and the increments of one
year are equal to that of the preceeding or succeeding
year.' However there seems to be a rhythm during the
growth process. T n is growth rhytnm is most clearly
seen in stature or body height.
The first wave of growth is seen in both
sexes from birth to tne fifth or sixth year. It is most
intense and rapid during the first two yeors. There
follows a slower increcse terminating in boys c bout the
tenth to twelfth year and in girls no I c te r than the tenth
year. Then both sexes enter upon anotner period of

19
accelerated growrh corresponding to adolescence
functional and orthodontic app'iances elicit better a. The head takes up about 50% of the total body length
response during growth spurts. Surgical correction around the third month of intrauterine life. At the
involving the maxilla and mandibi'e should be carried time of birth, the trunk and the limbs have grown
out only after cessotion of the growth spurts. more than the head, thereby reducing the head to
about 30% of body length. The overall pattern of
Differential growth 200-
The human body does not grow at the same rate
throughout life. Different organs grow at different rates,
to a different cmount and c- different times. This is
termed differential growth.
Here it would be best to mention two
important aspects or growth, both of which help us
1CO
understand the concepts of diFerontial growth more -
clearly. These are :
1. Scammon's curve of growth
2. Cephalo-caudal gradient of growth

Scammon's curve of growth ; The body tissues can be i

3
broadiy classified into four types. They are lymphoid
tissue, neural tissue, general tissue and genital tissue.
Each of these tissues grow ot different times and rates Fig 1 Scammons growth curve
(fig 1). growth continues with a progressive reduction in
Lymphoid tissue oroliferctes rcpidly in late the relative size of the head to about 12% in the
childhood and reoches almost 200% of odulf size. This adult.
is an adaptation to protect children from infection as
they are more prone to it. By about 18 years of age,
lymphoid tissue undergoes involution to reach adult
size.
Neurol tissue grows very rapidly and almost
reaches adult size by 6-7 years of age. Very little
growth ot neural tissue occurs after 6 - 7 years. This
facilitates intake of further knowledge. General tissue
or visceral tissue consists of the muscles, bones and
other organs. These tissues exhibit an "S" shaped
curve with rapid growth upto 2 - 3 years of age followed
by a slow phase of growth between 3-10 years. After
the tenth year, a raoid phase of growth occurs
terminating by the 18 r 20th year.
Genital tissue consists of the reproductive
organs. They show negligible growth until ouberry.
However they grow raoidly at puberty reaching adult
size after which growth ceases.

Cepria.'o-caudai gradient of growth : Ceo halo-caudal

gradient of growth simply means that there is an axis of
increased growth extending from head towards the
feet. A comearison of the body proportion between
pre-nctal and post-natal life reveals that post-natal
growth of regions of the body that are away from the
hypophysis is more.
This growth concept can be illustrated as
follows :
b. The lower limbs ore rudimentary oround the 2nd c. It is possible to get a large somple as the duration
month of intrc-uterine life. They later grow and of study is short.
represent almost 50% of the body length d. It is possible to repeat the study in case of any
Growth
ctadulthood. and Deuelopment - General Principles
flow. Thisand
mayConcepts 11in
not be possible a longitudinal
c. This increased gradient of growth is evident even study.
within the head and face. At the time of birth, tne
cronium is proportionally larger than the face. Sem/ - longitudinal studies
Post-natally the face grows more than the It is possible to combine the cross-sectional ond
cranium. longitudinal methods so as to derive the advantages of
both the systems of gathering growth dota.
METHODS OF GATHERING GROWTH DATA
ryp£S OF GROWTH DATA
The various growth studies can be broadly grouped as:
a. Longitudinal studies The physical growth can be studied by a number of
b. Cross sectional studies ways :
c. Semi - longitudinal studies
Opinion
Longitudinal studies
Opinion is the crudest means of studying growth.
In this type of study, the observation and Opinion is a clever guess of on experienced person.
measurements pertcining to growth are made ori a This method of studying growth is not very scientific
person or a group of persons ct regular intervals overo and should be ovoided when better
prolonged period of time. Thus longitudinal studies arc
long term studies where the same sample is studied by
means of follow-up examination.
The longitudnal studies have the following advantages:
a. As the same subjects are followed up over a long
period, the specific developmental pattern of an
individual can be studied and compared.
b. Variation in development among individuals within
the sample can be studied.
The longitudnal studies have the following
disadvantages : a. Longitudinal studies ore carried out
over long periods of time. It often takes years or
decades to complete a study as the same sample is
studied ct regular intervals.
b. Longitudinal studies require maintenance of
laboratory research personnel and data storage
systems for a long period of time. Thus they can
be expensive.
c. As these studies are performed over prolonged
periods of time there is a risk of the sample size
reducing due to change of place, or other
unforeseen events.

Cross-sectional studies
Cross-sectional studies are carried out by observation
and measurement mode of different samples and
studied at different periods. Cross- sectional studies
offer the following advantages :

M
a. These studies are of short duration.
b. They are less expensive than longitudinal studies
as they are completed in c shorter span of time.
12 Orthodontics - The Art and Science

They are tests in which phys'cal characteristics such as

methods ore available.
weight, height, skeletal maturat'or and ossification are

Observat/ons measured and compared with standards based upon

the examination oc large groups of healthy subjects.
Another method of gathering growth related
information is by observation. They are useful in Vital staining
studying all or none phenomena such as presence or
In 1936, Belchieraccidental'y noted that bores of
absence of caries, presence or absence of a Class II
animals who had eaten madder plants were stained
mo ar relation, etc.,.
red. Subsequently, the dye in the madder plant, alizarin

Ratings and Rankings was identified and used fo- bone research.
This technique involves administration o*
Whenever quantification of a particular data is difficult,
certain dyes to the experimental animal which get
it is possible to adoot a method of rating and ranking.
incorporated in tne bones. It is possible to s'udy the
Rating makes use of standard,
manner in which bone is laid down, the site of growth,
conventionally accepted scales for classification.
the direction, duration and amount of growtn at different
Ranking involves the arrangement of data in an orderly
sites in the bone. The dyes used for this purpose are :
sequence based on the value.
Alizarin Red 5
Quanf/tat/ve measurements Acid Alizorin Blue C.
Trypon Blue
A scientific approach to study growth is ore thct is
d. Tetracycline
based on accurate measurements. The measurements
e. Lead acetate
made can be of three types.

?. Direc,1 Doio : Direct data are obtained from Radioisotopes

measurements that are taken on living persons or
Radioisotopes of certain elements or compounds,
cadavers by mecns of scales, measuring tapes or
when injected into tissue gei incorporated in the
calipers. developing bone and act as in vivo markers.
2. .Indirect Data ; The growth measurements can also
be had from images or reproduction of the person such
as photographs, radiographs or den to I cas's.

3. Derived Data : They are data that are den'ved after

comparing two measurements. These two sets of
measurements can be of different time frames or of two
different samples.

METHODS OF STUDYING GROWTH

According to Profitt there are two main approaches to

studying ohysical growth.
I. Measurement aaproacnes
They comprise of rneasjrement techniques that are
corried out on living individuals. These metnods do not
harm the animal.
II. Experimental approaches
These are destructive technic u es where the onimal
that is studied is sacrificed. Experimental aoproacnes
are usually not carried out on humans.

Blmetrfc tests
 B

Growth and Development - General Principles and Concepts

A process medial to the first molor. In case of tne

rig 2 Ares s where implarrs are places |A) & (B| in maxi.la C) in mandible the implants are located as follows (fig 2.c):
mandible
1. Anterior ospect of symphysis, in the midline below
the root tips.
These radioiso'opes con larer be detected by tracking
2. Two pins on the right side of the mandibular body.
down the radioactivity they emit. The radio-isotopes
One pin under the first premolar and the other
used inc ude :
below the second premolar or first molar.
a. Technetium - 33
3. Ono pin on the external aspect of the right ramus
b. Calcium - 45
at the level of occlusal surface of molars.
c. Potassium- -32

Radiographic techniques
Implants
After Roentgen's discovery of X rays more than 100
Tne use of implants to study bone growth was firs*
years ago, different types of radiographic techniques to
introduced by Biork in 1969. It involves the implanting
study growth and development were devised. The
of small bits of biologically inert ciloys into growing
most commonly used techniques are cephalomerry
bone. These serve as radiographic reference points for
and hand-wrist radiographs.
serial radiograohic analysis. The metallic imp ants
used for studying growth are usually very tiny. They are
around 1,5mm in length and 0.5mm in diameter and
are made of Tantalum metal. These implants ere
embedded in certain areas of tne maxima end
mondible in order to study the growth of the skull.
The areas where the implants arc placcd in
the maxilla are (fig 2.a & b) :
1. Hard palotc behind the deciduous canines (prior to
eruotion of maxillan^ permanent incisors).
2. Below the anterior nasci spine (after eruption of
maxillary incisors).
3. Two implants on either side of the zygomatic
process of maxilla.
4. Border between hard palate and alveolar

13
 of a bone can be used as
natural markers to study
growth by means of serial
radiographs. Natural
markers can be used to
study bone deposition,
Fig 3 Rodiograpnic
techniques of studying
bone growth £A) Using
Lateral cephalogrorrs (B)
Using Hand • Wrist
radiograph

resorption and bone

remodeling.

Comparative
anatomy
Cepha/omefry : It is a standardized radiographic
technique of the cranio-focial region. After its Certain basic principles of growth that ore universol to
introduction by Broadbent in tne year 1931, this all species can first be studied on laboratory animals.
technique has contributed significantly to our
knowledge of human craniofacial skeletol growth {fig
3.a). Cephalometry makes it possible to take serial MECHANISMS OF BONE GROWTH
radiographs of a patient's skull in order to study the
growth changes taking place. Not only is this technique
useful in studying growth, it is also a valuable aid in Bone is a specialized tissue of mesodermal origin. It
orthodontic diagnosis, treatment planning, evaluation of
treatment results and for growth prediction. (More forms the structural framework of the body. Bone is a
details on cephalometry are given in chapter 12).
calcified tissue that supports the body and gives points
Hand-wrist X-rays : Radiographs of the hand- wrist
of attachment to the musculature. Normal bone
region are used to study the biological or skeletal age of
contains between 32 - 36% of orgonic mailer.
a person. The hand-wrist area has a number of small
spongy bones called carpels that have a definite Bone deposition and resorption
schedule of appearance and ossification (fig 3.b). Bone changes in shape and size by two bosic
mechanisms, bone deposition and bone resorption.
Natural markers
The process of bone deposition and resorption together
Normal bone has certain histological features such as is called bone remodeling.
nutrient canals, lines of arrested growth and certain
prominent trabeculae. These developmental features

t
 Growth and Development - General Principles and Concepts

lII
Fig 4 Example ot displacement (A) Primary displocemcnr maxilla of maxilla due 'o i'S OWN growrh |8)
dje to growth of the cran'cl l>ose Secondary displacement ot

Tne process of bone formation is colled osteogenesis.

The changes that bone deposition and resorption can
Bone formation takes place in two ways.
produce are :
1. Endochondral bone formation.
a. Change in size
2. Intra-mernbranous bone formation.
b. Change in shape
c. Change in proportion Endochondral bone formation
d. Change in relationship of the bone with adjacent In this type of osteogenesis the bone formation is
structures preceded by formation of a cartilaginous model which
is subsequently replaced by bone. Endochondral bone
Cortical drift
formation occurs as follows.
Most bones grow by interplay of bone deposition and
a. Mesenchymal cells become condensed at the site
resorption. A combination of bone deposition and
of bone formation.
resorption resulting in a growth movement towards the
b. Some mesenchymal cells differentiate into
depositing surface is called cortical drift. If bone
chondroblaslsand lay down hyaline cartilage.
depostion ond resorption on either side of a bone ere
c. The cartilage is surrounded by a membrane colled
equal, then the thickness of the bone remains constant.
perichondrium. This is highly vasculor
If in case more bone is deposited on one side and less
bone resorbed on the opposite side then the thickness
of the bone increases.

Displacement
It is the movement of the whole bone cs a unit.
Displacement can be of two types. Primory
Dispfacement : If a bone gets displaced as a result of
its own growth, it is called primary displacement. For
example, growth of the maxilla at the tuberosity region
results in pushing of the maxilla ogainst the cranial
base which results in the displacement of the maxilla in
a forward and downward direction {fig 4.a).

Secondary Displacement r If the bone gets displaced

cs a result of growth and enlargement of an adjacent
bone, it is called secondary displacement. For
example, the growth of the cranial base causes the
forward and downward displacement of the maxilla {fig
4.b).

OSTEOGENESIS
 and contains osleogenic cells.
d. The inter-cellulcirsubstance surrounding the
cartilage cells becomes calcified due to the
influence of enzyme alkaline phosphatase
secreted by the cartilage cells.
e. Thus the nutrition to the cartilage cells is cut off
leading to their death. This results in formation of
emp^y spaces called primen/ areolae.
f. The blood vessels and osteogenic cells from the
perichondrium invode the calcified cartilcginous
matrix which is now reduced to bars or walls due
to eating away of the calcified mctrix. This leaves
large empty spaces between the walls called
secondary areolae.
g. The osteogenic cells from The perichondrium
become osteoblasts and arrange cior.g the
surface of these bars of calcified matrix.
h. The osteoblasts lay down osteoid which later
becomes calcified to form a Icmella of bone. Now
another layer of osteoid is secreted and this goes
on and on. Thus the calcified matrix of cartilage
acts as a support for bone formotion.
THEORIES OF GROWTH
Genetic theory
This theory simply states t'ncr all growth is controlled
by genetic influence and s pre-planned. This is one of
the earliest theories put forward.
Sufuraf theory
Sicher believed that cranio-fadal growth occurs at the
sutures. According to him paired parallel sutures that
attacn facial areas to the skull anc the cranial base
regior push the ncso-mcxillary complex forwards to
pace its growth with that of the mandible. This theory
olso acknowledges the genetic influence of growth.
A number of points were raised agains1 this
theory. The following are some of them :
1. When on arec of the suture is transplanted to
onother location, the tissue does not continue 'o
grow. This clearly indicates a ack of innate growth
potential of the sutures.

intra-membranous bone formation 2. Growth takes place in untreated cases of cleft

oalate even in the absence of sutures.
In this iype of ossification, the formation of bone is not
3. Microcephaly and hydrocephaly raised doubts
preceded by formation of a cartilaginous model.
about the intrinsic genetic stimulus of sutures.
Instead bone is loid down directly in a fibrous
membrane. The intra-membranous bone is formed in
Cartilaginous theory
the following manner:
a. At the site of bone formation, mesenchymal cells
become aggregated.
b. Some mesenchymal cells lay down bundles of
collagen fiber.
c. Some mesenchymal cells enlcrge and ccquire a
basophilic cytoplasm and form osteoblasts.
d. These osteoblasts secrete a gelatinous matrix
called osteoid around the collcgen fibers.
e. They deposit calcium salts :nto the osteoid leading
to conversion of osteoid into bone lamella.
f. Now the osteob asls move away from the lamellae
and a new layer of osteo'd is secreted which aiso
gets calc'fied.
g. Some of the osteoblasts get entrapped between
two lamellae. They are called ostoocytes.
This theory was put forward by James Scott. According chewing, digestion, swallowing, speech and neural
to him intrinsic growth controlling factors are gresenr in integration.
cartilage and periosteum with sutures being only Each of these functions is carried out by a

secondary. He viewed the cartilaginous sites functional crania! component. Each functional17
cranial

througnout the skull as primary centres of growth. component consists of all of the tissues, organs,

Growth of the maxilla is attributed to the spaces and skeletal parts nccessary to carry o jt a
given funcrion. The functional cranial component is
nasal septoI cartilage. According to Scotr, the nasal
divided into :
septal cartilage is tne pacemaker for growth of the
1. Functional matrix
enrire naso-maxillary complex. The mandible is
2. Skeletal unit
considered as tne diaphysis of a long bone, henf into a
All the tissues, organs and functioning
horse-shoe shape with epiphysis removed so that
spaces taken as o whole comprise the functional
there is cartilage constituting half an epiphyseal plate
matrix, while the skeletal lissues related to this specific
at the ends which are represented by tne condyles.
functional matrix comprise the skeletal unit. All skeletal
Points in favour of this theory include :
tissues originate, grow and function completely
In many bones, cartilage growth occurs, while
embedded in their several matrices. Thus changes in
bone merely replaces it.
size, shape ond spatial position of all skeletal units
If o pai of on epiphyseal plofe is transplanted to c
including their very maintenance is due to the
different location, if will continue to grow in the
operational activity of their related functional matrices.
new location. This indicates the innate growth
potential of the cartilage.
Nasal seolal cartilage olso shows innate growth
potential on being transplanted to another site.
Experiments on rabbits involving removal of the
nosal septal cartilage demonstrated relcrded
mid-face develooment.

The functional matrix concept

The functional matrix concept o-r Melvin Moss
revitalized the studies on growth and development at a
time when the Sutural growth theory of Sicher and
Cartilcginous growth theory of Scott were severely
criric'zed for their inadequacy. Moss introduced rhe
doctrine of functional matrix complimentary to tne
original concept of functional cranial component by
Van der Klaous. The funcrionol matrix concept
attempts to comprehend the relationship between form
ond function.
The functional matrix hypothesis claims that
tne origin, form, position, growth and maintenance of all
skeletal tissues and organs ore always secondcry,
compensatory and necessary responses to
chronologically and morphologically prior events or
processes thot occur in specifically related non-skcieral
tissues, organs or functioning spaces.
• A number of relatively independent functions
are carried out in the cranio-facial region of tne human
body. Some of the functions corried out include
respiration, olfaction, vision, hearing, balance,
 28 z unif:
The skeletal Orthodontics - The
All skeletal tissues Art and
associated with aScience
single function are called 'the skeletal unit'. The
skeletal unit may be comprised of bone, cartilage and
tendinous tissue. When a bone is comprised of several
contiguous skeletal units, they are
'micro-skeletal units'. The maxilla and mandible are
comprised of a number of sucn micro-skeletal units.
For example, the mandible has within it alveolar,
angular, condylar, gonial, mental, coronoid and basal
micro-skeletal units. In case of the maxilla it is made up
of orbital, pneumatic, palatal and basal micro-skeletal
units. When adjoining portions of a number of
neighbouring bones are united to function as a single
craniol comoonent, we term this a 'macro- skeletal
unit'. The entire endocranicl surface of the colvarium is
an example of a macro-skelctol unit.
The functiona/ matrix : The functional matrix consists
of muscles, glands, nerves, vessels, fat, teeth and the
functioning spaces. The functional matrix is divided
into two r
1. Periosteal matrix
2. Capsular matrix
1. Periosteal Matrices : The oeriosteal matrices ad
directly and octively upon their related skeletal units.
Alterations in their functional demands produce o
secondary compensatory transformation of the size
and or shape of their skeletal units.
transformations are brought obout by the interrelated
processes of bone deposition and resorption. The
periosteal matrices include the muscles, blood
vessels, nerves, glands, etc.,. These tissues oct
directly on their related skeletal un:ts thereby bringing
about a transformation in *heir size and shape. This
transformation due to -he action of periosteal matrices
is brought about b. bone deposition and resorption.
2. Capsular Matrices : The capsular matrices oC
fldescfy and passively on their related skeletal uni^i
p-odocing a secondary compensatory translator -
space. These alterations in spatial position cr s« e etal
units are brought about by the expansicr cr the
oro-facial capsule within which the faco bones arise,
grow and are maintained. Theioocl skeletal units are
passively and secondarily i—oved in space as their
enveloping capsule is expanded. This kind of
translative growth is :>c' brought about by deposition
and resorption.
The neuro-cranial capsule and the orofacial
capsule are examples of capsular matrices. Each of
these capsules is an envelop which contains o series
of functional cranial components (skeletal units and
related functional matrix) which as a whole are
sandwiched in between two covering layers. In the
neuro-cranial capsule, the covers consist of the skin
and dura mater where as in the oro-facial capsule the
termed skin and mucosa form t ho covering.
The neuro-cranial capsule surrounds ond
protects the neuro-cranial capsular functional matrix
which is the brain, leptomeninges and C.S.F. The
neurocranial copsule is made up of skin, connective
tissue, aponeurotic layer, loose connective tissue
layer, periosteum, base of the skull and the 2 layers of
dura mater. The orofacial capsule surrounds and
protects the oro- naso-pharyngeal saaces which
constitute the orofacial capsular matrix. The growth of
the facial skull is influenced by the volume and patency
of these spaces.
van Llmborgh's theory
A m u Iti-factorial theory was put forward by van
Limborgh in 1970. According to van Limborgh the three
popular theories of growth were not satisfactory, yet
each contains elements of significance that cannot be
denied, van Limborgh explains the process of growth
and development in a view that combines all the three
existing theories. He supports the functional matrix
theory of Moss, acknowledges some aspects of
Sicher's theory and at the same time does not rule out
Such
genetic involvement, van Limborgh has suggested the
following five factors that he believed controls growth :
intrinsic genetic factors : They are the genetic control
of the skeletal units themselves.
Local epigenetic factors : Borie growth is determined
by genetic control originating from adjacent structures
like brain, eyes etc.,.
General epigenetic factors : They are genetic t'actors
determining growth from distant structures. E.g. Sex
hormones, growth hormone etc.,.
Loccl environmental' factors : They are non- genetic
fcctors from loco external environment. E.g. habits,
muscle force, ctc.,.
General' environmental factors : They are general
non-generic influences such as nutrition, oxygen etc.,.
The views expressed by van Limborgh can
be summarized in the following six points :
1. Chondrocrcniol growth is controlled mainly by the
intrinsic genetic factors.
2. Desmocrcnial growth is controlled by a few
intrinsic, genetic factors.
3. The cartilaginous parts of the skull must be 3. Middle craniol fossa and breadth of ramus a re
considered cs growth centres. counterparts.
4. Suturcl growth is controlled mainly by influences 4. Maxillary and mandibular arches are mutual
originating from the s*ul! cartilages and from other counterparts.
adjacent skull structures 5. Bony maxilla and corpus of mandible are mutual
5. Periosteal growth largely depends upon growth of counterparts.
adjacent structures. 6. Maxillary tuberosity and lingual tuberosity are
6. Sutural and periosteal growth are additionally counterparts.
governed by local non-genetic environmental
influence.

OTHER THEORIES RELATED TO

CRANIOFACIAL GROWTH

Enlow's expanding 'V' principle

Many facial bones or parts of bone have a V shaped
poltern of growth. The growth movements and
enlargement of these bones occur towards the wide
ends of the V as a result of differential deposition and
selective resorption of bone. Bone deposition occurs
on the inner side of the wide end of the V and bone
resorption on the outer surface. Deposition also takes
place at the ends of the 2 arms ot the V resulting in
growth movement towards the ends.
The V' pattern of the growth occurs in a
number of regions (fig 5) such as the base of the
mandible, ends of long bones, mandibular body, palate
etc.,.

Enlow's counterpart principle

The counterpart principle of craniofacial growth states
that the growth of any given facial or cranial part
relates specifically to other structural and
geometriccounterparts in the face and cranium.
There are regional relationships throughout
the whole face and cranium. If each regional part and
its particular counterpart enlarge to the same extent,
balanced growth occurs.
Imbalances in the regionol relationships are
produced by differences in :
a. Amounts of growth between the counterparts.
b. Directions of growth between the counterparts.
c. Time of growth between the counterparts.
The different parts & their counterparts
are ;
1. Nasomaxillary complex relates to the anterior
cronialfossa.
2. Horizontal dimension of the pharyngeal space
relates to the middle cranial fossa.
 Neuro-viscera f frophism : The sal vary glands, fat
tissue and other organs are trophically regulated, at
least in port.
20 Orthodontics - The Art and Scicnce
References

1. Cong'clcsi, Moss. McAlamey, N' : Growth urd -rcst- ment

effects whn conventiona roentgenography cepholcmetry ond
F EM onalvs's. An .1 OrhoH 1994,
153-7 60
2. Lnlow : Hand boo< of focia growh, WB Sounders Company,
1982
3. Enlow, Hen/old, Latham, Mcffi", Oristianscn and Hauscb :
Research on control of croniofac'al
normogenesis. Am J Orthcd 1977 ; 509-530
4. Grobcr TM : Orthodontics : Principles and practice. VVB
B Sounders,i 988
Fig 5 V Princio e of grov4h in (A) V.cndble 5. Mess : Genetics, epigere-ics, ond causat'on. Am J
(B) Moxillo Orthcd 1981 r 366-375
6. Moss and Sa entijn : The prima"/ role cf functional matrices in
;
ocia growth, Am „ Orthcd 1969 ; 20-31
Neurotrophic process In
7. Moss, Ska lak, Patcl, Sninozu<a, Mess-Sale nri n. anc
oro-facfal growth Vilrrann : An nllomet'ic ne\vork model of craniofacial growK
Air J Orhoc 1964 ,• 316-332
Neurotropism is a non-impulse transmifling neural 8. Moss, Skalok, Shinozuka, Fatcl, Moss-Sclen-"n, Vilmarn. end
function that involves axoplasmic transport and Mehta : An allometric centered model cf craniofacial growth.
Am J Orthcd 1983 ; 5-18
provides for long term interaction between neurons and 9. Profit! WR: Con-empora'y Ortnccont'cs, St Louis, CVMosby.l
innervated tissues that homeostatically regulates the 986.
10. Robert E Moye'S : Hand book of Orthodontics, Yccr boo<
morphological, compositionol and functional integrity of
medical pjblisners, "nc. 1988.
those tissues. The nature of neurotrophic substances 11. S-iaw Wc : Orthcdomic and Occlusal managemenr, Wright,!
993
and the process of their introduction into the target
tissue are unknown at present.
The different types of neurotrophic
mechanisms are:
1. Neuro-epithelial trophism
2. Neuro-visceral trophism
3. Neuro-musculartrophism Neuro-epitfie/ia/ trophism
; Epithelial mitosis and synthesis are neurotrophically
controlled. The normal epithelial growth is controlled by
releosc of certain neurotrophic substances by the
nerve synapses. If this neurotrophic process is lacking
or is deficient, abnormal epithelial growth, orofacial
hypoplasia and malformation etc., occur.
For example, the presence of taste buds is dependent
upon an intact innervation. The nen/es are not only
important for the sensation of taste but they also hcve
a neurotrophic effect in sustaining healthy growth of
the taste buds ond nearby epithelial tissue. If the taste
buds crede- innervoted, they became atrophic ond so
also the nearby epithelial cells.

Neuro-muscular trophism : Embryonic myogenesis is

independent of neural innervation and trophic control.
Approximately ot the myoblast stage of differentiation,
neural innervation is established without which further
myogenesis usually cannot continue.
i'
 wth and Development of
Cranial and Facial Region

mk
ff/t.

G
rowth ond development of an individual
can be divided into prenatal and tne
post-natal periods. The pre-natal period of
development is a dynamic phase in the development of
a human being. During this period, the height increases
by almost 5000 times as compared to only a threefold
increase during the post-natal period. The prenatal life
can be arbitrarily divided into three periods :
1. Period of the ovum
2. Period of the embryo
3. Period of the fetus
growth of the cranio-faciol structures occurs resulting in
an increase in their size. In addition, a change in
proportion between the various structures also occurs.
PRENATAL GROWTH OF CRANIAL BASE
The earliest evidence of formation of the cranial base is
seen in the post or late somilic period (4th - 8th week of
intro-uterine life). During this late somitic period
mesenchymal tissue derived from

Period of the ovum

This period extends for a period of approximately two
weeks from the time of fertilization. During this period
the cleavage of the ovum and the attachment of the
ovum to the infra-uterine wall occurs.
Period of the embryo
This period extends from the fourteenth day to the fifty
sixth day of intra-uterine life. During this period tne
major part of the development of the facial and the
cranial region occurs.

Period of the fetus

This phase extends between the fifty sixth day of
intra-uterine life till birth. In this period, accelerated
22 Orthodontics - The Art and Science

the primitive streak, neuro^' crest and occipital

sclerotomes condense around the developing brain.
Thus a capsule is formed around the brain called
Ecfomenix or Ectomeningeal capsule. The basal
portion of this capsule gives rise to the future cranio.'
base.
The development of the skull and :on7iation of
the cartilages of the cranial base is dependent upon the
presence of many other cranial structures like brain,
cranial nerves and •3-.es. Thus evidence of skull
Fig t Cartilages of -he cranio I base : I. Nasa aacsu'e, 2. Prsspheno'c
formation is seen comparatively late after the primordia cortilage, 3. Qrbito - sphenoid enri nge, •1. Parachcrdu csrtilage, 5.
of many c*~e'cranial structures have developed. O'ic car'iage. 6. At! - spheroid ccrilnge, 7. Post - Sphenoid cart'lage

From around the fortieth day onwards,

- s ectomeningeal capsule is slowly converted rrx>
cartilage. This heralds the onset of cranial rose
format'on. The conversion of mesenchymal
's into cartilage or chondrification occurs in 4 ons
(fig 1) : 3 Parachordal r Hypophyseal
- Nasal
r Otic
Parachordal
7?-e chondrification centres forming around the —r-ial
end of the notochord are colled rcrschordal cartilages.
ffrpophyseal
Zrzrk}\ to the termination c: nctochord, (which : — —e
level of the oro-phcr'oeol membrane) ■fe -roophyseal
pouch cevekscs which gives rise
- —e anterior lobe of the c gland.
On either side of the b.-ccc - .iecl stem two
;
-•oophyseol or post sc~-r--o d cortilages develop.
These carti'coes tacether and ryrr\ the posterior
part <? the roc. o: sphenoid, i' Cranial to the pr_ -o
glond, two cresphenoid or trabec. c- oges develop
which fuse together and form the anterior part of
body of sphenoid. Anteriorly, the pre- sphenoid
cartilage forms a vertical cartilaginous plate
called mesethmoid cartilage which gives rise to
the perpendiculor plate of ethmoid and cristagalli.
(iii) Lateral to the pituitary gland chondrification
centres are seen which form the lesser wing
(orbito-sphenoid) and greater wing [ali- sphenoid)
of sphenoid.
Nasat
Initially during development, o capsule is seen around
the nasal sense organ. This capsufe chondrifies and
forms the cartilages of the nostrils which fuse with the
cartilages of the cranial base.
Otic
A capsule is seen around the vestibulocochlear sense
organs. This capsule chondrifies ond later ossifies to
give rise to the mastoid and petrous
 Growth and Development of Cranial and Facial Resion

portions of the temporal bone. The otic curtilages also
fuse with the caiti ages of the cranial base.
The initially separo'e centres of cartilage
formation in the cronial base, fuse togetner into a single
irregular and creatiy perforated crar'al base. Tne early
establishment of the various nerves, blood vessels etc.,
from and to the brain results ir rurerous perfo'ations or
foramina in the developing cranial base. The ossifying
chondro-crar'um meets the ossifying desmocrarium
(cranial vault) to form the neurocroniuTi.
(iii) The petrous part of temporal bone ossifies from 4
endochondral centres that appear in the 5th
montn of infra-uterine life.
(iv) The styloid process ossifies from 2 endochondral
centres.
EJtimoia1 Sor?e ; This bone shows only endochondral
ossification. It ossifies from three centrcs :
(i) One centre located centrally that forms the median
floor of the anterior cranial fossa.
(ii) Two ateral centres in the nasal capsule.

Spncnoia' Bone : This bone ossifies both

Chondro-craniai ossification
intromembranously and endochondral^. There ere at
The cranial base which is now in a cartilcginous form
least 15 ossification centres.
uncergoes ossification. Tne oones of the crania base
(i) Lesser wing : Endochondral ossification occurs.
undergo both endochondral as well as
The ossification centre is seen in the
inlramembranous ossification. Occipffof Bone ; The
orbitosphenoid cartilagc.
occipital bone shows both endochondral and
(ii) Greater wing and ateral pterygoid plate : Two intra
nt-a-membranous ossification. Seven ossificction
membra nous ossification centres are seen in the
centres are seen, two intrcmernbranous and five
ciisphenoid carti:aoe. A part of the greater wirg
endochondral.
ossifies encochcndrally.. .
(i) The suoranuchcl squamous aart ossi'ies
(iii) Medial pterygoid plate : Ossifies endocnondrally
int'arncmb'anously from one pair of ossification
from u secondary cartilcgc in the hamular process.
ccntrcs whicn appear in the 8tn week of intra-uteri
(iv) Anterior part ot body of sphenoid : Ossifies
n e life.
endochondral^ from five centres (iwo paired and
(ii) The infranjchal squamous part oss'fies
one in the midline). The cenrrc of ossification is
encocnondrally from two centrcs which appear at
seen in pre-sphenoid cartilage.
the 10*h week of intrc-uterine life.
(v) Posterior pert or body o I sphenoid: Ossifies
(iii) The basil ar part ossifies endochondrallyfrom a
endochondrally from -our centres. The centre
s'rg'e ^edian ossificcr'on centre appearing in the
114i week ol 'ntra-uterire life. This gives rise to the
anterior portion of the occipital condyles and the
anterior boundary of foramen magnum.
(iv) A pair of endochondral ossification centres
appears in -he 12th week forming the lateral
boundary of foramen magnum and the posterior
no ii o n of occipital condyles.
Te.Tipo.ra.1 Bo.ne ; Tne temooral bone ossifies both
endochordrally and intrc-membranously from 1 1
centres.
(i) Squamous part of the temporal bone ossifies from
a single intramembrcnous centre that appears in
the 8th week of intrc-uterine life.

M
(ii) The tympanic ring ossifies from four
intramembranous centres that appear
in the 12th week of intra-uterine life.
24 Orthodontics - The Art and Science
of ossificotion is the post-sphenoid cartilage.
Thecraniol bose orchondro-cranium
important as a junction between the cron'al vault and
the facial skeleton, being shared by both. The cranial
bose is relatively stable during growth compared to the
cranial vault and the face. Thus the cranial base can be
taken as a basis against which the cranial vault and
facial ske/efon can be compared. The ebon d
ro-cranium is relatively stable. This aids in maintaining
the early established relationship of blood vessels and
nerves running to and from the brcin. The craniol base
of a newborn is small when compared to •he cranial
vault that extends beyond the base laterally and
posteriorly.
Flexure of the cranial base
During the embryonic and early fetal period, the cranial
base becomes flexed in the region between the
pituitary fossa and the soheno-occipita! •unction. The
face is hence tucked under the cranium. This flexure of
the cranial bose is accompanied by a corresponding
flexure of the developing brain stem. Thus the spinal
chord and 'he foramen magnum which during the early
stages of development were directed backwards now
become directed downwards (fig 2). This
r By around the 4th week of intra-uterine life,
ig 2 Flcxu'e of 't c
crarial bass - arrow
indicating the
direction cf the
fororren magnum
downward directed foramen magnum is an cdaptation
seen in man who, unlike animals, stands erect. This
flexure of the cronial base aids in increasing the
neurocranial co pa city. Another consequence of tne
flexure is the predominant downward rather than
forward displacement of the face during its growth from
is the cranial base.
At around the 1 Oth week of intro-uterine life,
the flexion of the bese is about 65". This flattens out a
bit at the time of birth.
Uneven nature of growth of cranial base
The growth of the cranial base is highly uneven. T.nis
is attributed to the uneven nature of growth seen in the
different regions of the brain. Thus the cranial base
growth resembles the growth of the ventral surface of
the overlying brain.
The anterior end oosterior parts of the cranial
base grow at different rates. Between the 1 Oth and
the 40th weeks of intra-uterine life, the anterior cranial
base increases in length end width by 7 times while,
during the same period the posterior cranial base
increcses only five fold.
PRENATAL EMBRYOLOGY OF MAXILLA
Around the fourth week of intra-uterine life, a
prominent bulge appears on the ventrol aspect of the
embryo corresponding to the developing brcin. Below
the bulge a shallow depression which corresponds to
the primitive mouth appears called stomcdeum. The
floor of the stomodeum is formed by the
buccopharyngeal membrane which separates the
stomodeum from the foregut.
five branchial arches form in the region of the future
head and neck. Each of these arches gives rise to
muscles, connective tissue, vasculature, skeletal
components ond neural components of the future face.
The first branchial
Growth and Development of Cranial and Facial Region 25

Fronto-nasal process Medial nasal Process

Lateral nasal process Mandibular Process

Fig 3 Prenatal develccment of the rrcxTc ar.d the face


26 z Orthodontics - The Art and Science
Fig A Cororcl sec'ion of tie hecid Slewing -ho pa ctcl
shelves growing vertically down towards tne foor of "he
mouth
arch is called the mcndibulcr crch and plays an important
role in the develooment of the nasomaxillary region.
The mesoderm covering the developing
forebrain proliferates and forms a downward projection
that overlaps the upper part of stomodeum. This
downward projection is cal ed fronto-nasal process.
The stomodeum is thus overlapped superiorly by
the fronto-nasal process. The mandibular arches of both
the sides form the lateral walls of the stomodeum. The
mandibular arch gives off u bud from its dorsal end called
the mcxillon," process. The moxillan/ process grows
ventro-medio-crarial to the main part of the mandibular
arch which is now called the mandibular process. Thus at
this stage the primitive mouth or stomodeum is
overlapped ^rom above by the frontal process, below by
tne mandibular process and on either side by 'he maxillary
processes.
The ectoderm overlying the fronto-nascl orocess
shows bilateral localized thickenings obove the
stomodeum. Tnese are called the nasal placodes. These p
acoces soon sink and form the nasal aits.
The fomction o-*these nasal pits divides the :'onto- nasal
process into two parts :
a. The medial nasal process and
b. The lateral nasal process
The two mandiou'a r processes grow
medicllyand fuse to form the iower lip and lower jow. As
the maxillory process undergoes growth, the fronto-nasal
process becomes narrow so that the two nasal pits come
closer. The line of fusion o- the maxillary process and the
medial nascl process corresponds to the naso-'acrimal
duct.
DEVELOPMENT OF PALATE
The palote is:ormed by contributions of the :
a. Maxillary orocess
b. Palatal shelves given off by the maxillary process
c. Fronto-nasal process
The fronto-nasal process gives rise to the
premaxillan/ region while the pa'atal she'ves form the
rest o; the pc ate. As the palatal shelves grow medially,
their union is prevented by the presence of the tongue.
Thus iriiticlly the developing pa'atal shelves grow
vertically downwards towards the foor of the mouth (fig
4). Sometime during the seventh week o' intra-uterine
Ire, a transformation in the position o"" the palatal
shelves occurs. They change from a vertical to a
horizontal position. Thistransformo*'on is believed to
Icke place within nours. Various reasons are given tc
explain how this transformation occurs. They arc :
a. Alteration in oiochernical and physical consistency
of tne connective tissue of the palatal shelves.
b. Alteration in vasculature and blood supply to the
palatcl shelves.
C. Appearance of an intrinsic shelf force.
d. Rapid differential mitotic activity.
e. V uscu I a r move menrs.
I I
f. Withdrawl of the em bryon ic face from ago i nst the
heart prominence results in slight [aw opening. Tnis
results in wilhdrawl of the toncue from between the
palatal shelves and aids in the elevation of the
polatal shelves from a vertical to a horizontal
position.
The two palatal shelves, by 8 1/2 weeks of
intra-uferine life, are in close approximation with each
other. Initially the two palatal shelves are covered by an
epithelial lining. As they join, the epithelial cells
degenerate. The connective tissue of the pclatal shelves
intermingle with each other resulting in their fusion.
The entire palate does not contact and fuse at
the same time. Initially contact occurs in the central
region of the secondary palate posterior to the
premaxilla. From this point, closure occurs both
anteriorly and posteriorly. The mesial edges of the
palatal processes fuse with the free lower end of nasal
septum and thus separates the two nasal cavities from
each other and the oral cavity.
Ossification of palate
Ossificalion of the palate occurs from the 8th week of
intra-uterine life. This is an intra membra nous type of
ossification. The palate ossifies from a single centre
derived from the maxilla. The most posterior part of the
palate does not ossify. This forms the soft polate. The
mid-palalal suture ossifies by 12-14 years.
DEVELOPMENT OF MAXILLARY SINUS

Growth
The maxillary sinus and Development
forms sometime of
around the 3rd month Cranial and Facial Region \ 27
of irilra-uterine life. It develops by expansion of the nasal
mucous membrane into tr*e maxillary bone. Later the
sinus enlarges by resorption of the internal wall of maxilla.
PRENATAL EMBRYOLOGY OF MANDIBLE

About the 4th week of intra-uterine life, the developing

brain and the pericardium form two prominent bulges on
the ventral aspect of the embryo. These bulges are
separated by the primitive oral cavity or stomodeum. The
floor of the stomodeum is formed by the bucco-pharyngeal
membrane, which separates it from the foregut.
The pharyngeal arches are laid down on the
lateral and ventral aspects of the cronialmost part of the
foregut which lies in close approximation with the
stomodeum. Initially there are six phan/ngecl arches, but
the fifth one usually disappears as soon as it is formed
leaving only five. They are separated by four branchial
grooves. The first arch is called the mandibular arch and
the second arch, hyoid arch. The other arches do not have
any specific names.
Each of these five arches contain :
1. A central cartilage rod thatforms the skeleton of the
arch.
2. A muscular component termed as branchiomere.
3. A vascular component.
4. A neural element.
The mandibular asch forms the laterol wall of the
stomodeum. It gives off a bud from its dorsal end. This bud
is called the maxillary process. It grows ventro-medially,
cranial to the main part of the arch, which is now called the
mandibular process. The mandibular processes of both
sides grow towards each other and fuse in the midline.
They now form the lower border of the stomodeum i.e.
the'lower lip and the lower jaw.

/WecJce/'s cartilage
The Meckel's cartilage is derived from the first branchial
arch around the 41st - 45th day of
 J
lingula of mandible to the spnenoid bone also fonns a
remnant of tne Meckel's cartilage.

Endochondral bone formation

Endochondral bone formation is seen or y in 3 areas of
the mandible :
1. The condylar process
2. The coronoid process
3. Tne menlc' region

Condylar procoss : At about the 5th week of

intra-uterine life, an area of mesenchymal
Fig S IA) Meckel S cati'age (B.I
Inferior olveolcr rerve (C) Initiction of condensation car be seen above rhe ventral part of *he
ossificate n orojrc -he Meckel's developing mandible. Tnis develops ir*o c cone -
cortilogc
shaped cartilage (:ig 6) by abcu- 10th week and starts
ossification by T 4th week. It then migrates infer'orly
intra-uferine life. It extends and fuses with the mandibular ramus by abou* 4
from the cartilaginous otic capsule to the midline or monlns. Much o: tne cone - shaped cartilage is
symphysis ard provides a temolare for guiding the growth rep'aced by bone by the middle of fetal life but its upper
of the mandible (fig 5). A major portion of the Meckel's end pe-sisfs irrt> aduHooc' f acting both asa growth
cartilage disappears during growth and the remaining part cartilagoand cn articular cartilage.
develops into the following structures:
Coronoid process : Secondary accessory cartilages
1. The mental ossicles
appear in rhe region of the coronoid orocess by ooou'
2. Incus and Malleus
the 10-14 week of intra-uterine fe. This secondary
3. Spine of sphenoid bone
cartilage of coronoid process is believed to grow as a
4. Anterior rgament of malleus
response to the developing temporalis muscle. The
5. Spheno - mandibular ligament
coronoid accessory
The first structure to develop ir the primordium of
the lower jaw is the mandibular division of the trigeminal
nerve. This is followed by the mesenchymal condensation
forming the first branchial arch. Neurotrophic factors
coduced by the nerve induce osteogenesis in the
ossification centres. A single ossification centre hr each
half of the mandible arises in the 6th •ve-ek of
intra-uterine life in the region of 4he b 'urcation of the
inferior alveolar nerve into —ental ond incisive branches.
The ossifying membrane is located latercl •o 'He
Meckel's cartilage and its accompanying reuro-vascular
bundle. From this primary centre, ossification spreads
below and around the inferior cveolar nen/e and its
incisive branch ond upwards to form a trough for
accommodating *he developing tooth buds. Soread of the
intramembrcnous oss"fica4ion dorsally ard ventrally forms
the body and rcmus of the mandibe.
As ossif'carion continues, the Meckel's
cartilage becomes surrounded ard invaded by oone.
Oss'fication stops at the site ^har will ! ater become the
mandibular lirgula from where the Meckel's cartilage
continues into the middle ear ana develops into the
auditor/ ossicles i.e. malleus & incus. The
spnenomandibulc ligament wh'ch extends from the

.t
cartilage becomes incorporated into the expanding processes occurring ot the cranial base con affect the
intramembranous bore of the ramus "d disappears before placement of maxii.'a and the mcndible.
Growth and Development of Cranial and Facial Region \ 29
birtn. The cranial base grows post-narally by-

venfo/ region : In the mental region, on either side of the complex interaction between the following three growth

symahysis, one or two small cortilages rspeorand ossify in processes.

the 7th month of irtra-uterine a. Extensive cortical drift and remodeling

b. Elongation ot synchondroses
c. Sutural growth

Cortical drift and remodeling

Remodeling refers to a process where bor.e deposition
ard resorption occur so as to bring about change in s'ze,
shape ana relationship of the bone. The cranium is
divided into a number of compartments by bony
elevations and ridges present 'n the cranial base. These
elevated ridges end bony partitions show bore
deposition, while Ihe predominant part ot the floor shows
bone resorption (fig 7). This intracranial bone resorption
helps in increasing the intracranial space to
accommodarethc growing brain.
The cranial base is perforated by the passage
of a number of blood vessels end nerves communicating
with the brain. The foramina that allow the passage of
these nen/es and blood vessels undergo drifring by bone
deposition and resorption so as to constantly maintain
their proper relationship with Ihe growing orain.

Fig 6 Corey cr cart lags ceveloos

rria'ly cs c seoa'cts area and
fuses with tne mardibtlar body
oiround Ihe fcjrti rnont.n ot intra
.re'ine life

life to form vcriable numbers of mental ossicles in the

fibrous tissues of the symphysis. These ossic es become
incorporated into the intramembranous bore when the
symphysis ossifies completely during tne firstyecrof
post-natol life.

POST-NATAL GROWTH OF THE

CRANIAL BASE

The maxil a is at-ached to tne cranial base by meens of a

number of sutures. The mandible too is ottached to Ihe
cranial base at the temporo- mendibu ar joint. Tnus growth
 Orthodontics - The Art and Scicncc

The struclure of a synchondrosis is like 2

epiphyseal plates positioned back to back and

Fig 7 Bone remodeling seen in cranial bcse.

Elongation at the synchondroses

Most of ihe bones of the cranial base are formed by a
cartilaginous process. Later the cortilage is replaced by
bone. However certoin bands of cortilage remain at the
junction of various bones. These areas are called
Synchondroses. They are important growth sites of the
cranial base. They are primary cartilages. The important
synchondroses found in the cranio! base are :
a. Spheno-occipital synchondrosis
B
b. Spheno-ethmoid synchondrosis Fig 8 (A) Spheno occipital - synchondrosis (BJ
c. Inter-sphenoid synchondrosis O > owl h ol Sphcrio - occipital synchondrosis
results in increase iri length and width of
d. Intra-occipital synchondrosis
sphenoid and occicitol bones

Spbeno-ocdprfa/ synchondroses r It is the cartilaginous

junction between the sohenoid and the occipital bones (fig
8.a). The spheno-occipital synchondrosis is believed to be
the principal growth cartilage of the cranial base during
childhood. It is considered to be Ihe most important growth
site of the cranial base. The spheno-occipital
synchondrosis is believed to be active up to the age of
12-15 years. The sphenoid and the occipital segments
then become fused in the midline area by 20 years of age.
The spheno-occipital synchon-drosis provides a
pressure or compression adapted bone growth, in
contrast to the tensron adapted growth seen in sutures.
This is because the cranial base supports the weight of
the brain and face which bears down on the
synchondros:s in the midline of the cranial base. As
endochondral bone growth occurs ctthe spheno-occipital
synchondrosis, tne sohenoid and the occipital bones are
moved aport. At the same time new endochondral bone is
laid down in the medullary region, and cortical bo.ne is
formed in the endosteal and periosteal regions. Thus the
sphenoid and occipital bones increase in length and width
(fig 8.b).
separated by a common zone of reserve cartilage. 7ns is simply moved anteriorly as Ihe middle cranial fossa
direction of growth of the spheno-occipital synchondrosis grows «n that direction. The passive disp'acement of the
Growth and Development of Cranial and Facial Region \ 31
is upwards. It therefore carries the anterior part of the maxilla is an importantgrowth mechanism during the
cranium bodily forwards. The growth at the syncondrosis primary dentition years but becomes less important as
continues till the cbliteration of the some by formation of growth of cranial base slows.
bone. Sadies by various scientists have shown that the In addition, a primary type of displacement is
dosure of ihe syncnondrosis occurs on an average c: also seen in a forward direction (fig 9.a). This occurs by
13-15yecrsofage. growth of the maxillary tuberosity in a posterior direction.

Sp/ieno-etfimoia' synchondrosis : This is a ccrtilaginous This results in the whole maxilla being carried anteriorly.

bond between the sphenoid and eihmoid bones. It is The amount of this forward displacement equals the

believed to ossify by 5-25 .ears of age. amount of posterior lengthening. This is a primary type of
displacement as the bone is displaced by its own
/nter-spheno/da/ synchondrosis : It is a cartilaginous band
enlargement.
betwoen the 2 parts of the sphenoid bone. It is believed to
ossify at birth. Growth at sutures
Intra-occ/pital synchondrosis : This ossifies by 3-5 The maxillo is connected to the cranium and cranial base
years of age. by a number of sutures. These sutures include : a.
Fronto - nasal suture
Sutural growth
The cranial bcse has a number of bones that are joined to
one another by means of sutures. Some of the sutures
that are present include : o. Spheno - frontal
b. Fronto - temporal
c. Spheno - ethmoid
d. Fronto - ethmoid
e. Fronto - zygomatic
As the brain enlarges during growth, bone
formation occurs at the ends of the bone (thot is at either
ends of the suture).

Timing of cranial base growth

a. By birth, 55-60% of adult size is attained.
b. By 4-7 years, 94% of adult size is attained.
c. By 8-13 years, 98% of adult size is attained.
POST-NATAL GROWTH OF MAXILLA

The growth of the n aso-maxillary complex is produced by

the following mechanisms
a. Displacement
b. Growth at sutures
c. Surface remodeling

D/spiacement
Maxilla is attached to the cranial base by means of a
number of sutures. Thus the growth of the cranial base
has a direct bearing on the nasomaxillary growth.
A passive or secondary displacement of the
naso-maxillory complex occurs in o downward and
forward direction cs the cranial base
grows. This is a secondary type of
Ji
displacement as the actual enlargement of these parts is
not directly involved (fig 9.b). The naso-maxillary complex
/^Orthodontics - The Art and Science

the orbital rim leading to latere movement ol Ihe

eye ball. To compensate, *here is bone deposition
on the medial rir of the orbit end on Ihe external
surface of the lateral rim.
i11 (2) The floor of the orbit faces superiorly, latere11 y ond
A anteriorly. Surface deposition c-ccurs here ond
-ig 9 ;A; P'ima7 displocener or moxil results in growth in a superior, Ictercl and anterior

b. Fronto - maxillary suture direction.

c. Zygonatico - temporal suture (3) Bore deposition occurs along Ihe posterior margin

d. Zygomatico-maxi!'ary suture of the mcxiiIory tuberosity. This causes

e. Pferygo - palatine suture lengthening of the den*al arch and enlargement of

These sutures arc cII ob ique and more or less the antero-oosterior dimens'on of Ihe entire

parallel to eacn ctne'. This allows the downword and maxillary body. This helps to accomodctc the

forward reoositioning of the maxilla c s growth occurs crjpting molars.

at these sutures. .As growth of the surrounding soft (4) Bone resorp-ion occurs on the lateral wall of the

tissue occurs, the maxilla is carried downwards and nose leading to an ircrease in size of tne nasal

forward. This leads to opening up of space at tne cavity.

sutural attachments. New bone is now formed on {5) Bone resorption is seen or the floor cf the nosal

either side of the suture. Thus the overall size of the cavity. To compensate there is bone deposition on

bones on either side increases. Hence a tension the palalu side. Thus a nel downward shift occurs

related bone formation occurs at the sutures. leading to increcse in maxillary he'ghl.
(6) The zygomatic bone moves in a posterior direction.
Surface Remodeling
This is achieved by reso'ption on the an*erior
In addition to the growth occurring ct the sutures, surface end deposition on Ihe posterior s J rfacc.
massive remodeling by bone deposition and resorption (7} The fcce en'arges in width by bone formation
occurs to bring about :
Increase in size
Change in shcoe of bone
Change in funcional relationship
The following ore the bone remodeling
changes that are seen in ihe naso-maxillcry complex
{fig 10):
(1) Resorption occurs on the lateral surface of

B
(B) Secondary disc ocemert cf no*'Ila
 Growth and Development of Cranial and Facial Region \ 33
SSiftKi

........ Resorption
+ 4+ Deposition

D
Fig 10 Surface re mode ng changes in *iic micr'ac© (A| Bene remoceling seen n the mid:acial region (B & C) Bono remodeling
of tne palate resulting 'n irs dov/nward displacement (D) G'Owth of the palcto exhibiting V pattern of gro'.vlfi (t) 3onc
remodeling o* the Zygomatic process
POST-NATAL GROWTH OF MANDIBLE

si
E

on the lateral surface of the zygomatic arch and

resarplion on its medial surface. Of the facial bones, the mandible undergoes the largest
(8) The anterior nasal spine prominence increases amount of growth post-natalfy and also exhibits the
due lo bone deposition. In addition there is largest variability in morphology. While the mandible

resorption from the periosteal surface of labiol appears in the adult as a single bone, it is

cortex, /vs a comuensalory mechanism, bone
deposition occurs on the endosteal surface of tne
labial cortcx and periosteal surface of the lingual
cortex.
(9) As the leeln start erupting, bone deposition occurs
developmental^ and functionally divisible into several
skeletal sub-units. The basal bone or the body of the
mandible forms one unit, to which is attached Ihe
alveolcr process, the coronoid process, the condylar
process, the angular process, the ramus, the lingual

at the alveolar margins. This increases the
maxillary heignt and the depth of the palate.
(10) The entire wall of the sinus except the mesial wall
undergoes resorption. This results in increase n
size of the maxillary antrum.
tuberosity and the chin. Thus the study of post-natal
growth of the mandible is made easier and more
meaningful when each of the developmental and
functional parts are considered separately (fig 11).
Ramus
The ramus moves progressively posterior by a
combination of deposition and resorption.
 Resorption occurs on the anterior part of the ramus
Growth
while bone deposition occurs and
on theDevelopment
posterior region. of Cranial and Facial Region 35
This results in a 'drift' of the ramus in a posterior
direction. The functions of remodeling of the ramus are
:
1. To accommodate the increasing mass of
masticatory muscles inserted into it.
2. To accommodate the enlarged breadth of the
pharyngeal space.
3. To facilitate the lengthening of the mandibular
body, which in turn accommodates the erupting
molars.

E F
Fig 71 Posi - natal deve'opmen- of mand:ble (A & B) 8one remodeling seen in mandible (CJ Bone rcrnodcl ng seen ir lingucl tuberosity and lingulo
{D) Bone resorption Jeoding to formation of antiponial notch jE) Mancibtlor growth following V put'ern |F) Cross-section of rarrvjs showing bone
remodeling

Corpus or the body of mandibfe

As observed earlier, the anterior border of the adult
ramus exhibits bone resorption while the posterior
border shows bone deposition. That is, the
displacement of the ramus results in the conversion ol
former ramal bone into the posterior part of the body of
mandible. In this manner the body of

95"
 combination of resorption in the fossa and deposition
on the medial surface of the tuberosity itself
accentuates the prominence of Ihe lingual tuberosity.

The alveolar process

Alveolar process develops in response to the presence
of tooth buds. As the teeth erupt the alveolar process
develops and increases in height by bone deposition at
the margins. The alveolar bone adds to the height and
thickness of the body of the mandible and is
particularly manifested as a ledge extending lingual to
the ramus to accommodate Ihe 3rd molars. In case of
absence of teeth, the alveolar bone fails to develop
and it resorbs in Ihe event of tooth extraction.

Fig 12 (A) Mandibular growth due to bone -Jepos'tion
ar -r>2 condylar cartilage (B) Maildibu'cr crcwth at the
condyle •allowing 1ne downworc disp acerrent of the
ma-id b^e due to soft tissue growth
:ne mandible lengthens. Thus additional space made
available by means of resorption of the anterior border
of the ramus is made use of to accommodate the
erupting permanent molars.
Angle of the mandible
On the lingual side of the angle of mandible, resorption
lakes place on the posterio-inferior aspect while
deposition occurs on the antero- superior aspect. On
the buccal side, resorption occurs on
anterio-superior part while deposition takes piace on
Ihe postero-superior part. This result in flaring of the
angle of the mandible os age advances.
The chin
The chin is a specific human characteristic and is
found in its fully developed form in recent man only. In
infancy, the chin is usually underdeveloped. As age
advances Ihe growth of chin becomes significant. It is
influenced by sexual and specific genelic factors.
Usually males are seen to have prominent chins
compared to females. The mental protuberance fomns
by bone deposition during childhood. Its prominence is
accentuated by bone resorption that occurs in the
olveolar region above it, creating a concavity. The
deepest point in this concavity is known as 'point B' in
cephabmetric terminology.
the

The Ungual tuberosity

The lingual tuberosity is a direct equivalent of the
maxillary tuberosity, which forms a major site of growth
for the lower bony arch. It forms the boundary between
the ramus & the body.
The lingual tuberosity moves posteriorly by
deposition on its posteriorly facing surface. It can be
noticed that the lingual tuberosity protrudes noticeably
in a lingual direction and that it lies well towards the
midline of the ramus. The prominence of the
Tuberosity is increased by the presence of a large
resorption field just below it. This resorption field
produces a sizable depression, the lingual fossa. The

Growth and Development of Cranial and Facial Region 37
The condyle
The mandibular condyle has been recognized as an
important growth site. The head of Ihe condyle is
covered by a thin layer of cartilage called the condylar
cortilagc. The p'escncc of the condylar cartilage is an
adaptation to withstand Ihe compression that occurs at
the joint. Tne role of the condy'e in the growth of
mandible has remained a controversy. There are two
schools of thought regarding the role of the condyle.
a. It was earlier believed that growth occurs at the
surface of the condylar cartilage by means of bone
deposition. T n us the condyle grows towards the
cranio I base. As the condylc pushes against Ihe
crania! base, the entire mandible gets displaced
forwards and downwards (fig 12.a).
b. It is now believed that the growth of soft tissues
including Ihe muscles and connective tissues
carries the mandible forwards away from the
cranial base (carry away phenomenon). Bone
growth follows secondarily at the condyle to
maintain constant contact with the cranial base.
The condylar growth rate increases at
puberty reaching a peak between 12 1/2 - 14 years.
The growth ceases around 20 years of age.
The coronold process
The growth of the coronoid orocess follows the
enlarging V principle. Viewing, the longitudinal section
of the coronoid process from the posterior aspect, it
can be seen that deposition occurs on the lingual
(medial) surfoces of the left and right coronoid process.
Although additions takes alace on the lingual side, the
vertical dimension of the coronoid process also
increases. This follows the V principle. Viewing it from
the occlusal aspect, 'he deposition on the linguol of the
coronoid process brings about a posterior growth
movement in tne V pattern. Briefly tne coronoid
process has a propel er-iike twist, so 'hat its lingual side
faces three general directions all at once, i.e
posteriorly, superiorly and medially.
References
*. Avotb or d V.os'afo : .Vcndibdo' growth. An J O-triad 1992 r
255-265
95"
2. Bcrnabei arc Johis'on : T ic g-Owlh n situ of isola'ed mairJiojIar
segments. Am J Ortnod 1973 ; 24-35
3. Bha cjhi SI : Dental Anatomy, Histology and Devel- opment,
Arya publishing house. New Delhi, 1993
4. Bprk : P'ec'iction of mandibular growth rota-ion. An J Orthod
1969 ;3?-53
5. Ejscncna, Tcnauay, Dcrrirjian, LuPalme, and Goldsieir :
Modeling longitudiral mandibular growth. Am J Orhoc 1939
60-66
6. da Silva, Nlonrcndo, and Cupu oiza : "nflcence cf deft type on
ncndibUar growth. Am J 0*tnod 1993 .-269-275
7. Erlow : Horn nook of r'cria growh, WB Saunders Conpcny,
1962
8. G'obsr TM : Orhocontics : Principles and practios. WB
Sounders,T 933
9. -egg ond Ahstrom ; Estirrotec mandiojlor growth. Am J Orthcd
1992 ;146-152
10: Herneber<e nnd Prahl-Anderser : Cranicl base growth. Am J
Olhod 1994 ; 503-512
11. Koski : Cronia growth centers: Facts or *'a lades? Am J
Orthod 196B ; 566-583
12. Kraut end K-orman : Relaiionsh p octwcen potency ot max'l
c.rf s'nus ard cran'ofadal growfn in 'obbit. Am J Orthod 193B .
467-476
13. Mi tani : Prepubertal growh of rnendibulo' prcgnoth'sm. Am J
Orthod 1981 ; 5^6-553
"4. Mi tani, Scto, and Sugav/aro : lals grawtn of mandibular
prognctnlsm. Am J Crthcd 1993 ; 330-336
15. Nielsen, Biovo, ond Miller : Nomial rroxiltary ond mandibular
growth a id dcntoalveola' deve'opirent
in Macaco mulatto. Am J Orthod 19B9 . 405-415
16. Nielsen, B'avo, ore Miller ; Normol moxil'ory end mandibular
growth and Hentonlveola' development
in Macaco mulatto. Am J Orhoc 1969 r 405-415
17. Prof it V-/R: Confcmpo'ary Oihodontics, S' lou s, CV
Mosby,1986.
13. Robert E Moyers : Hand book 0; Orthodontics, Year book
medical publishers, inc,l 986.
19. Rossovw, Lomba'd, and Han-is : Frontal sinus and
mano'ibula' growth prediction. Am J O-tnod 1991 ; 542-546
20. Sclzmar JA . Pracioe of Orlhodortics, J B L'ppincott ccmpony,
1966
21. Ter cate AR : Oral Histology : Development Siruc •Lre and
Function, C.V.Mosby, Si lo>jis,19B0
T
he embryonic oral cavity is lined by stratified
squamous epithelium known as the oral
ectoderm. Around the 6th week of intra-uterine
life, the infero-latercl border of Ihe maxillary arch and
the supero-lolerci border of the mandibular arch show
localized proliferation of the ore' ectoderm resulting in
the formation of a horse-shoe shaped band of tissue
called the dental lamina (figl). This dental lamina ploys
an important role in Ihe development of the dentition.
The deciduous teeth are formed by direct proliferation

Development of Dentition
and Occlusion
of the dental lamina. The permanent molars develop as
a result of its distal proliferation while the permanent
teeth mat replace deciduous teeth develop from a
lingual extension of the dental lamina. Thus all teeth
originate from the denial lamina.
. '.-'-V-V •'.■"•".v'.vVl
The ectoderm in certain
areas of the dental lamina proliferates and forms
knob-like structures that grow into the underlying
mesenchyma. Each of these knobs represents a future
deciduous tooth and is called the enamel organ. The
enamel organ passes through a number o~ stages
ultimately forming the teeth. Based on the shape of the
enamel organ, the development of teeth con be divided
into three stages. They are the bud, cap and the bell
stage.

Fig 1 Dental larnino

BUD STAGE The stellate reticulum expends further due to
39 z Orthodontics - The Art and Science
continued accumulation of intra-cellularfluid. The cells
This is the initial stage of tooth formation where the
of this area are star shaped, having large processes
enamel organ resembles a small bud (fig 2.a). During
that anastomose with those of adjacent cells. As the
the bud stage, the enamel organ consists of
enamel formation starts, the stratum reticulum
peripherally located low columnar cells aria centrally
collapses to a narrow zone thereby reducing the
located polygonal cells. Tne surrounding
distance between the outer enamel and inner enamel
mesenchymal cells proliferate, which result in their
epithelium.
condensation in two areas. The area of condensation
The cells of the outer enamel epithelium
immediately below the enamel organ is the dental
flatten to form low cuboidal cells. The outer enamel
papilla. The ectomesenchymal condensation that
epithelium is thrown into folds which are rich in
surrounds the tooth bud and the dental papilla is the
capillary network. This provides a source of nutrition
dental sac. The dental papilla as well as the de.ntol sac
for the enamel organ. Before the inner enamel
are not well defined during the bud stage. They
epithelium begins to produce enomel, the peripheral
become more defined during the subsequent cap and
cells of the dental oapilla differentiate into
bell stages. The cells of the dental papilla form the
odontoblasts. They are cuboidal cells that later
dentin and pulp while the dental sac forms cementum
assume a columnar form and produce dentin.
ond periodontal ligament.
The dental sac exhibits a circular
CAP STAGE arrangement of its fibres and resembles a copsule
around the enamel organ. The fibres of the dental sac
7r*9 tooth bud continues to proliferate resulting in c cap form the periodontal fibres that span between the root
shaped enamel organ (fig2.b). This is crcccterized by a and bone. The junction between the inner enamel
shallow invagination on the ■j-rier surface of the bud. epithelium and odontoblasts outlines the future
The outer cells of the cap covering the dentino-enomel junction.
coTvezrty are cuboidal and are called the outer enamel
epithelium. The cells lining the concavity of the cap
become tall columnar and are referred to as the inner
enamel epithelium. The central area of the enamel
organ between the outer ond inner enamel epithelium
which initially consisted of polygonal cells, accquire
more inter-cellular fluid and forms a cellular network
called the stellate reticulum. The stellate reticulum
reveals a branched network of cells. The
ectomesenchymal condensation i.e. the dentol papilla
and dental sac are pronounced during this stage of
dental development.
BELL STAGE

Due to continued uneven growth of the enamel organ it

acquires a bell shape (fig 2.c). The celfs of the inner
enamel epithelium differentiate prior to amelogenesis
into tall columnar cells called ameloblasts which lay
down enamel. The cells of the inner enamel epithelium
exert a strong influence on the underlying
mesenchymal cells of the dental papilla.
A few layers of flat squamous cells are seen
between the inner enamel epifhelium and the stellate
reticulum. This layer is called the stratum intermedium.
It is believed to be essential for enamel formation.
 Fig 2 (A) Bud iloge [3) Ccp stage \C; Ball stogo (D) Root formation

ROOT FORMATION 4. The permanent dentition period.

Root development begins after -he dentin and enomel

formation reaches the future cemento- enamel junction.
The outer and inner enamel epithelium join and form a
sheath that helps in molding the shape of the root. This
sheath is called the Hertwig's epithelial root sheath.
PERIODS OF OCCLUSAL DEVELOPMENT

Occlusal development can be divided into Ihe following

developmental periods:
1. Pre - dental period.
2. The deciduous dentition period.
3. The mixed dentition period.

49
 Fig 3 G u-n pads (A) Maxillary (B; Mcmdi bu la'

PRE - DENTAL PERIOD there is a complete over jet all around. Contact occurs
between the upper and lower gum pads in Ihe first
This is the period after birth during which the neonate
molar region and a space exists between them in the
does not have any teeth. It usually lasts for 6 months
anterior region (fig 4). This infantile open bite is
after birth.
considered normal and it helps in suckling.
Gum Pads
The alveolar processes at the time of birth are known
as gum pads. The gum pads arc pink, firm and are
covered by a dense layer of fibrous periosteum. They
are horse-shoe shaped and develop in two parts (fig 3).
They are the labio- buccal potion and the lingual
portion. The two portions of the gum pads are
separated from each other by a groove called the
dental groove. The gum pads are divided into ten
segments by certain grooves called transverse
grooves. Each of these segments consists of one
Fig ^ Relation between j c per and lower gum pods o I birth
developing deciduous tooth see.
The gingival groove separa^s the gum pad
from the palate and floor ol the mouth. The transverse
groove between the canine and first deciduous molar
segment is called the lateral sulcus. The lateral sulcii
ore useful in judging the :nter-arch relationship at a very
early stage. The lateral sulcus of the mandibular arch is
normally more distal to that of the maxillary arch.
The upper and lower gum pads ore almost
similar to each other. The upper gum pad is both wider
as well as longer than the mandibular gum pad. Thus
when the upper and lower gum pads are approximated,
The status of dentition Spacing In deciduous dentition
Tne neonate is without teeth for about 6 months cf life. Spacing usually exists between the deciduous teeth.

AT birth the gum pads are not sufficiently ^ide to These spaces are called physiological spaces or
Development ofdevelopmental
Dentitionspaces
and (fig
Occlusion 41
5). The presence of spaces
cccommodate The developing incisors which are
crowded in their crypts. During the first year of life the in tne primary dentition is important for the normal

gum pads grow rapidly permitting the incisors to erupt development of the permanent dentition. Absence of

in good alignment. spaces in the primary dentition is an indication that

Very rarely teeth are found to have erupted ct crowding of teeth moy occur when the larger

the time of birth. Such teeth that are present at the time permc.nent teeth erupt.

of oirtn are called nctal teeth. Sometimes teeth erupr at Spacing invariably is seen mesial to the

an early age. Teeth that erupt during the first month of maxillary canines and distal to the mandibular canines

age are called .neonatal teeth. The ncral and neonatal (fig 6). These physiological spaces are called primate

teeth are mostly loccted in the mandibular incisor spaces or simian spaces or anthropoid spaces as they

region and show a familial tendency. ore seen commonly in primates. These spaces help in
placement of the canine cusps of the opposing arch.
THE DECIDUOUS DENTITION PERIOD

The initiation o" primary tooth buds occurs during the

first six weeks of intra-uterine life. Tne primary teeth
begin to erupT at the age of about 6 months. The
eruption of all primary teeth is completed by 2 1/2 • 3
1/2 years of age when the second deciduous molcrs
come into occlusion.

Eruption age and sequence of

deciduous dentition ■Sg 6 ^rirnatft spores
The mandibular central incisors are the first teeth to
erupt into the oral cavity. They erupt around 6 -7
months of age. The average age of eruption of the
deciduous dentition is given in Table I. The timing of
tooth eruption is nighly variable. A variation of 3 months
from the mecn age has been accepted as normal. The
sequence of eruption of the deciduous denlition is : A -
B-D-C-E.
The primary dentition is usually established
by 3 years of age on eruption of the second deciduous
molars. Between 3 - 6 years of age, Ihe dental arch is
relatively stable and very few changes occur.

m
Fig 5 Spacing in dco'duous dentition
 52 z Orthodontics - The Art and Science
Illl
ssssssj

flush terminal plane

The mesio - distal relation between the distal surfaces
of the upper and lower second deciduous molars is
called the terminal plane. A normal feature of
deciduous dentition is a flush terminal plane where the
distal surfaces o1 the upper and lower second
deciduous molars are in the same vertical plane.

Deep bite
A deep bite may occur in the initial stages of
development. The deep bite is accentuated by the fact
that the deciduous incisors are more upright than their
successors. The lower incfsal edges often contact the
cingulum arec of the maxillary incisors. This deep bite
is later reduced due to the following factors.
a. Eruption of deciduous mo'ars.
b. Attrition of incisors.
c. Forward movement of the mandible due to
growth.

THE MIXED DENTITION PERIOD

The mixed dentition period begins at aporoxi.motely 6

years of age with the eruption of the first permanent
molars. During the mixed dentition period, the
deciduous teeth along with some permanent teeth are
present in the oral cavity.
The mixed dentition period can be classified
into three phases.
1. First transitional period
2. Inter-transitional period
3. Second transitional period

First transitional period

The first transitional period is characterized by the
emergence of the first oermanent molars and Ihe
exchange of the deciduous incisors with the
F'g 7 (A; Flusl- termircl plcne (B) Dislal step terrninol plane (Cj Mes
permanent incisors. cl step termina clone
 Development of Dentition and Occlusion \ 43
Emergence of the first permonont molars: The leeway space. This occurs in the late mixed dentition
mandibular first molar ist'ne first permanent tooth to period and is thus called late shift.
erupt at around 6 years of age. Tne location and S. Mesra/ step terminal plane : In this type of relationship
relationship of the first permanent molar depends the distal surface of the lower second deciduous molar is
much upon the distal surface relationship between the more mesial than that of the upper (fig 7.c). Thus the
upper ond lower second deciduous molars. The first permanent molars erupt directly into Angle's Class I
permanent molars are guided into ihe dental arch by
occlusion. This type of mesial step terminal plane most
the distal surface of the second deciduous molars. The
commonly occurs due to early forward growth of the
mesio-distal relation between the distal surfaces of the
upper and lower second deciduous moiars can be of
three types.

A. Piush terminal plane: The distal surface of the

upper and lower second deciduous molars are in one
vertical plane (fig 7.a). This type of relationship is
called flush or vertical terminal plane. This is a normal
feature of the deciduous dentition. Thus the eruping
first permanent molars moy also be in a flush or end on
relationship. Forthe transition of such an end on molar
relation to a Class I molar relation, the lower molar nas
to move forward by about 3 - 5 mm relative to the upper
molar (fig 8).This occurs by utilization of the
physiologic spaces and leeway space in the lower arch
Fig 8 (AJ Ecrly shift of -ha erupting firs' permanen? molars moving
and by differential forward growth of the mandible. B
utilizing the primate spaces (B) Lata shift by utilization of tha leeway
The shift in lower molar from a flush terminal spaco
plane to c Class I relotion can occur in two ways. They
are designated as the early and the lale shift.
Early shift occurs during tne early mixed
dentition period. The eruptive force of the first
permanent molar is sufficient to push the deciduous
first and second molars forward in the arch to close the
primato space and thereby establish a Class I molar
relationship. Since this occurs early in the mixed
dentition period it is called early shift.
Many children lock the primate space

and thus the erupting permanent molars are unable to

move forward to establish Class I relationship. In these
cases, when the deciduous second molars exfoliate
the permanent first molars drift mesially utilizing the

43
 44 z Orthodontics - The Art and Science

mandibular arch. The incisal liability is overcome by

the following factors :

A. Utilization of intera'enfa/ spaces seen in

primary dentition : The physiologic or the
developmental spaces tha* exist in -he orimary
dentition ore utilized *o partly accojnt for the incisal
liability. The oermanent ircisors are much more easily
accommodated in normal aligrment in cases exhibit'ng
cdequate inter-dental spaces than in an arc.n thaA has
no space.

S. Increase in inter - ccmirte width : During the

transition from the primary incisors to 'he permanent
incisors an increase in in-er-canme width of both the
maxillary as well as the mandibular arches has been
obse^/ed. This is on important fcctor which allows the
much larger permanent incisors to be accommodated
in the arch previously occupied by tne decidjous
incisors.

C. Cna.nge i.n incisor inc/ination : One of 'he

mandible. H the differential growth of the mandible in a differences between deciduous crd permanent
forward direction persists, it car lecd to an Angle's incisors is their inclination. The primary incisors are
Class III molar relation. If Ihe forward mandibular more upright than Ihe permanent incisors. Since Ihe
growth is minimal, itccn estcblish a Class I molar permanen- incisors erupt more labially inclined they
relationship. tend to increase Ihe dental arch perimeter. This is
C. Dis.'ai step fermina/ p/ane : This is characterized by another factor that helps in accommodating the larger
the distal surface of the lower second deciduous molar permanent incisors.
being more distal to that of the upper (fig 7.b). Thus the
Inter • transitional period
erupting permanent molars maybe in Angle's Class II
occlusion. In this per'od the maxillan/ and mandibular arches

The exchange of incisors ; During the first transitional consist of sefs of deciduous and permanent teeAh.

period the deciduous incisors are replaced by the Between the permanent incisors and Ihe first
permcrent molars are the deciduous molars and
permanent incisors. The mandibular central incisors
canines. Tnis phase during the mixed dentition
are usually the first to erupt. The permanent incisors
are considerably larger than the deciduous teeth they
replace. This difference between the amount of space 'J U
needed
for the accomodation of the inciso's and the
cmountof space available for this is called incisal
liabi ity. The irciscl liability is roughly about 7 mm in
the maxillan/ arch and about 5 mm in the
Completed Hard Tissue Formation Amount of Enamel Enamel Completed Eruption Root

Begins Formed at Birth

PRIMARY DENTITION

Maxillary
Central mclsor 4 mos. in utero Five sixths 1 1/2 mos 71/2 mos 1 1/2 Yrs
Laterai incisor 4 1/2 mos. in utero T//o thirds 21/2 mos 9 mos 2 Yrs
Cuspid 5 mos. in utero One third 9 mos 18 mos 3 1/4 Yrs
First molar 5 mos. in utero Cusps united 6 mos 14 mos 2 1/2 Yrs
Sccond molar 6 mos. in utero Cusp tips still isolated 11 mos 24. mos 3 Yrs

Mandibular
'h
Central incisor 4 1/2 mos. in utero Three fifths 2 1/2 mos 6 mos 1 1/2 Yrs
Lateral incisor 4 1/2 mos. in utero Three litths 3 mos 7 mos 1 1/2 Yrs
Cuspid 5 mos. in utero One third 9 mos 16 mos 31/4 Yrs
First molar 5 mos. in utero Cusps united 5 1/2 mos 12 mos 2 1/4 Yrs
Second molar 6 mos. in ulero Cusp tips stilt isolated 10 mos 20 mos 3 Yrs
 Amount of Enamel Eruption Root
Hard Tissue
Tooth Enamel Complet Completed
Formation Begins
Formed at Birth ed

Maxillary
7 - 8 Yrs 10 Yrs
Central incisor 3 - 4 mos.
8 - 9 Yrs 11 Yrs
Lateral incisor 10-12mos.
Cuspid 4 -5 mos.
First bicuspid 11/2 - 1 3/4 Yrs.
Second bicuspid 2 - 2 1 / 4 Yrs
First molar at birth
Second molar 21/2 - 3 Yrs

Mandibular
Central incisor 3 - 4 mos.
Lateral incisor 3 - 4 mos.
Cuspid 4 -5 mos.
First bicuspid 13/4 - 2 Yrs.
Second bicuspid 21/4 -2 1/2 Yrs
First molar at birth
 Development of Dentition and Occlusion 47

12 Yrs 13-15 Yrs 1 0 - 1 1 Yrs

12 -13 Yrs 1 0 - 1 2 Yrs
12-14 Yrs 6 - 7 Yrs 9-10

Yrs 11- 13 Yrs t4

- 1 6 Yrs
Second molar 21/2 - 3 Yrs

Some times a trace

6 - 7 Yrs 9 Yrs
7 - 8 Yrs 10 Yrs
9 - 1 0 Yrs 12-14
'fW/ififj'//'1': Yrs 10 - 12 Yrs 1 2 - 1 3 Yrs
1 1 - 1 2 Yrs 1 3 - 1 4 Yrs
Some times a trace 6 - 7 Yrs 9 - 1 0 Yrs
1 1 - 1 3 Yrs 1 4 - 1 5 Yrs
 Development of Dentition and Occlusion 48

Fig 10 Ugly duckling stage > the development of dentition. Note l ow lho erupting ccninc causcs the displacement of 'he roo'S
of the latera arc central ncisor mesially resuming in a midline diastema which corrects inter by f jrtner erjp-ion of the canines.
 Orthodontics - The Art and Science

period is relatively stable and no change occurs.

molars. Tne mean eruption dates of the permanent

The second trans/t/o n a/ period dentition is given in Table II.

The eruption sequence of the permanent
The second transitional period is characterized by the
dentition may exh ib it va riation. The freq uent ly see n
replacement of the deciduous molars and canines by
sequences in the maxillan/ arch are : 6 - 1 - 2 -
the premolcrsand permanent cuspids respectively.
4 - 3 - 5 - 7 o r 6 - 1 - 2 - 3 - 4 - 5 - 7 .
The combined meslo-distc! width of the permanent
In case of the mandibular arch the sequence
canines and premolars is usually 'ess than that of the
is :
deciduous canines and molars. The surplus space is
6 - 1 - 2 - 3 - 4 - 5 - 7
called leeway space of Nance (fig 9). The amount of
o r
leeway space is greater in the mandibular arch than in
6 - 1 - 2 - 4 - 3 - 5 - 7 .
the moxillary arch. It is about 1.8mm (0.9 mm on each
side of the arch) in the maxillory arch ond about 3.4mm
(1.7mm on each side of the arch) in the mandibular fteferences
arch. This excess space available after the exchange
1. BMojii SI : Dsrto' Anctomy, Histology and Development. Arya
of the deciduous mo'ars and canines is utilized for publishirg house. New Delhi, 1998
mesial drift of the mandibular molcrs to establish Class 2. Raoerr E Mayers : Hard book of Orthodontics, Year book
medicol publishers, he/988.
I molor relation.
3. Ten cote AR : Oral Hista'ogy : Development Structure and
The ugly duckling stage : Sometimes a transient or self Function, C.Wosby, St Louis,198C
A. Van der Lir den : Developmen* of ine dentition, gu ntessence,
correcting malocclusion is seen in the maxillary incisor
Chicago, 1983
region between 8 - 9 years of age. This is a particular 5. Van rier Lirden, F.RG.Vi. and DuteHco HS : Development cf the
human dentition: An ctlos : Ho'per and Rev/, 1976
situation seen during the eruption of the permanent
canines. As the developing permanent canines erupt,
they displace the roots of the lateral incisors mesially.
This results is transmitting of the force on to the roots
of the central incisors which also get displaced
mesially. A resultont distal divergence of the crowns of
the two central incisors causes a midline spacing. This
situation has been described by Broadbent os the ugly
duckling stage as children tend to look ugly during this
phase of development. Porents are often
apprehensive during this stage and consult the dentist.
This condition usually corrects by itself when the
canines erupt and the pressure is transferred from the
roots to the coronal area of the incisors.
THE PERMANENT DENTITION PERIOD

The permanent dent'tion forms within the jaws soon

after birth, except for the cusps of the first permanent
molars which form before birth. The permanent
incisors develop lingual or palatal to the deciduous
incisors and move labiallyas they erupt. The premolars
develoo below the diverging roots of the deciduous

«'/I
 T
he orofacial region perorms a wide range of
-unctions such cs mastication, swallowing,
respiration and speech. It is now an accepted
fact tnat form and function are interrelated. Normal
development of The orofacial region is to a large extent
dependent upon normal function.Tne functions of the
oro-facicl region include mastication, swallowing,
respirotion, speech, facial expression and maintanance
of mandibular position. In this chapter we study some of
the important functions of Ihe oro-facicl region end their
role on development.
MASTICATION
Mastication is a complex activity aimed at breaking
down and insalivalion o; tne food, preparatory to
swallowing. In infants, the food is taken in by sucking as
their diet is mostly confined to liquids. Thus masticction
in the true sense is nor present in infants. As the infant
switches on to solid or semi-solid food, it quickly lecrns
Crushing phase
Tne food is crushed by equal activity on bo+h sides of
the dentcl arch. Tne crushing rarts with a high velocity
and gradually slows down.
Tooth contact
During this phase tne teeth come in contact and
signifies the end of the crushing phase.
Guiding phase
During this phase, the contcct becomes unilateral and
there is transgression of the mandibular mo'ars across
the maxillary counterparts.
Centr/c occlusion
The teeth come to a definite and distinct stop.
DEGLUTITION
Deglutition or swallowing is an im portent function
carried out by the stomatognathic system. The
swallowing pattern in infants is different from that seen
in adults. Thus two main forms of swallowing are
recognised. They are the infantile swallow and the
mature swallow.
H3
to use the lips to keep the food from being forced out of
The mouth. The bolus of food is mixed with salivo by
the oction of the tongue and is forced between the gum
pads or the occlusal surfaces of the erupting teeth.
Tne mastication of food in an adult occurs in
the following six phases as outlined by iViurphy.
Preparatory phase
During this phese, the ingested food is positioned by
the tongue towards the chewing side and the mandible
moves to the same side.
Food contact
This phase is characterised by a momentary pause in
the mastication. During this period, the sensory
rcceptors evaluate the apparent viscosity of the
ingested food and the probable load on the masticalory
apparatus.
infantile swallow
The ability to feed from the breast is oresent in the new
born child. During the process of suckling, the nipple is
drawn into the mouth by negative pressure from within.
The tongue lies over the lower gum pads and protrudes
between the nioplc and lower lip.
The milk is directed continuously to the
pharynx by an automatic peristaltic movement of the
tongue and mylohyoid muscle. During this process,
regular breathing continues. The milk passes between
the fa u c ia I pillars and the lateral cnannels of the
pharynx. Any excess milk in the mouth dribbles down
the chin.
The chorac'eristics of cn infantile swcltaw as
outlined by Moyers is as follows :
a. The jaws are apart and the tongue is placed
between the upper and lower gum pods.
b. The mandible is stabilised by the contraction of the
muscles of the seven-h cranial nerve and the
interposed tongue.
c. The swallow is guided and to a large extent
controlled by sensory interchange between he lios
and tongue.
As the infant begins to eat solid food, there is
a distinct change in tne swallowing pattern. The tongue
is contained within the denial arches and the mandiblo
is ro longer protruded. This here Ids tne onset of the
mature swallow. Functional Development x 51
Mature swallowing
Mature swallowing is seen after a year of life. The
infantile swallow gradually disappecrs with the eruption
of the buccal teeth in the primary dentition. The
cessation of Ihe infanti e swallow and the appearance
of the mature swa low occur groduolly. During the
transitional period, characteristics of both; infantile and
mature swa low ccn be observed.
Deglutition occurs in four phases :
1. The preparatory swallow
2. The oral phase
3. The pharyngeal phase
4. The oesophageal phase

Trie preparatory swa'fow r The food after mastication is

assembled asa compact bolus on the dorsum of Ihe
tongue. In order ^o achieve this the teeth are parted a
little and the cheek muscles contract. The teeth are
then broug.nt into occlusion to stabilize the jaws and to
close the oral ccvily properly and isolate it from the
labial vestibule. The posterior aspect of the tongue
presses agains* the soft palate to isolate the oral cavity
from the pnarynx. Thus at this time, the
 spontaneously at birth and is oided by Ihe posture ol the
mandible and hyoid bone. Normal oro-facial
development is to a large extent dependent upon
presence of normal respiration.

Fig 1 Pariant habituated to noj-h breathing Note the ■larroWing ot the

mcxillary arch producing posterior cross b te. lateral cephalogram rcvecls a
land face and vertical growth potfern.

oral cavity forms a sealed unit.

The oral phase : The soft palate is raised to seal off the
nasal cavity arid Ihe posterior pari ol me tongue drops
down. These movements create a smooth path for the
bolus as it is pushed into me pharynx by tne peristaltic
action ol the tongue.

The pharyngeal phase ; The pharyngeal phose begins

as soon as the food pesses through the faucial pillars.
As the food reaches Ihe pharyngeal walls, there is a
reflex upward movement of the entire pharyngeal
complex. When the pharyngeal walls touch the soft
palate a peristaltic movement sets up to move the food
down.

The oesophageal phose : This phase commences as

soon as Ihe food passes the cricopharyngeal sphincter.
Peristaltic activity of the oesophogcal wolls occur to
pass tne food into the stomach.
The tongue and the palate return to their
original position to start the next cycle.

RESPIRATION

Respiration is an inherent reflex activity. The newborn

infant is basically a nasal breather. Breathing is evoked
 Functional Development x 53

Fig ? Paiienl v/'th o n Icy og ossio of tongue. Note -he na-row mcxilla'y arch ard widening O" mcrcibular orch dje to lowered tonouo position

In potients having partial or total nasal PASSIVE MUSCLE FUNCTION

obstruction, nasal breathing may not be possible. A number of muscles exert force on the developing
These patients breathe through the mouth. The jaws. There has been obsen/ed to be a strong
alteration in breathing pattern brings obout a lowered inter-depend e nee between the bone and the muscles.
mandibular and tongue oosition. Thus theoro-facial Although the bone is one of the hardest tissues in the
muscular balance is lost leading to abnormal body, it is most responsive to environmental factors
development of the dental arches. including musculature.

SPEECH

Speech is largely a learned activity. The first sounds

produced by a child is often the baby cr/. The
mechanism of crying is intimately related to respiration
with laryngeal and pharyngeal coordination.
Speech is an acquired skill that involves
production of basic notes in the larynx known as
p'nonalion, and modification of these sounds by
changing the shape of the cavities in Ihe mouth, nose
end throat, which is known as articulation.
A lorge number of muscles are involved in
production of speech. They include the muscles of the
wall of Ihe torso, resp;ratory tract, the pharynx, the soft
palate, the tongue, lips and foce. Speech does not
moke gross demands on the oeri-oral musculature and
hence speech defects are rarely a cause for
malocclusion.
 The teeth and the supporting structures are
blanketed from all directions by muscles. Thus -«e
integrity of the denrol arches and the relationship of the
teeth with each other and with sseth of the opposing
arch is to a large extent nfluenced by muscles.
The dentition is covered by a continuous
muscle band that encircles it starting with the fibers of
the lips, the muscles run laterally and posteriorly
around the comer of the mouth, joining the fibers of
buccinator which insert into the pterygomandibular
raphoe. These fibers intermingle with the fibers of the
superior constrictor and continue posteriorly and
medially to anchor at the origin of the superior
constrictor i.e. at the pharyngeal tubercle. The
dento-alveolar region is thus encircled from the buccal
aspect by this band of muscles and this phenomenon
is referred to as the bu cc i n otor mechanism.
Opposing the buccinator mechanism rrom
within is a very powerful muscular organ, me tongue.
Tne dentition is in a constant state of dynamic
equilibrium. There is o balance of forces
holes assumed a linear form in the direction of the
bony trabeculae. These were called Benninghoff's
lines or trajectories which indicate • the direction of Ihe
functional stresses.
Trajectories of the maxilla
The trajectories of Ihe maxilla can be broadly
classified as vertical and horizontal trajectories. The
vertical trajectories include the fronto-nasal bullress,
the malar-zygomatic buttress and the pterygoid
buttress.
Fronto-nasaf buttress : This trajectory originates from
Ihe incisors, canines and the first maxillory premolar
and runs craniallyalong the sides of the piriform
aperture, the crest of the nasal bone and terminates in
the frontal bone.
Molar- zygomoi/c buttress : This trajectory transmits
the stress from the buccal group of teeth in three
pathways:
a. Through the zygomatic arch to the base of the
skull.
b. Upward to the frontal bone through the lateral
walls of the orbit.
c. Along the lower orbital margin to join the upper
port of the fronto-nasal buttress.

?:g 3 Trajeriores of force (A) Fronto-noso buttress ■S/

Molar-zygotrolic buttress (C) Pterygoid buttress D. Mend ibu la r
trajecto'ies

between muscles that is believed to influence the

position and stability of the dentoolveolar complex.

TRAJECTORIES OF FORCE

The trojectorial theory of force states that the lines of

orientation of the bony trobcculae correspond to the
pathways of maximal pressure and tension ond tnal
bone trabeculae are thicker in the region where the
stress isgreoter.
Benninghoff studied the naturol lines ol
stress in the skull by piercing small holes into a fresh
skull. Later as skulls were dn'ed, he observed that the
 Pterygoid buttress : This trajectory transmits the 1. Graber TV. : Orthodontics : Principles end practice. WB
Saurdsrs. 198S
stress from the second and third molars to the bcse of 2. Guytcn AC, Hall JE: Tex'book of Medical Physiology,
Saunders. 1996.
P'ofi-t VV3: Con-err pa ra'v Orhedontics, St Louis, CV Mosby,
55 z Orthodontics - The Art and Science 3.
1986.
the skull. 4. Rcoert E Vioyers : Hand boc< ol Orthodontics, Year book
medico I publ'she's, inc. 1988.
The horizontal trcjectories of the maxilla
5. Salzman JA : Practice of Orthodontics, JB lico'ncot: com cany.
include : 1966

a. Hard palate
b. Orbital ridges
c. Zygomatic arches
d. Palatal bones
e. Lesser w i ng s of sphenoid

TRAJECTORIES OF THE MANDIBLE

A line of stress extends from one condyle to the other
passing along the symphysis. A number of vertical
trajectories rcdiate down below the roots of the
mandibular teeth.
The lower border of the mandible and the
mylohyoid ridges are the other prominent buttresses of
the mandible.

WOLFF'S LAW OF TRANSFORMATION OF

BONE

Bone, unlike other connective tissues responds to mild

degrees of pressure and tension, by changes in its
form. Those changes are accomplished by means of
resorption of existing bone and deposition of new bone.
This may take place on the surface of the bone under
the periosteum, or in the case of cancellous bone on
the surface of the trabeculae, or on the walls of marrow
spaces or air sinuses. The architecture of a bone is
such that it can best resist the forces which are brought
to bear upon it with the use of as little tissue as possible.
In this respect bone is more plostic than any other
connective tissue. It has been found that bone is
formed in just the quantity and shape that will enab'e it
to withstand tne physiccl demands made upon it, with
the greatest amount of economy of structure. This is the
basis of Wolffs
law of transformation of bone
Thus, not only is the quantity of bone tissue
the minimum that would be needed for function
requirements, but olso its structure is such that it is best
suited for the forces exerted upon it. If a long bone such
as the femur is cut open, it will be found that dense
cortical bone is on the outside and spicules ot the cance
lous bone within are arranged in such a way that they
support the cortical bone along well defined paths of
stress and strain.

References
55
T
he study of occlusion is on important aspect of Physio/ogic occ/usr'ort ; This refers to an occlusion that
d entistry. The study and practice of most deviates in one or more ways from ideal yet it is well
branches of dentistry should be based on a adapted to that particular environment, is esthetic and
strong foundation of the knowledge of occlusion (fig 1). shows no pathologic
Orthodontics is no exception to this as great many
changes occur in the occlusion during orthodontic
thcropy. The orthodontist should know what constitutes
normal
occlusion
in order to
be oble to
recognize
abnormal

Basic

occlusion.
The term 'occlusion' has both static and
dynamic aspects. Static' refers to the form, alignment
and articulation of teeth within and between the arches,
and the relationship of teeth to their supporting
structure. 'Dynamic' refers to the function of the
slomatognathic system as a whole comprising teeth,
supporting structure, temporomandibular joint,
neuromuscular and nutritive systems. The terms
'normal' and malocclusion'as used in orthodontics refer
mainly to the static aspect or the form of the dentition.
Angle defined occlusion as the normal
relation of Ihe occlusol inclined planes of the teeth
when the jaws are closed. This definition is an
over-simplification of what it actually constitutes.
Occlusion is a complex phenomenon "involving the
teeth, periodontal ligament, the jaws, the
temporomandibular joint, the muscles and the nervous
system. The aim of this chapter is to throw light on
normal occlusion and to highlight the orthodontic
aspects of occlusion.

TERMINOLOGY

ldea( ocelusion : It is a pre-conceived theoretical

concept of occlusol structural & functional relationships
that include idealized principles & characteristics that
an occlusion should have.
manifestations or dysfunction. the lower teeth while the lower stamp cusps fit into all
the upper fossae except the distal ones of bicuspids.
Ba/anced occlusion : An occlusion in which balanced
This kind oz a-rangement where contacts occur
and equal contacts are maintained throughout Ihe
between single opposing teeth is called a cusp-fossa
entire arch during all excursions of the mandible.
occlusion or a tooth to tooth arrangement.
Fufrcffonaf occlusion ;• It is defined as an arrangement
of teeth which will provide the highest efficiency during Cusp-embrasure occiusion
all the excursive movements of Ihe mandible which are Another type of occlusion between the upper and
necessary during function. lowerteeth is called the cusp-e m bras u re or tooth to
ihorapewtic oco'us/on : An occlusion that has been two teeth occlusion. In this type of arrangement, each
modified by appropriate therapeutic modalities in order tooth occludes with two oppos'ng teeth.
to change a non-physiological occlusion to one that is
tMAGINARY OCCLUSAL
at least physiologic if not ideal.
PLANES & CURVES
Travrnotic occ/usion : Trcumatic occlusion is an
abnormal occlusal stress whicn is capable of producing
Curve of Spee
or has produced an injury to the periodontium.
It refers to the antero-posterior cun/ature of the
Trauma from occ/usion : It is defined as peridontial
occlusal surfaces beginning at the tip of the lower
tissue injury caused by occlusal forces through
cuspid & following the cusp tips of *he b'cuspids &
abnormal occlusal contacts.
molars continuing cs an arc through the condyle (fig 1

TYPES OF CUSPS .a}. If the curve is extended, it would form a circle of

about 4 inch diamete'.
The human posterior teeth constitute two types of
cusps. They arc the centric holding cusps and the non-
supporting cusps.

Centric holding cusps

The facial cusps of mandibular & palatal cusps of
maxillary posterior teeth arc called the centric holding
cusps. They occlude into Ihe central fossae and
marginal ridges of opposing teeth. They are also called
the stamp cusps.

Non - supporting cusps

The maxillary buccal and mandibular lingual cusps are
called non-supporting cusps. They contact and guide
tne mandible during lateral excursions & sheer food
during mastication. Hence they are also called
shearing orgu'dirig cusps.

ARRANGEMENT OF TEETH IN HUMANS

Human dentition exhibits two types of -ooth

arrangement when the uaper end lower teeth occlude
wit.n one another. They are :
a. Cusp- fossa occlusion
b. Cusp-embrasure occlusion

Cusp- fossa occlusion

In this type of occlusion, the stamp cusp of one tooth
occludes in a single fossa of a single opponent. The u o
per stamp cusps fit into all exceol the mesial fossae of
 The curve results from vcriatiors n axial
alignment of the lower reeth. Tne long axis of each
lower tooth is aligrcd nearly parallel TO its .--dividual arc
of closure around the condylar axis. This requ>es a
gradual progressive increased mesial tilting ofreetn
towards molars which creates •ne curve of Spee.

Curve of Wilson
This is a curve that contacts ihe buccal & lingual cusp
tips ol Ihe mandibular buccal teeth (fig 1 .b}. Tne curve
of Wilson is medio-lateral on eccn side of the arch. It
results from inwerd inclination of •ne lower posterior
teeth. Cu've of Wilson nclps in two wcys :
a. Teeth are aligned parallel to -he direction of medial
pterygoid for optimum resistance :o masticctory

A B
Fig {A) Cur/8 of Spee (B; Curve o: Wilson

forces.
b. The elevated buccal cusps prevent food from
going past the occlusal table.

Curve of Monson
The cun.'e of Monson is obtained by extending the
curve of Spee & curve of Wilson to all cusos & incisol
edges.
CENTRIC RELATION & CENTRIC
OCCLUSION

Centric relation is the relation of The mandible to tne

maxilla when the mandibular condyles are in tne most
superior and retruded position in their glenoid fossa
with the articular disc properly interposed. Centric
relation is clso called ligamentous position or terminal
hinge position. At centric relation both the condyles are
simultaneously seated most superiorly in their glenoid
fossa. In trying lo obtain centric relation the mandible
may be forced too far back, thus the term 'unstrained'
appears in some definitions.
Centric occlusion is that position of Ihe
mandibular condyle when the teeth ore in maximum
intercuspation. Centric occlusion is also called
inter-cuspal position or convenience occlusion
Centric relation and centric occlusion should
coincide in order to have perfect harmony between the
teeth, the temporomandibular joint and the
neuromuscular system. Some studios have shown thai
majority of the population have a maximum
inter-cuspation 1-2 mm toward of centric.
 Posterior centric contacts

The posterior centric contacts consist of the fccial

range of contacts and Ihe lingual range of contacts.
Fccicl range of posteriorcentre contacts involve the
mandibular facial cusp tips contacting the central
"fossae and mesial marginal ridges of the opposing
maxillary teeth. Lingual range of posterior centric
contacts involve the maxillary lingual cusp tips
contacting the central fossae and distel marginal
ridges of the opposing mandibular teeth.

Anterior teeth have only one range of centric contacts

and are in line with tne facial range of posterior centric
contacts.
Posterior centric contacts result in oxiolly
directed forces as convex cusp tips occlude on an
opposing tooth area thot is perpendicular to the force.
However centric contacts often occur on inclines of
posterior teeth. These contacts that occur on inclines
are called poded centric contacts. The contacts
occurring on inclines should be balanced by on equal
contoct on an opposing inclinc to resolve the forces in
an axial direction. If Ihe contact occurs on two inclines,
the contoct is termed bi-poded contact. Contacts thot
Fig 2 Centric contacts
occur on three inclines are called tri-poded contacts.
Maximum intercuspation can also occur Contacts that occur on four inclines are called
without the condyles being in centric. This is called quadro-poded conlocls.
maximum intercuspation, habitual occlusion or
ECCENTRIC OCCLUSION
acquired occlusion.

CENTRIC CONTACTS Eccentric occlusion refers to contact of teeth that

occurs during movement of the mandible. Eccentric
They are areos of the teeth that contact the opposing occlusion can be of two types :
teeth (fig 2). Centric contacts have been classified into a. Functional occlusion
posterior centric contacts and anterior centric contacts. b. Non-functional occlusion
Anterior centric contacts
Functional occlusion
Functional occlusion (also cclled working side
ocdusion) refers to tooth contacts tnat occur in
segment of Ihe arch towards which the :-cndib!e
moves. F jnctional occlusion can oe of -«•o types:
era/ functional occlusion : It includes tooth
contacts the* occur on canines ond posterior teeth cn
the side towards which rhe mondible moves. Tne latere
I functioncl occlusion can be of two -.oes:
Canine guided occlusion : During lateral -andibular
movement, the opposing upper & '■owe r canines of the
working side contact thereby causing disclusion of oil
posterior teetn on the working & balancing sides.
Conine guided occlusion is usually seen in young
individuals with unworn dentition. In a ccnine guided
occlusion, me mandibular canine cusp tip tracks from
the centric contact point at the mesial marginal ridge
•owards the cusp tip of the maxillary canine.
2. Grouped lateral occlusion : In addition :o canine
guidance, certain other posterior teeth on the working
side also contact during lateral movement of the
mondible. Such a type of contact during lateral
movement is colled grouped lateral occlusion.
Protrusive funcfjono/ occasion ; It includes eccentric
contacts that occur when the mandible moves forward.
Ideally the six mandibular anterior teeth contact along
the lingual inclines of Ihe maxillary anterior teeth while
the posteriors disocclude.
Non-functional occlusion
They are tooth contocts that occur in the segment
awoy from which the mandible moves. For example if
the mandible is moved to the left side, contacts occur
on the right side of the arch.
DISCLUSION
The term disclusion is used to describe disocclusion or
separation'of non-functional posterior teeth during
eccentric motions of the jaw. Disclusion of posterior
Occlusion - Basic Concepts
teeth is brought about by condylar
guidance and incisal guidance
-5
Condylar guidance refers to the downward
movement of both the condyles along the slopes of the
articular eminence during protrusive movements
leading to separation of the posteriors. In case of
lateral movements, the condyle on the non-functioning
side translates toward olong the eminence while the
condyle on the functioning side pivots in its fossa
leoding to disclusion of posteriors on the
non-functional side.
Anterior guidance refers to anterior tooth
functions which separate the posterior teeth during
eccentric motions of the jaw. During protrusive and
lateral movements of the mandible, the lower anterior
teeth track downward from their area of centric contact
towards the incisal edges of maxillary teeth while
disoccluding the nonfunctional posterior teeth.
Condylar guidance has its greatest influence
on discluding the most distal posterior teeth, while the
incisal guidance provides discluding effect on the more
mesial teeth. The condylcr guidance is a fixed
anatomic factor that cannot be controlled by the dentist
while the incisal •guidance can be controlled by
modifying the form and arrangement of the anterior
teeth.
ANDREWS' S/X KEYS TO NORMAL
OCCLUSION
Andrews during the 1970's put forward the six keys to
normal occlusion after studying models of 120 patients
with ideal occlusion. Andrews considered the
presence of these features essential to achieve on
optimal occlusion. The six keys to
F y 3 And'ews six <©ys tc normal occ Lsion Key 1 (A)
deal Class 1 molar ctioniB; Motor relation not Class I
Key 'l (Cj V.esooista crown anci. la-ion cea (D)
iVlesod's'al c'Own engulotien not ide-ol Key 3 (E) Ideal
lobio-lingjal crown rclinat on Key 4 (F| Idecl a ig n merit
of -octh without 'otot'ons ;Gi Rota-ed tooth not sctis'V'ng
key &
 Occlusion - Basic Concepts

:
ig 3 Andrews six <eys to normal occlusion Kay S (H) deal «itncj- spacing |IJ Scaccd deivilion no1 sctisfy'ng key 5 <oy 6 ;ji
Ideal curve of Scee

1 Andrews IF : The six keys to normal occlusion. Am J Orthcd!972 ; 63 : 296

(ft
 normal occlusion are considered under the "lowing
headings :
1. Molor inter-orch relationship
2. Mesio-distal crown angulation
3. Labio-lingual crown inclination
Absence of rotation
5. Tight contacts
6. Curve of Spee

Molar Inter-arch relationship

The mesio-buccal cusp of tne upper first molar should
occlude in the groove between rhe mesial and medial
buccal cusp of the lower first molar. The mesio-lingual Occlusion - Basic Concepts
cusp of Ihe upper first molar should occlude in the
central fossa ol lower first molar. The crown of the
upper first molor must be ongulated so that the distal
marginal ridge occludes with tne mesial marginal ridge
of lower second molcr.

Mesio-distal crown angulation

The second key makes use of a line thai passes clong
the long axis of the crown through the most prominent
part in the center of the labial or buccal surface. This
line is called the long axis of the clinical crown.
For the occlusion to be considered normal,
the gingival port of the long axis of the crown must be
distal to the occlusal part of the line. Different teeth
exhibit different crown angulation.

Labio-ilngual crown Inclination

The crown inclination is determined from a mesial or
distal view. If the gingival area of the crown is more
lingually placed than Ihe occlusal area, it is referred to
as positive crown inclination. In case the gingival area
of the crown is more labially or buccally placed than the
occlusal area it is referred to os negative crown
inclination.
Tne maxillary incisors exhibit a posilive
crown inclination while the mandibular incisors show a
ven/ mild negative crown inclination. The moxillary and
mandibular posteriors have a negative crown
inclination.

(ft
 Absence of rotation
Normol occlusion is characterized by absence of any
rotation. Rotated posterior teeth occupy more space in
the dental arch while rotated incisors occupy less
space in the arch.

Tight contacts
To consider an occlusion as normal, there should be
tight contact between adjacent teeth.

Curve of Spee
A normal occlusal plane according to Andrews should
be flat, with the curve of Spee not exceeding 1.5 mm.

References

M
alocclusion can present itself in malocclusions into simpler or smaller groups. In
numerous ways. Classification involves order to have a system of classification, standords
the grouping together of various should be set up that represent normalcy. The
deviations from the accepted norms should also be
grouped into various smaller divisions or categories.
The advantages of classifying malocclusion
is as follows ;
a. Classification helps in diagnosis and planning
treatment for the patient.
b. Classification helps in visualizing and
understanding tne problem associated with that
malocclusion.
c. Classification helps in communicating the
problem.
d. Comparison of the various malocclusions is made
easy by classification.
TYPES OF MALOCCLUSIONS -
TERMINOLOGIES

Malocclusion can be broadly divided into :

i) Intra-arch malocclusions that include variations in
individual tooth position and malocclusions
affecting a group of teeth within an arch.
ii) Inter-arch malocclusions that comprise of
rnalrelotion of dental arches to one another upon
skeletal bony bases which may themselves be
normally related
iii) Skeletal malocclusions which involve the
underlying bony bases

Malocclusions can occur in various

combinations and therefore it may be very difficult to
classify the malocclusion into intra- arch, inter-arch
and skeletal malocclusions. The above mentioned
catagoriztion of
fig Orthodontics - The Art and Scicnce

malocclusion gives us an idea of the possible types of Lmguai' displacement : This is a condition where the
malocclusion that can occur in an individual. entire tooth is disolcced in a lingual direction.

Buccoi displacement : This describes a condition

INTRA-ARCH MALOCCLUSIONS
A tooth can be abnormally related to its neighboring
teeth. Such abnormal variations are called individual
teeth malpositions. The individual teeth malposition
can be obnormal inclination (or tipping) of the teeth or
abnormal displacements. Abnormal inclination
involves the abnormal tilting of the crown, with the root
being in normal position. Bodily displacement involves
abnormal location of the crown as well cs the root in the
same direction.
Intra-arch malocclusions con also include
where the tooth is displcced bodily in o labial or. buccal
direction.
/nfraversiori or infra - occlusion : The terms
infraversion or infra-occlusion refer to a too+h that has
not erupted enough compared to the other teeth in the
arch.
Supravers/on o,r supra - occlusion : This is a tooth that
has over-erupted as compared *o other teeth in the
arch. It is also called suprc- occlusion.
.Rotations : This term refers to tooth movements

condition like spacing o r crowding within the dental around its long axis.

arch. D/sto - Z/nguaf or mes/o - buccaf rotah'o.n: This

Some of the commonly seen individual teeth describes a tooth which has moved around its long axis
malpositions are (fig 1): so that the distal cspect is more linguclly placed.

A'lesro - /ingua/ or disto - buccal rotat/on: This is a

Distal inclination or distal tipping ; This refers to a
condition where the tooth has rotated around its long
condition where the crown of the tooth is tilted or
axis so that the mesial aspect is more linguclly p'aced.
inclined distally.
Transposition : This term describes a condition where
Mesial inclination or mesial tipping : This is a
two teeth have exchanged places.
condition where the crown of the tooth is tilted or
inclined mesially. INTER-ARCH MALOCCLUSIONS
Lingua/ mc/fnaf/on or lingual tipping .-This is an
These malocclusions are characterized by abnormal
abnormal lingual or polatal tilting of the tooth. This
relationship between two leet.nor groups of teeth of
condition is also called' retroclination j
one arch to the other arch. These inter-arch
8ucca/ inclination or buccal tipping : This refers to
malocclusions can occur in the sagittal, vertical or in
labial (in case of anterior} or buccal (in case of
the transverse planes of space.
posterior) tilting of the tooth.This condition is also
called'.proclinotion^

Mesial displacement : This refers to a tooth that is

bodily moved in a mesial direction towards the midline.
Distoi1 displacement : This refers to a tooth that is
bodily moved in a distal direction away from the
midline.

A B
Fig 2 (A} formal vertical re clior» between the upper ond lower crches.
Sagittal plane malocclusions
TT^S includes conditions where the upper and the c*er
arches are abnormally relored to eachother in c
sagittal plane.
-norma/ occhsion): This term refers to a condition
where the lower arch is more forwardly pcced when
the patient bites in centric occlusion.
Post-norma/ occ/usior? ) This is a condition ».nere the
lowerarch is more distally placed when tre patient bites
in centric occlusion.
Vertical plane malocclusions
Tnese malocclusions include deep bite and open z '.e
where an abnormal vertical relation exists oetween the
teeth of the upper and lower arch.
Deep bite or increased overbite : It is a condition
where there is excessive_verticaI overlap oetween the
upper and lower anteriors (fig 2.c)
Open bite : This is a condition where there is no
vertical overlap between the upper andjower teeth.
Thus a space may exist between the upper and lower
teeth when the patient bites in centric occlusion. The
open bite con be in the anterior or the posterior region,
(fig 2.b)
ggg
'm
Classification of Malocclusion Mi
C
'(B) Open bite (C) Deeo bi'e
Transverse plane malocclusions
The transverse plone inter-arch malocclusion includes
various types oflcrossbites? The term crossbitc refers
to abnormal transverse relationship between the upper
and lower arches.
SKELETAL MALOCCLUSIONS
They are malocclusions caused due to abanormalities
in the maxilla or mandible. The defects can be in size,
position or relationship between the jaws. The skeletal
rha I occlusions can also occur in the three planes of
space namely sagittal, vertical and transverse planes.
In the sagittal plane, the forward placement of a jaw is
referred to as prognathism while retrognalhism refers
to a more backward placement of a jaw. These sagittal
abnormalities can occur in one or both Ihe jaws and
can occur in various
Fig 3 Diogromcric representa'ion of the possible skeletal relationships in the anlcro-postcrio' or sogittol o'ene (A|« Norrral Class I (B) Bimax llary
protrusion (C) Bimaxillary retrusion (0) Maxillary prognatnism (EjMandibu'ar retrognalVsn JFJ Moxilary prograthism end mandibu cr retropna'hisn
(G) Max'l'oiy rclrogrohism (H) Mandibulo' prognaihisn (I) Mcxilla'y rctrogn'Ot'nism or.d mandibular prognathism.

t
 Classification of Malocclusion

n
D

?g 4 Diayramatc re o reservation of the possible skeletal relationships r

the transverse plcne f.A^i Normal rransverse -elation (B; Un'latera
crossbite (CI Bictoral crossa'te (DJ Bucccl non-occiusion fEJ Lingual
non-occlusion

combinations. Figure 3 gives you the possible sagittal Angle's classification was based on the
skeletal malocclusions. mesio-distal relation of the teeth, dental arches and the
Skeletal malocclusions in the transverse jaws. According to Angle, the maxillary first permanent
plane are usually a result of narrowing or widening of molar is the key to occlusion. He considered these
the jaws. They can be described as narrow moxilla, teeth as fixed anatomical points
wide mandible etc. Those transverse malocclusions are
usually referred to as crossbites (Fig 4).
In the vertical plane abnormal variations n the
vertical measurements of the jaws can affect the
lowcrfacial height.
ANGLE'S SYSTEM OF CLASSIFICATION

Edward Angle introduced a system of classifying

malocclusion in the year 1899. Angle's classification is

■S3
still in use after almost 100 years of its introduction due
to its simplicity in application.
within the jows. Based on the relation of the lower first lower arches ore forwardly placed in relation to the
permanent molar to the upper first permanent molar, he facial profile.
classified malocclusions into three main Classes

D
division 1 (C! Class II, d'f/is'or 2 (Di Class III.
Fig 5 Angle's classfica'ion (A) Clcss I J3) Class II,

designated by the Roman numerals I, II, and III.

Angle's Class I
Angle's Class I malocclusion is characterized by the
presence of a normal jnter-arch molor relation. The
mesio-buccal cusp of the maxillary first permanent
molar occludes in the buccal groove of mandibu I or first
permanent molar, (fig 5.a) The patient may exhibit
dental irregularities such as crowding, spacing,
rotations, missing tooth etc.,. These patients exhibit
normal skeletal relation and i also show normal muscle
function/ Another malocclusion that is most often
categorized under Class I is bimaxillary protrusion
where the patient exhibits a normal Class I molar
relationship but the dentition of both the upper and

H
Angle's Class If
Fig 6 Pafent having Angle's Clussll, division I
malocclusion (A) Buccal view showing tne
Class I! mo or relation ond the inc.'eased
oyerjet (B) labia view (C) Increases overiet and
prodinalion of upper onleriors (DJ Radiograph
of the patient. Note Ihe severe prodi nation of
buccinator activity. The unrestrained buccinotor activity
the upper an'c.'ics.
results in -narrowing of Ihe upper arch at the premolar
This group is characterized by a Class II molar relation and canine regions thereby producing a V-shaped
where the disto-buccal cusp of the upper first upper arch. Another muscle aberration is a hyperactive
permanent molar occludes in the buccal groove of the mentalis activity. The muscle imbalance is
lower first permoncnt molar (fig 5.'b). Angle hos
sub-classified Class II malocclusions into two divisions :

Class II, division 1

The Class II, division 1 malocclusion is characterized

by prodined upper incisors with a 'esuliflnt increase in
overjet (fig 6}. A deep incisor overbite can occur in the
anterior region. A characteristic feature of this
malocclusion is the presence of abnormal muscle
activity. The upper lip is usually hypotonic, short and
fails to form a lip seal. The lower lip cushions the palatal
aspect of the upper teeth, a feature typical of a Class II,
division 1 referred to as lip trap'. The tongue occupies a
lower posture thereby foiling to counteract the
 wmrn

- The Art and Science

G H
C:
e / (A) Class I bimaxillary protrusion (B) C ess II, division 1 malocclusion (C! Class I , divsion 2
moloccljsion (D) Class III mal occlusion'(E) Anterior open u to (F) Poslerio' open b'te (GJ Crossbite |H)
spacing
Fig 8 ;A; Anterior crossbi1e(B) Posterior cossbile (C) Anterior s'ngle tooth crossbile (D) Midline diostemo (F) Deep bile (h) Scissors bi'c'JG) Ro 'otion ironspojition01 prcmola'
and nno!c:r
74 / Orthodontics - The Art and Science

Classification of Malocclusion Mi
«WiS'l
vV? /

mm

F g 9 Clcss II, division 1 malocclusion associated

whh lowe'ed tongue posture ond ihcreforc ur
restricted buccal muscle activity causing cons'ridior
ol llie ueocr arch.

produced by a hyperactive buccinator and mentalis

Class III malocclusion

ond an altered tongue position that accentuates the This malocclusion exhibits a Class III molar relation
narrowing of the upper dental arch (fig 9). with the mesio-buccal cusp of the maxillary first
permanent molor occluding in the interdental space
Class H, division 2 between the mandibular first and second molars (fig
As in Clcss II, division 1 malocclusion, the division 2 5.d). Class III malocclusion can be classified into true
also exhibits a Class II molar relationship. The classic Class III and pseudo Class III.
feature of this malocclusion is the presence of lingually
inclined upper central incisors ond labially tipped upper
lateral incisors overlapping the central incisors (fig 5.c).
Variations of this form are lingually inclined central ond
lateral incisors with the canines Icbially tipped. The
patient exhibits a deep anterior overbite.
The lingually inclined upper centrals gives the
arch a squarish appearance, unlike the narrow
V-shaped arch seen in division 1. The mandibular
labiol gingival tissue is often traumatized by the
excessively tipped upper central incisors. The patient
exhibits normal perioral muscle activity. An abnormal
backward path of closure moyalso be present due to
the excessively tipped central incisors.
iiiiiiii^^^liliilll^iii

Fig 10. Closs II, division 2

Class tl, Subdivision

When a Class II molar relation exists on one side and a
Class I relotion on the other, it is referred to as'.Class II,
subdivision^ Bosed on whether it is a division 1 or
division 2 it can be called Class II, division 1,
subdivision or Class II, division 2, subdivision.
True C/ass MJ Although Angle's classification has been used for
This is o skeletal Clpss III malocclusion of genetic almost a hundred years now, it still has a number of
origin that can occur due to the following causes: drawbacks thai include :
a. Excessively large mandible a. Angle considered malocclusion only in the

Comparison belwoen Angle's Class II, division 1 and division 2

Feature Division 1 Division 2

Overjet increased Decreased

Profile Convex Stragh; or mi idly convex

Lips Short, incompetent Normal

Arch form V shaped, narrow U shaped and square

Palate Deep Normal depth

Muscle activity Increased mentalis and buccinator Normal muscle activity

Path of closure Norma! Backward

Lower facia) height Normal or increased Decroased

Malar process Not prominent Prominent

b. Forwardly placed mandible antero-posterior plane. He did not consider

c. Smaller than normal maxilla malocclusions in the transverse and vertical
d. Retropositioned maxilla planes.
e. Combination of the above causes b. Angle considered the first permanent molars as
The lowerjncisors tend to be lingually fixed points in the skull. But this is not found to be
inclined. The patient can present with a normol so.

ove"rjet,)an'.edge to edge incisor relation'.or on c. The classification cannot be applied if the first

(anterior crossbite.ji The space available for the permanent molars are extracted or missing.

Tongue is usually more. Thus the tongue occupies a d. The classification cannot be applied to the

lower position, resulting in a narrow upper arch.

Pseudo Class III

This type of malocclusion is produced by a fqn«ord
movement of the mandible during jaw closure, thus it
is also called 'postural' or 'habitual' Class III
malocclusion. The following are some of the causes of
pseudo Class III malocclusion:
a. Presence of occlusal prematurities may deflect
the mandible forward.
b. In case of premature loss of deciduous
posteriors, the child tends to move the mandible
forward to establish contact in the
anterior region, c. A child with enlarged adenoids
tends to move the mandible forward in an ottempt to
prevent the tongue from contacting the adenoids.

Class III, Subdivision

This is a condition characterized by a Class III molar
relation on one side and a Class I relation onjhe
T-5
other side.

Drawbacks of Angle's classification

 Classification of Malocclusion Mi

deciduous dentition.

Fig 1.1 Class III r-ialoccljsicn. (A)

and |B) Buccal occlusion view
showing class III molar relction
ond anterior cross- bte tendency.
[CJ Anterior view fD) Lateral
cephclogrcn of ihe same pa lien'.

e. The classification does not differentiate between

skeletal and dental malocclusions.
f. The classification does not highlight the etiology of
the malocclusion.
g. Individual tooth malpositions have not been
considered by Angle.
DEWEY'S MODIFICATION OF ANGLE'S
MALOCCLUSION

Dewey proposed a modification of the Angle's

classification of malocclusion. He divided Angle's Class
I into five types and Angles Class III into three types.
CLass I modifications of Dewey (fig 12). Simon's system of classification mode use of
"ce 1 : Class I malocclusion with bunched or redded three anthropometric planes i.e., the Frankfort
anterior teeth. - horizontal plane, the orbital plane and the mid-sagittal
T»pe 2 : Class I with protrusive maxillary incisors. jjpe3 plane. The classification of malocclusion was based on

Mi
-.Class I malocclusion with anterior crossbite. Tv?e 4 : abnormal deviations of the dental arches from their
Class I molar relation with posterior rrcssbite. Classification of Malocclusion
normal position in relation to these three planes.
~upe 5 : The permanent molar has drifted mesially D.e
to early extraction of second deciduous molar IT
Frankfort horizontal plane

second premolar.
Class III modifications of Dewey
T,ce 1 : The upper and lower dental arches when .
ewed separately are in normal alignment. But •nen the
orches are made to occlude the patient STOWS an edge
to edge incisor alignment, suggestive of a forwardly
moved mandibular rental arch.
Tfpe 2 : The mandibular incisors are crowded end are
in lingual relation to the maxillary incisors. ~fpe 3 : The
maxillary incisors are crowded and ere in crossbite in
relation to the mandibular cnteriors.
This is a plane that connects the upper margin of the
external auditory meatus to the infra-orbital margin.
This plane is used to classify malocclusions in a vertical
plane. Two terms are used to describe any abnormal
relation of the teeth to this plane. When the dental arch
or part of it is closer than normal to the Frankfort plane,
it is called attraction. When the dental arch or part of it
is farther away from the Frankfort horizontal plone, it is
called abstraction.

USCHER'S MODIFICATIONS OF
ANGLE'S CLASSIFICATION

Lischer substituted the term Class I, II ond III given by

Angle with the terms neutrocclusion, distocclusion and
mesiocclusion. In addition to these, he added a few
more terms which designated certain other
malocclusions. Neufrocc/usr'on : Synonymous with
Angle's Class I malocclusion.
Distocclusion : Synonymous with Angle's Class
II malocclusion.
Mes/oc/usiori ; Synonymous with Angles Class
III malocclusion.
Buccocc/usron ; Buccol placement of a tooth or a
group of teeth.
i-inguocdusion ; Lingual placement of a tooth or o
group of teeth.
Supraocc/usion : When a tooth or group of teeth have
erupted beyond normal level. Jnfraocc/usjon ; When a
tooth or group of teeth have not erupted to normal level.
M estovers ion : Mesial to the normal position.
Drstoversion : Distal to the normal position.
Tronsversion .-Transposition of two teeth. Axiversion :
Abnormal axial inclination of a tooth
Torsivers/on ; Rotation of a tooth around its long axis.

SIMON'S CLASSIFICATION

Malocclusion can occur in a n tero-posterior,

transverse and in the vertical planes. Simon hod put
forward a craniometric classification of malocclusion
that related the dental arches in all these three planes
 Orbital plane Norman Bennet classified
This plane is perpendicular to the Frankfort horizontal
plane, dropped down from Ihe bony orbitol margin
directly under Ihe pupil of the eye. According to Simon,
this plane should pass through the distal third of the
upper canine. This is called Simon's Law of Canine.
This plane is used to describe malocclusion in a
sagittal or antero-posterior direction. When tM<^enf? I
arch or part of it is farthor from the Ojrf^fpldfce,; it is
called protraction. When th&Ofch or part of it is closer
or more posteriorly placed in relation to this plane, it is
called retraction. \
ft

MId-saglttal plane

The mid-sagittal plane is used to describe

malocclusion in the tronsversc direction. When a part
or whole of the arch is away from the mid- sagittal
plane it is called distraction. When the arch or part of it
is closer to the m id-sagittal plane it is called
contraction.

B BENNET'S CLASSIFICATION
malocclusion based on its etiology.
Class I - Abnormal position of one or more teeth due to
local causes.
Class II - Abnormal formation of a part of or whole of
either arch due to developmental defccts of bone.
Class III - Abnormal relationship between upper ond
lower arches, and between either arch and facial
contour and correlated abnormal formation of either
arch.

ACKERMA N-PROFITT SYSTEM OF CLASSI-

FICATION

Ackerman and Profitt in 1960 proposed a

diagrammatic classification of malocclusion to

Fig 12 Simons classification fA) F.H. plane (B> Orbital plane (C!
Mid-Sagittal plane.
 Transverse Deviation Sagittal Deviation
Buccal Palatal Trans- Class I
Unilateral Bilateral sagittal Class II division 1
Skeletal yf Class II division 2
Dental / Trans- Skeletal \
sagitto Dental
-
Vertico
transverse vertica
l

Convex [" Sagitto-

Concave I verrical
Straight \
Anterior ^
divergent
Posterior
Intfa^rcb ^divergent
alignment
Ideal
Crowding
Spacing
Profile
Vertical Deviation Open
bite anterior Open bite
posterior Deep bite
anterior Collapsed bite
posterior Skeletal /
Dental /

Fig. 13 Vern symbolic diagram - Ackcrmon Profitl Classification

overcome the limitations of the Angle's classification.
Salient features of Ihe classification mclude :
a. Transverse as well as vertical discrepancies can
be considered in addition to anteroposterior
malrelotions.
b. Crowding and arch osymmetry can be evaluated.
c. Incisor protrusion is taken into account.
This system of classification is based on the
Venn symbolic diagram {fig 13) that identifies five
major characteristics to be considered and described
in the classification.

Step 1 (Alignment)
The first step involves assessment of the alignment
and symmetry of the dental arch. It is classified as
80 Orthodontics - The Art and Science

ideal / crowded / spaced.

Step 2 (Profile)
It involves Ihe consideration of the profile. The profile is
described as convex/straight/concave. The facial
divergence is also considered i.e., anterior or posterior
divergence.

Step 3 (Type)
The transverse skeletal and dental relationship is
evaluated. Buccal and palotal crossbites if any are
noted. The crossbite is further sub-classified as
unilateral or bilateral. In addition, differentiation is
mode between skeletal and dental crossbite.

Step 4 (C/ass)
This involves the assessment of the sagittal
relationship. It is classified as Angle's Class I / Class II /
Closs III malocclusion. Differentiation is made between
skeletal and dental malocclusion.

Step 5 (Bite depth)

Malocclusions in the vertical plane are noted.
They are described as anterior or posterior open »
bite, anterior deep bite or posterior collapsed bite. A
mention is mode whether the malocclusion is skeletal
or dental.
References
 Etiology of Malocclusion
.fV''SSafiSSf

T
he orthodontic speciality deals with treatment teeth. The general factors on the other hand are those
of various malocclusions. Etiology of that affect the body as a whole and have a profound
malocclusion is the study of its cause or effect on the greater part of the dcnto-facial structures.
causes. Malocclusion can occur due to a number of
possible causes. Broadly speaking malocclusions are HEREDITY
caused by either genetic factors or by environmental
In everyday life, we come across quite a number of
factors.Comprehensive orthodontic management
families where the inmates hove o lot of resemblonce.
involves identification of the possible etiologic factors
Thus it is quite logical to assume that offsprings inherit
and an attempt to eliminate the same. Although it may
quite a few attributes from their parents. Heredity has
not be possible to eliminate the cause in most cases of
for long been attributed as one of the causes of
malocclusion, it nevertheless is of value in preventive
malocclusion.
and interceptive orthodontic procedures where a
The child is o product of parents who
possible malocclusion is prevented or intercepted by
timely removal of the cause.
Development of normal dentition and
occlusion depends on a number of interrelated factors
that include the dentoalveolar, skeletal ond the
neuromuscular factors. Thus localization of the
possible etiology may be a very difficult task. A number
of classifications of etiologic factors o^ malocclusion
have been put forward (refer to table 1).
Graber has classified the etiological factors
as local and general factors. The loco! foctors
responsible for malocclusion produce a localized
effect confined to one or more adjacent or opposing
 Etiology of Malocclusion 83
Orthodontics - The Art and Science 5. Habits
a. Thumb sutfrg and finger sucking
MOVER'S CLASSIFICATION
b. Tongue testing
1. Heredity c. Lip sucking and lip tiling
a. Neuromuscular System d. Poslure
Classifications of etiology of malocclusion e. Nail biting
b. Bone
c. Teelh f. Other habits 8. Diseases
d. Soft Parts a. Systemic diseases
2. Developmental defers of unknown cigin b. Endocrine disorders
3. Trauma c. Local diseases
a, Prenatal trauma and birth injuries i. Nasopharyngeal diseases anc disturbed
b. Postnatal trauma respiratory funclicn it; Gingiva'^ and periodontal
4. Physical agenls disease MTumors V'v:-S

a. P'enature extraction of primary teeth iv. Caries 7 Mafnutritlon

b, Nature ot tood

WHITE AND GARDINER'S CLASSIFICATION

A. Dental base abnormalities

Anlerc-poslerior na'relationship
Velical malrelationstvo
Lateral malrelalic^ship
Disproportion of size between teeth
and basal fcons
Congenital abnormalities
B. Pre-eruptbn abnormalities
Abnormalities in pos'lion of
developing tooth germ
Missing teeth
Supernumerary leeth and teelh
abnormal In form
Prolonged retention of deciduous teeth
Large labial Irenum
Traumatic injur/ C. Post-eruption
abnormalites
1. Muscu'ar
a. Active muscle toroe
b. Best position of
' 2
•

o, Sucking habits d.
Abnormalites in path c?
closure
2. Premature loss of deciduous teeth
3. Extraction ot permanent teeth. ■

2 Heredity
GRABER'S CLASSIFICATION
GENERAL FACTORS
g.Resolralory abnormalities [mouth breathing
etc.,.! h Tonsi'-s a^d adenoids I, Psychogenic
tics;arid bruxism
Poslure
Trauma and accidenls

LOCAL FACTORS
1. Anomalies of number:
Supernumerary teeth, Missing
leeih [congenital absence or loss
due to accidents cares etc]
2. Anomalies of tooth si2e
3. Anomalies of looth shape
f,. Abnormal labial frenum : mucosal barriers
5. Premalure loss ot deciduous teeth
6. Profohgwl retention of dectiuous teeth
7. Delayed eruption of permanen teelh B. Abnormal
eruptive path
9. Ankylosis
10. Dental caries .
11. improper dental restoration
 -c.e dissimilar genetic material. Thus the child -ray
CONGENITAL DEFECTS

I inherit conflicting traits form both the parents ^suiting

in abnormalities of the denlofacia region. Another
reason attributed for genetically 3e?ermined
malocclusion is tfie racial, ethnic and •egipnal inter-mixture
Congenital defects or developmental defects are
malfonnations seen crrhe time of birth. They may be
Etiology of Malocclusion 85
caused by a variety of factors including genetic,
radiologic, chemical, endocrine, infections ond
which migh: nave led to .rco-ordinated inheri-ance of teeth mechcnical factors.
and jaws. The congenital abnormalities that cause
According to Lundstrom there exists a malocclusion can be broadly classified as general end
-omber o^ human traits that ore influenced by genes locol congenital abnormalities.
that include:
General congenital factors
e Tooth size : The size of the dentition is to a c'ge
a. Abnormal state of mother during pregnancy
extent determined by genes. Abnormoiiries — rooth
b. Malnutrition
size such as microdontia and macrodontio
c. Endocrinopathies

! cre attributed to heredity.

d.
e.
f.
Infectious diseases
Metobolicond nutritional disturbances
Accidents during pregnancy and child birth
a. Arc/t dimensions ; The dental arch length zr<d arch width g. Intro-uteri no pressure
are believed to be inherited. h. Accidental Iraumatization of the fetus by externol
Crowding / Spacing : Crowding and spacing of teeth are forces
believed to be of genetic --gin. Most of these conditions are
believed to a result of uncoordinated inheritance of arch
ength and tooth moteriol.

r Abnorma'.'ties of tooth shape : Anomalies cf tooth

shape such as tne presence of peg shaped cterals is
another trait that shows nigh genetic predisposition.

f Abnormalities of tooth number : Presence -•"either

more or less number of teeth con also be .-herited.
This includes condition such as cnodontia and
oligodontic.

r. Over/et; The horizontal overlap of the upper cod

lower dentition referred to as the overjet is c<=!ieved to
be genetically influenced.

g. Intcr-arch variations : Discrepancies in -e

transverse, scgittal and vertical planes between —e
upper and lower jaws can be inherited.
h. Frenum ; The size, position and shape of the frenum is
said to be genetically influenced. Thus malocclusion such
as midline diostemo that may be due to abnormo ities of the
frenum are to a large extent determined genetically.
According to Harris and Johnson a number of
craniofacial parameters showed significcnt genetic
influence. These include the following cisrances : sella -
gnathion, sella - point A, sella - gonion, nasion - anterior
nasal spine, articulare - pogonion, bizygomatic width,
anterior facial height.
As so many traits show a strong genetic pattern a
njmoerof malocclusions can be pertly or solely attributed to
genetic factors. These genetic traits can be further
influenced by existing prenatal or post-natal environmental
factors.
a. Abnormalities of jaw development due to intra-uterine Various pre-notal and post-natal environmental factors
position can cause malocclusion.
b. Clefts of the face and palate
c. Macro a n d m ic rog I ossia Prenatal factors
d. Cleidocranial dysostosis The fetus is well protected against injuries and
Local congenital factors The following Cleidocranial dysostosis nutritional deficiencies
are some of the congenital conditions frequently during pregnancy. But there are certain factors, the
encountered by the orthodontist. presence of which can result in abnormal growth of the
oro-faciol region thereby predisposing to malocclusion.
Clefts of the Up and palate
Abnormal fetal posture during gestalion is
Clefts involving the lip and palate are the most commonly said to interfere with symmetric development of the
seen developmental defects that occur as a result of non- face. Most of these deformities are temporary and
fusion between the various embryonic processes. Cleft usually disappear as age advances.
patients may exhibit a number of dentcl problems including The other prenatal influences include
missing teeth, mobile teeth, rototions, cross bite, etc., maternal fibroids, amniotic lesions, maternal diet and
(discussed later as a separate chapter). metabolism.
Maternal infection such as German measles
Congenital syphilis and use of certain drugs during pregnancy such as
Syphilis of congenital origin is transmitted from the infected Thalidomide can cause gross co ng en into I
mother to the child. The child exhibits one or more of the deformities including clefts.
following features:
a. Hutchinson's incisors
b. Mulberry molars
c. Enamel deficiencies
d. Extensive dental decay
e. The maxilla may be smaller in size relative to the
mandible
f. Anterior cross bite

Maternal rubella Infections

Maternal rubella infections during pregnancy is believed to
cause widespread congenital malformations in the child.
The following are some of the feature that can be seen.
a. Dental hypoplasia
b. Retarded eruption of teeth
c. Extensive caries
This is a congenital condition characterized by unilateral or
bilateral, partial or complete absence of the clavicle. The
patient may exhibit the following features:
a. Maxillary retrusion and possible mandibular protrusion
b. Over retained deciduous teeth and retarded eruption of
permanent teeth
c. Presence of supernumerary teeth
d. Presence of short and thin roots

Cerebral palsy
This is a condition where in the patient locks muscular
co-ordination. It usually occurs due to birth injuries.The
uncontrolled ond oberrant muscle activity upsets the muscle
balance resulting in malocclusion.

ENVIRONMENT
 Teeth
that are
extra to
the
normof

Fig 1 (A) and (8) Mcsiodons between the ncxilicry

control rncisore. Note how the exrra tooth has resulted
in crowding and rotarion of the cdjocent ccr.-ral incisor.
|C) Occlusal radiograph of the some oa'icnt.

Postnatal factors complement are termed s upem u mera ry teeth. These

The following ore some of the post-nalal factors that can teeth have abnormal morphology and do not resemble

cause malocclusion : C- Forceps delivery con result in injury norrnol leeth. Extra teeth that resemble normal

to the temporomandibular joint area wnich can undergo

ankylosis. Such patients show retarded mandibular growth
and thus have o hypoplostic mandible. z. Cerebral palsy is a
condition characterized by muscle inco-ordination. This
may occur due to birth injuries. The patient can exhibit
malocclusion due to loss of muscle balance.
c. Traumatic injuries that cause condylar fracture can
cause growth retardation resulting in marked facial
asymmetry.
Presence of scar tissue such as those caused by burns
or as a result of cleft lip surgery may produce
malocclusion due to their restrictive influence on
growth.
e. Milwaukee braces are used for treatment of scoliosis.
These braces derive support from the mandible.
Prolonged use of these braces can cause marked
mandibular growth retardation.

ANOMAUES IN NUMBER OF TEETH

In order to achieve good occlusion, the normal number of

teeth should be present. Presence of extra teeth or absence

87
of one or more teeth predisposes to malocclusion.

Supernumerary teeth
teeth are called supplemental teeth.
A frepuently seen supernumerary tooth is the

mesiodens which occurs in the maxillary midline(fig 1).

They can occur singly or as a pair and are usually conical in
shape. Unerupted mesiodens is one of the causes of
midline spccing. Supernumerary teeth can also occur in tne
premolar or third molar regions.
Supplemental teeth are most often seen in the
premolar and lateral incisor region. It is not uncommon to
find an extra lower incisor. The supernumeran,> and
supplemental teeth couse non-eruption of adjacent teeth
(fig 2)and ccn deflect the erupting adjacent teeth into
obnormal locations. In addition extra teeth occupy arch
length intended for normal complement of teeth. Thus they
can result in crowding and rotations of adjacent teeth.
Unerupted supernumerary teeth pose a risk of cystic
transformation.
F;g 2 (A) A 10 year eld shewirg unerup'ed sypemvmora'y
'00-b in the uppsr central incisor region, blockiig tne
erjptici oi tne cert'cl inc sor (BJ Rad ocraph of the same
ca-ient.
c. Mandibular second premolers
d. Mcndibulor incisors
e. Moxillary second premolars
Absence of teeth can be unilateral or
sometimes bilateral. They may occur along with other
onomalies such as presence of extra teeth. Absence of
one or more teeth predispose to spacing in the dental
arch. The adjacent 'eeth migrate and therefore cause
abnormal location and axial inclination of teeth (fig 5).
Absence of a permanent tooth ouite often results in

Missing teeth over- retained deciduous teeth.

Congenitolly missing teeth are by far more common than

ANOMALIES OF TOOTH SIZE
supernumerary teeth and can occur in either of the jaws,
The following ore some of the commonly missing teeth in In order to have normal occlusion, tnere should be
decreasing order of frequency: hcrmony between the +ooth size and arch length and
a. Third molars also between the maxillary and
b. Maxillary lateral incisors
 Etiology of Malocclusion 89

G H
Fig 3 (Aj & (B! S jpp emental Icreral incisor (C) & (D) 5tpfi'numerary ooth seen erupting palotaily (E) & |F; S jpp eTienlal
la"e:al incisor yG) & |H} Macrodontic supernumerary incisor n Ihe rn'r.lire
Orthodontics - The Art and Science

Fig 4 [A|- & (B) Missing lower incisor (Q & [D', Bilateral missing uppo' lateral inciscrs (EJ & (F) Bilateral missirg lower
second premolars (G) & (H) Bila'col massing upper lateral incisors.
 Etiology of Malocclusion ^ 89

F g 5 |A) ond <BJ Upper left loleral incisor congenitally missing. Note tne resultant spacing of th.e maxillary arc/i and non coincident of i/Dper and
lov/er iri'd'ines. The
maxillary rigrr latere I is also micradoniic. JC) Radiograph of rhe same pntienl.

—andibular tooth size. An increase in size of ■sern results b. Another anomaly of tooth shape is the presence of an
in crowding while, smaller sized teeth -rsdispose to abnormally large cingulum on a maxillary incisor (fig
spacing. A commonly seen anomaly a me presence of 7). The presence
smaller sized maxillary lateral rcisors. Anomalies of size
can also occur in the f-cndibular premolars. Fusion
between two ^r!acent teeth or between a supernumerary
tooth z-.d a normal tooth may predispose to malocclusion.
Variations in size of tooth can occur ^ong with variations of
shape.
The size of teeth is to a large extent reiermined
genetically. Thus most of these conditions show a positive
family history.
ANOMALIES OF TOOTH SHAPE

Anomalies of tooth size and shape are very often

interrelated. Abnormally shaped leelh predispose to
malocclusion. The following are some of Ihe examples of
frequently seen tooth shape anomalies:
J
a. The presence of peg shaped maxillary lateral incisors
is often accompanied by spacing and migration of
teeth (fig 6).
 of an exaggerated cingulum prevents establishment of
normal overbite and overjet. The involved tooth is

f Orthodontics - The Art and Science

Fig 6 !A) And <B) Upper left lateral incisor nicrodontic .

Reduced tooth mote'iol results in soacing of ihe dentition.
(Cl ond (D) Mocrcdoniic nobiliary right central incisor. E)
Lower peg incisors.

usually in labioversion due to the forces of occlusion.

c. The mandibular second premolars may rorely hove an
additional lingual cusp, thereby increasing the
mesio-distal dimension of the tooth.
d. Congenital syphilis is often associated with presence
of obnormal tooth form. Peg shaped laterals and
mulberry molars are classical findings in such patients.
e. Anomalies of shape can occur as o result of
developmental defects like amelogenesis imperfecta,
hypoplasia of teeth, fusion and gemination.
f. Dilaceration is described as a condition characterized
by an abnormal angulation between the crown ond
root of a tooth or angulation within the root. It usually
occurs due to a blow to a deciduous tooth which is
transmitted to the underlying permanent tooth bud.
Dilacerated teeth fail to erupt to normal level and can
thus cause malocclusion.
 a.
Premature
loss of
deciduous
molars

- z 7 Maxillary central incisors showing prominent c-gulum.

predispose
Abnormalities of the maxillary to
A3N0RMAL LABIAL FRENUM
labial frenum ore :..*e often associated with a maxillary
midline scodng. Prior to the eruption of teeth, the
moxillary cc-icl frenum is attached to the alveolar ridge
«.-•n some fibers crossing over lingually to the -«c"on of
the incisive papilla. As the teeth start •erecting, alveolar
bone is deposited and the frenal —achment migrates
into o more apical position, icrely, a heavy fibrous
frenum is found attached x Tie interdental papillaFig 8 |A) Thick maxillary lebiai frenum causing a midline
c'iasremo (B) Radiograph shows a midline notching of rhe
region. This type of frenal zreenment can preventinrcrdcntcl alveolar bone.
the two moxillary central jrcsors from approximating malocclusion due to shifting of adjacent teeth into the
each other, {fig 8.a). space. Early loss of anteriors most often do not
This condition is diagnosed by a positive Dcnch produce any
test. When the upper lip is stretched for a period of time, a
noticeable blanching occurs over —.5 interdental papilla. A
midline intra-oral periapical radiograph usually exhibits
notching cf me inter-dental alveolar crest(fig 8.b).
Midline diastema may also occur due to o number
of causes including presence of .rerupted mesiodens,
anomalies of tooth size and -=«jnber.

PREMATURE LOSS OF DECIDUOUS TEETH

refers to loss of a tooth before its permanent accessor

is sufficiently advanced in development and eruption to
occupy its ploce. Early, loss of deciduous teeth con cause
migration of adjacent teeth into the space and can
therefore prevent the eruption of the permanent successor
(fig 9).
Premature loss of an incisor seldom leads to
malocclusion. Loss of a deciduous second molar con
cause a marked forward shift of the permanent first molar
thereby blocking the eruption of the second premolar,
which either gets impacted or is deflected to an abnormal
position.
The severity of malocclusion caused due to early
loss of a deciduous tooth depends on the following factors :
 Orthodontics - The Art and Science

Fig 9 (A) and (B) FVerrcture loss of deciduous socord inolar Second
premolar lias erupted inguolly due ro iradequote s
malocclusion.
b. The earlier the deciduous teeth are extracted
before the successional teeth are ready to erupt,
the greater is the possibility of malocclusion.
c. > In a person having arch length deficiency or
crowding the early loss of deciduous teeth may worsen the
existing malocclusion.
permanent successors. Prolonged retention of buccal
teeth results in eruption of the permanent teeth cither
bucally or ling u all y or may remain impacted within the
jaws.
Quite often certain parts of the deciduous
roots which arc away from the path of eruption of the
permanent teeth fail to get resorbed thereby leaving
small fragments of the root within the jaw. These root
fragments can deflcct or block the adjacent erupting
teeth.
The following are some of the reasons for
prolonged retention of deciduous teeth :
a. Absence of underlying permanent teelh(fig 10,11).
b. Endocrinol disturbances such as hypothyroidism
c. Ankylosed deciduous teeth that fail to resorb
d. Non - vital deciduous teeth that do not resorb

Fig 10 Ovcr-rc'a'ncd lower deciduous oen-rcl incisors due to

congenital absence of the permanent cenlrol incisors
lias resu ted in mesial migra-ion of the fret penronent -nolar. :ace.

PROLONGED RETENTION OF DECIDUOUS

TEETH

This refers 1o o condition where there is undue

retention of deciduous teeth beyond the usual eruption
age of their permanent successors. A deciduous tooth
that fails to undergo resorption will prevent the normal
eruption of its permanent successor.
Prolonged retention of deciduous anteriors
usually results in lingual or palatal eruption of their
 DELAYED ERUPTION OF PERMANENT
TEETH

There ore a number of reasons (hot can delay the

eruption of permanent -eeih. The following are

Fig 11 Lowe' clccidjOv's second molar ovc lu'ahod lo ccngen tol absence ot ower righ- second premolar

some of them :
r Congenital absence o: the permanent tooth, r Presence of
supernumerary tooth can block the e-up:ing
Fig ' 7 Imcaced maxl or/ can ries. I lie uioxi lory canines are frequent
permanent tooth. Presence of a heavy mucosal barrier y impacted ond en.pt in ectopia ncsirici.
can prevent tne permanent tooth from emerging into
the oro: cav'ly. A surgiccl incision in most cases
accelerates the eruption. ± Premature loss of
deciduous loot h can result in delayed eruption of the
underlying permanent teeth due to formation of bone
over ihe erupting permanent tooth.
e. Endocrinol disorders such as hypothyroidism can
cause a delay in eruption of the permanent teeth.
f. Presence of deciduous root fragments that arc rot
resorbed can block the erupting permanent teeth.

ABNORMAL ERUPTIVE PATH

One of the causes of malocclusion is cr. abnormal path of

eruption which could be due to arch length deficiency,
presence of supernumerary teeth, retained root fragments,
or formation of a bony bonier.
Tne maxillary canines develop almost near the
floor of the orbit and trcvel down to their final position in Ihe
oral cavity. Thus they are most often found erupting in an
abnormal position (fig 12).

33
 Ankylosis is a condition wherein a part or whole of the root also causes food lodgement and periodontal weakening of
surface is directly fused to the bone with the absence of the teeth.
the intervening periodontal membrane. This most often
occurs as a result of trauma to the tooth which perforates PREDISPOSING METABOLIC
the periodontal membrane. Ankylosis can also be CLIMATE AND
ANKYLOS/Sassociated with certain infections, endocrinal DENTAL CARIES DISEASE
disorders and congenital disorde' such as cleidocranial
A number of endocrinal disorders, infectious conditions and
dysostosis. Clinically, these teeth foil to eruottothe normal
metabolic disturbances can predispose to malocclusion.
level and are therefore called submerged teeth (fig 13). At
times these ♦eeth ore totally submerged within the jaw Endocrine Imbalance
and therefore cause migration of adjacent teeth into the
Certain endocrinal disorders may result in malocclusion.
space.
The following are some of Ihe endocrinal disturbances that
can cause malocclusion,

Fig 13. Maxillary |sft first pepr,oper;t rnolar is tinkybsed. Note the tpojh
is submerged and is infraocclusicn with ■lo rest of the defitl'i^n,

Caries can lead to premature loss of deciduous or

permanent teeth thereby causing migration of contiguous
teeth, abnormal axiai inclination and supra-eruption of
opposing teeth.
Proximal caries that has no^ been restored can
cause migration of the odjccent teeth info the space leadirg
to a reduction in arch length. A substantial reduction in arch
length can be expected if several adjacent teeth involved
by proximal caries ore le*t unresto'ed.

IMPROPER DENTAL RESTORATIONS

Improoer dental 'estorations may predisoose to

r
malocclusion. Over-contoured occlusal estorations cause
premature contacts leading to functional shift of the
mandible during jaw closure. Under-cortoured occlusal
restorations ccn perm": tne opoosing dentition to
suora-erupt. Proximal restorations thctare under-contoured
invariably result in loss of arch length due to drifting of ad
jacenf teeth to occupy the space. Poor oroximal contact
Hypothyroidism • Hypothyroidism is characterized by the associated with abnormal pressure and muscle imbalance
presence of one or more of -re following features: thereby increasing the risk of malocclusion. ">

; Retcrdation in rale of calcium deposition in Children who support their,head by resting the

bones and teeth, r Marked delay in tooth bud Etiology

chin on their of Malocclusion
hand and those who hang their head so that
formation and the chin rests against the chest are obsen/ed to have rnand

eruption of teeth z. Delayed carpel and epiphyseal ibu la r deficiency. Poor posture as a cause of malocclusion

calcification r. The deciduous teeth are often over-retained although not proved may nevertheless be an accentuating
and the permanent teeth are slow to erupt = Abnormcl factor for other malocclusions.
root resorption £ Irregularities in tooth arrangement- and
ACCIDENTS AND TRAUMA
crowding cf teeth can occur
Children are highly prone to injuries ofthedento- facial
Hyperthyroidism : This condition is :~aracterized by
.region during the early years of life when they learn to
increase in the rate of —saturation, and an increase in
crawl, walk or during play. Most pf these injuries go
metabolic rale. Tne patient exhibits premature eruoTion of
unnoticed and may be responsible for non-vital teeth that
deciduous teeth, disturbed root resorption of deciduous
do not resorb and deflection of erupting permanent teeth
teeth and early eruption of permanent •seth. The oatient
into abnormal positions.
may have osteo- porosis which contra-indicates
orthodontic treatment.

-ypoporoihyroidism : This endocrinal disorder is

associoted with changes in calcium metabolism. It can
cause delay in tootn eruption, w'*ered tooth morphology,
delayed eruption of zeciduous and permanent teeth and
hypoplastic *eth.

Hyperparathyroidism : Hyperparathyroidism produces

increase in blood calcium. There is demineralization of
bone and disruption of trabecular pattern. In growing
children, interruption of tooth development occurs. The
•eeth may become mobile due to loss of cortical bone and
resorption of the alveolar process.

Metabolic d/stttrt>ances

Acute febrile diseases are believed to slow down tne pace

of growth and development- These conditions may cause a
disturbance in tooth eruption and shedding thereby
increasing the risk of malocclusion.

Diseases affecting the oro-facial muscles con

have a profound effect on the dento-alveolar complex
predisposing to malocclusion.

DIETARY PROBLEMS (NUTRITIONAL

DEFICIENCY)

Nutritional deficiencies during growth may result in

abnormal development, causing malocclusion. These
diseases ore more common in the developing countries
than in the developed world. Nutrition related disturbances
such as ricketts, scurvy and beriberi can produce severe
malocclusion and may upset the dentol developmental time
table.

POSTURE

Poor posturcl habits ore said to be a cause for

malocclusion. Although not substantiated, they may be
 r*
i' 'NU ..... lii'IW—HWIMFIII ........................... ........................ i'» 1

96 Orthodontics - The Art and Science

References
nclccclLsion. Am J O-thcd 1959 ; 192-199
23. Robert E Meyers : -crd book of O-thcdcn-ics, Year boo< ncdica
cua ishers, inc," 985.
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eer-narent -no ars : Prevent'on aid Treatment. J Am Dent Assoc
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Am J Orhod 1991:171-179
28. Thilander B Skagijs 5 : Orthodont'c Seauelae cf extract or, of
pe-monenl first melcrs : Alongi'udrcl study. Trans Eut Orthcd See i
97C; 429-^42.
29. ~ ask, Shcpi'o, crd Shaciro : E;tec*s o; allergic rnin'tis or dental and
skeletal development. Am J Orhod 1987; 256-293
30. Tulley : Adverse muscle :orces Their c'agnoslic significance. Am „
Orthod 1956 ,- 301-8'4
31. Urg. Koeng. Snapi'o, Shapiro, ara "-ask : Qjarti- fisd rasa ra-ion
and :acial :orm. Am J Ortnod " 990 ; 523-532
32. V g : Nasal airflow ir relation to toe 'c I rrorono ogy. Am J O-thcd
1981 ; 263-2/2
33. V'v'a-rer, Hatfield, and Da s-on . Nascl a'rwoy impairment. Arr J
O-t-ied "991 ; 346-353 Warren, Hnirf'e c, Seatcn, Mcr, arc Smith :
Nasal size and ncsal breathing. Arr J Orthod i 983 ;289- 293
35. Warren, Hersney, Turkey, H n to n, and Hairf e a : Nasa airwav
foHov/ng maxillary expansion Am J Orhoc
1987;! II.316
36 Warrer, Lehman, ond -inton : Analysis of s-imu- latea upper aiiwov
o-ea-hing. Ar J Orhod i 98^ ; 197-206
37. Weber, Preston, and Wright : Resistance to nasol airflow related
to charges in nead posture. Am J O-thcd 1981 ; 536-545
38. Wendell V Arrdt, Dds, Ms : N'ckel Titanium Polatol Expander . J
C'in Crthcd 1993 ; 129-137
39. William Christie S lio v/ : Orthodortics crd Occlusal management.
Wright, 1993
40. Wrtner : Surgically assisted pcla'al expansion. An J Orthod 1991;
85-90
41. Wccdside.linder-Aronson, Urdsirom, and McW'l iam : Wordibula-
end maxillary growtn a-ter changed node of breath'rg. Am J Orhod
1991 ; 1- 18

3 B'esoin, Shapiro, Snaairo, Cnacko, and Dassel : Mcu'h brecthirc in cllerg'c children. An J Orhod
1953 ,-334-340
2. E l'ngsen, Vandevanter, Shapiro, and Shapiro : Temporal vcr c t ion ir a-ea-hira. Air J Orhoc 1995 ;4' I - 417
3 Fielc's. Warren, Black, ana Fhillios : Vertical nor- aio'oey and respirat or in aoolescen's An J Orthod
"99" ; 147-154
4. Graber: ~ne 'three Ms': Musees. Malformation ond Ma OCCIJS or. Am J O-tnod 1963 ; -118-45C
5. Graaer TM : Orhocort cs : Principles arc practice. WB Sounde's,1988
6. Gross, Kalium, Morris, Franz, M'chas, Foster. Wa ke', and Bisnoo ; ^hincmetry and open-moj-h posture. An J Orhoc
1993 ; 526-529
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299-3C3
8. u
in-or, 'A'cren, end -ci-field : Upcor airway prss- SJre$ djring brceth rg. Am J Orhoc 1956 : ^92- 498
9. Jacchsor : Psychology and early ortnedentic t-eat- mert. Am J Or'hoc 1979 ; 5' 1-52?
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O
ra r.ab'ts in children have a definite bearing on
the development cf occlusion. Frequency,
children acquire certain habits that may either
temporarily or permanently be harmful ro dental occlusion
end to the tooth supporting structures.
A habit can be defined as the tendency towards
an act tnai has become a repeated performance, relatively
fixed, cons'stentand easy to perform by an individual.
Habits are tnuS acquired as a result o: repetition.
In the initial stages there is a conscious effort to perform the
act. Later the act becomes less conscious and if repealed
often enougn may enter the realms of unconsciousness.
Habits can be classifiec in a number of ways. One
classification is to divide habits into pressure, non pressure
ana biting habits. I labits can also be classified as
compulsive and non-compulsive habits or empy and
meaningful hobits (refcrtable i fora detolledclassification).
THUMB AND DIGIT SUCKING

Digit sucking is defined as placement of the thumb or one

or more fingers in varying depths into the mouth. Thumb
and digit sucking is one of the commonly seen habits that
most children indulge in. Reccnt studies have shown thai
thumb sucking may be practiced even during intrauterine
life. The presence o; this habit is considered quite normal till
the age of 3 1/2 - 4 years. Persistence of the habit beyond
this age con lead to various malocclusions.

Etiology
A number of theories have been pul forward to exolain why
thumb sucking occurs. The following are some of the more
acceptea ones :

.'reuoVan theory : This theory was proposed by Sinmond

Freud in the early pari ol this century. He suggested lhat a
child passes through various distinct phases of
psychological development o^

q>
 Table 1 Classification ot habits
Phase f: (Normal and sub-clinically significant): The first
I. Useful and harmtul habits
phose is seen during the first three yeors of life. The
presence of thumb sucking during this phase is considered
98 Orthodontics - Ihe Art and Science
quite normal and usually terminates at the end of phase
Useful habits
These incline habits that are considered essential tor normal tunciion
one.
such as proper positmrg of tte tor^iie. respiration and normal Phose (/ : (Clinically significant sucking) : The second
deglulition. Harmful habits
phase extends between 3 - 6 1/2 years of age. The
These include habits that have a deleterious effeci on the teeth and
oresence of sucking during this period is an indication that
Iheir supporting structures sutt as thumb sucking, tongue 1hrus:ing
the child is under great anxiety. Treatment to solve the
etc...
dental problems should be initiated during this phase.
II. Empty and Meaningful habits Empty habits

They are habits that are not associated with any deep rooted
psychological problems. Meaningful habits
They are habits that have a psychological bearing,

III. Pressure, non pressure and bitelng habits Pressure habits

These include sucking habits si># as thumb suctorg, lip sucking, linger
sucking and also tongue thrusting. Non - pressure habits
Habits which do not aoply a direct force or. the teeth or its supporting
structures are lermed non-pressure habits. An example of a
non-pressure habil is mouth breathing. Biting habits
These u>clude habits such as nail biting, pencil biting and lio Wing.

IV. Compulsive and Non compulsive habits Compulsive habits

These are deep rooted habits that have acquired a fixation m the child
to the extent that the child retreals lo the habit whenever te security is
threatened by events which occur around him. The child lends to sutler
increased anxiety when attempts arc made to correct the habit.
Non - compulsive habits
They are habits thai are easily learned and dropped as Ihe child
matures.
which -he oral and the anal phases are seer "n the first
three year o1 life. In +he oral ohose, the mouth is believed lo
be an oro-erotic zone. The child has Ihe tendency to place
his fingers or any other object into the oral cavily.
Prevention of such an act is believed to result in emotional
insecurity and poses the risk of the child diversifying into
other habits. Oro.f drive theory of Sears o.na' Wise : Sears
and Wise in 1950 proposed that prolonged suckling can
lead to thumb sucking.

Be n io m in's rhe on/ : Benjamin has suggested that thumb

sucking arises from the rooting or placing reflex seen in all
mammalian infants. Rooting reflex is the movement of'he
infant's head and tongue towards an object touching his
cheek. Tne object is usuolfy the mothers breasl but may
also be a finae' or a pacifier. This "ooting reflex disappears
in normal infnnts around 7 - 8 months of age.

Psychological aspects : Children deprived of parental love,

care and affection are believed to resort to this habit due ro
a feeling of insecurity.

Learned pattern : According to some authors, thumb

sucking is merely c learned pattern with no underlying
cause or psychological bearing.

Phases of development
 Ficj 1 Pholc-yfOphs o' a patient who
indt.lnec in llitwbsucking Mil thu cge ol
9 years [A!, IB) ond {C; Int'ao'ol
photographs (Dj .cloia! cepha'ocrarr.
ol lite scne aotient

Thumb and digit sucking are believed to cause a

Phase l/l r (Intractable sucking) : Any thumb sucking

the mandibular anteriors during tne sucking act. In
persisting beyond the fourth or fifth year o: life should such children lingual tipping
alert the dentist to the underlying psychological
aspects ot the habit. A psychologist might have to be
consulted during this phase.

Effects of thumb sucking

number of changes in the dental arch and the supporting
structures. The severity of the malocclusion caused by
thumb sucking depends on the trident of factors. They are :
a. Duration : The amount of time spent
indulging in the habit.
b. Frequency : The number of times tne habit is activated
in a doy.
c. JnferisiJy : The vigor with which the habit is performed.
The following are some ot the effects of
thumb sucking :
a. Labial tipping of the maxillary anterior teerh resulting
in proclination of maxillary arileriors.
b. The overjet increases due to proclination ol the
maxillary anteriors. Some children rest their hand on
Fig 2 Photographs d C pcriont who in'tiolly hod o thumosucking habit arr: loter diversified into -oi,nge "hvs' nabi*. Nore rha df.p.r. palote v/tli
rsrrowing ot "he maxi lary arrh wh ch ocojrs dje -o lev/Ore v to'iate posit'or associated with tie hcbi". A lixci; hobit brenkftf wos JSC d to irre'cep" rhe
'ounge -hn.st hobil.

of the mandibular inc'so's can be expected which further

increases the overjet. Anterior operi bite can occur as a
result of restriction cf incisor eruotion and supraeruption of

d. tne buccal 'eeth (fig I), The cheek muscles contract during
thumb sucking resulting in a narrow maxillary arch
which predisposes lo posterior crossbites (fig2).
9-

e. The child may develop tongue thrust hcbil as a result of

the open bite. The upper lip is generally hypotonic while the
lower part of Ihe face exhibits hyperactive menlalis activity.
 Zagnosls These
appliances
usually
consist of
a crib
placed
palatal to
the
maxillary
incisors.
Habit

A B
~-e parents should be
:khg end rorgue tirust'ng. [A; Rem ova b e hebi' breaker ;3)
'•z 2 ncbi" brea<ers jsec ir 1he ncnagarrant of rhumb si,: rabit breaker;

breakers can be of two types (fig 3).

quest'oned on Ihe frequency
a) Removable habit breakers : They are passive
[ 3 r d duration of tne habit. The child's emotional f s^r JS
removable appliances that consist of a crib and is
should be assessed by enquiring into such Ifetngs as:
anchored to the oral cavity by means of closps on the
; Feeding habits a. Porenral care of the child r. Wh elh
posterior teeth.
er tne pa ren ts a re wo rki n g
b) Fixed habit breakers: Heavy gauge stainless steel wire
An intra-oral clinica examination should
can be designed -o form a frame that is soldered to
oecord all the features seen such cs oroclination, bands on the molars.
icen bite etc.,. The child's fingers should be examined.
Other aids that can be used to intercept
Presence of clean nails and callus on ~e finger is
commonly associated with thumb :jcking.

Management of thumb sucking

Ps/cho/ogfco/ approach ; It is usually said —at
children lacking parental care, love and cnection
resort to this habit. Thus the parents should be
counseled to provide the child with idequate love and
affect on. The parents should iso be advised to divert
Ihe child's allention to other things such as play end
toys.
The success of any habit interception
oroceduro'largely depends uoon the subject's co-
operation and willingness to be helped to
discontinue his sucking habit. Thus the parents and the
dentist should seek to motivate :he cnild.
D jnlop out forward c theory called Beta
hypothesis that states that the best way to break a habit's
by its conscious, purposeful repetition. Dunlop suggests
thct the child snould be asked to sir in front of a large mirror
and asked losuck his thumb observing himself as he
indulges in the habit. Tnis procedure is very effective if the
J
child is asked to do the same at a time when he is involved
in on enjoyable activity.

Mechanical aids : They are basically reminding appliances

that assist the child who is willing to quit Ihe habit but is not
able to do so as tne habit has ertered a subconscious level.
 the ho bit include bandaging the thumb, end ba n da g ing of Tongue thrust can also be classified as simple
the el bow. tongue thrust and complex tongue thrust.

102 Orthodontics - The Art and Science

Chemicai1 approach : Use of bitter tasting or foul smelling
preporation placed or the thumb that is sucked can make
the habit distasteful. The medicaments that car be used
include :
a. Pepper dissolved in a volatile medium
b. Quinine
c. Asafetia'a

TONGUE THRUST HABIT

Tongue thrust is defined as a condition in which the tongue

makes contact with any teeth anterior to the molars during
swallowing.

Etiology of tongue thrust

Fletcher has oroposed the following facrors as being the
cause fo>-tongue thrusting.

Genetic ioctors ; They are specific anatomic or

neuromuscular variations in the oro-facio region that can
orecipilate tongue thrust, e.g. Hypertonic orbicularis oris
activity.

Learned behavior (ha b ft) : Tongue th Tuscan be acquired

as a habit. The following are some of Ihe predisposing
factors that con iead to tongue thrusting :
a. Improper bottle feeding
b. Prolonged thumb sucking
c. Prolonged tonsillar and upper respiratory tract
infections
d. Prolonged duration of tenderness of gum or teeth can
result in a change in swallowing pattern to avoid
pressure on Ihe lender zone
Moiuraiionoi : Tongue thrust can present as part of a
normal childhood behavior that is grodually modified os ihe
age advonces. The infnntile swallow changes lo a rnalure
swallow once the posterior deciduous teeth start enjpting.
Sometimes Ihe maturation is delayed and t.nus infantile
swallow persists for a longer duration of time.
Tabfe
2 Braneram
Type I: Non-determing tongue thrust Type I I :
Deforming anterior fcygje thrust Sub group t :
Anterior open bite Sub group 2 : Anterior
proclination Sub group 3 I Posterior crossbite.
Type III : Deforming lateral longue thrust
Sub group 1: Posterior open bite Sub group
2 : Posterior crossbite Sub group 3 : Deep overbite Type
IV : Deforming anterior and lateral tongue thrusi
Sub group 1: Anterior and posterior open bite
Sub group 2 : Prodination ot anterior teeth Sub
group 3 : Posterior crossbite

Mecfidnicaf restrictions ; The presence of certain

conditions such as macroglossio, constricted dental arches Simple Classification of Tongue
thrust
and enlarged adenoids predispose to tongue thrust habit.
Simple tongue thrus! Complex tongue thrust
Neurological disturbance ; Neurological disturbances
affecting the oro-facial region such as hyposensitive palate
and moderate motor disability can cause tongue thrust
habit.

Classification of tongue thrust

Toblc 2 gives the James and Holt classification of tongue
thrust. The term non-deforming in this classification imolies
that the inter-digilafior of teeth and the profile ore
acceptable and within normal range. Deforming tongue
thrust is associated with some dento-alveolar defect.
 Habits

Pig 'l Patient will anterior -oncjje tn'LS*

rsycnoge^ic factors : Tongue thrust con sometimes occur
as a result of forced dscontinuarion of other habits like
thumb sucking. - is often seen that children who are forced
to ;eave thumb sucking habit often lake up tongue testing.
SimpJe tongue thrust
The following features can be observed : c The simple
tongue thrust is cnaracleri/ed by a normal tooth contact
during the swallowing act.
c Presence of an anterior open bite, jc They exhibit good
inlercuspalion of teeth, z Tne tongue is thrust forward
during swallowing
lo help establish an anterior lip seal, e Abnormal
mentalis muscle activity is seen.
The tongue thrust can be intercepted by use of habit
breakers as described for thumb sucking. Both fixed
and removable cribs or rakes are valuable aids in
brooking the habit.
The child is taught the correct method of swallowing.
Various muscle exercise of the tongue can help in
training il lo adopt to the new swallowing pattern
(Refer chapter 20).
Treatment of ma/ocdusion :' Once the habit is intercepted
the malocclusion associated with Ihe tongue thrust is
treoled using removoble or fixed orthodontic appliances.

Complex tongue thrust

The following features are seen : c This kind of tongue
thrust is characterized by
a teeth apart swallow, c The anterior open bite con be
diffuse or absent.
c Absence of temporal muscle constriction
during swallowing. ^ Contraction of the circumorol
muscles during
swallowing, e The occlusion of teeth may be
poor.
Clinical features
The rongue thrust habit con be associated with the
following features:
a. Proclination of anterior teeth
b. Anterior open bite •
c. Bimaxillary prolrusion
d. Posterior open bite in case ot lateral tongue thrust
e. Posterior crossbite

Management of tongue thrust

The monagement of tongue thrust involves interception of

Iw
the habit followed by treatment to correct Ihe malocclusion.

Habr'f interception ;
 MOUTH BREATHING HABIT b. Narrow nose and nasal passage C.
Short and fiaccid upper lip
Mouth breathing has been at'ibuted csa possible
d. Contracted upper arch with possibility of posterior
104 Orthodontics - The Art and Science
cross bite
etiologic factor for malocclusion. The mode of
e. An expressionless or blank face
resp'ration influences the posture of the jaw, the tongue
f. Increased overje* as a result of flaring of Ihe incisors
and to a lesser extent the head. Thus it seems ouite
g. Anterior marginal gingivitis can occur due to dn/ing of
logical "hat mouth breatning can result in altered jaw and
the gingiva (fig 6)
tongue posture whicn could alter the oro-fac'al
h. The dryness of the mouth predisoosestocaries i .
equilibrium thereby leadirg to malocclusion. Most
Anterior open bite con occur
normal people indulge in mouth brecthing when they are
under physical exertion such cs during strenuous 0/agnos/s of mouth breathing
exercise or sports activity.
History : A good history snould be recorded from the
C/ass/ftcae/ort of mowt/i fcreat/iers patient as well as parents. Clinical examination : Loo< out
for its various clinical leatures. A number ot simole tests
Mouth breathers can be classified 'nto 3 types :
can be carried out to diagnose mouth breathing such cs
a. Obstructive
the mirror test, wo tor test ctc. (Refer chapter 11}.
b. Habitual
c. Anatomic Cepho/omefrics ; Cephalometric examination
Obsfryctfve : Complete or partial obstruction of tne
nasal passage can result in mouth brecthing. The
following are so Tie of the causes ' o^ nasal obstruction:
a. Deviated nasal septum
b. Nasc' oolyps
c. Chronic inflammation of nasal mucosa
d. Localized benign tumors
e. Congenital enlargement of nasal turbinates
f. Allergic reaction of tne nasal mucosa
g. O bstru ctive a den o id s

Hobitooi : A nabitual mouth brcatner is ore who

continues to breathe through his mouth ever though the
nasal obstruction is removed. Thus mouth breathing
becomes a deep rooted he bit that is performed
unconsciously.

Anatomic ; An anatomic mouth breather is ore whose lip

morn h o logy does not permit complete closure of the
moutn, such as a patient having short upper lip.
Pathophysiology
During oral respiratior, rhe following three charges in the
posture occur :
a. Lowering of the mandible.
b. Positioning the tongue dowrwards and forwards.
c. Tipping bcck cf the nead.
Lowering of the tongue ard mondible upsets the
oro-facicl equ'librium. There is an unrestricted buccinator
activity that influences -ne position of the -eeth ond o so
the growth of the jaws.

Clinical features of mouth breathing

Tne type of malocclusion most ofter associated with mouth
orccthing is called iong :aco syndrome or the clcssic
adenoid facies. These patienrs exhibit the following
featu'es :
a. Long and narrow face I'fig 5)
Habits
 Orthodontics - The Art and Science

'ntercepfion of the habit : Mouth breathing can be

intercepted by use of a vestibular screen. Alternatively
adhesive tapes con be used to establish lip seal.
,Rop/d maxillary expansion : Patients with narrow,
constricted maxillary arches benefit from rapid palatal
expansion orocedures aimed at widening the arch.
Raoid maxillary exoansion has been found lo increase
the ncsal air flow and decreose the ncsal air
resistance.

o. Occl usa I wea r facets ca n be o bse n/ed o n the

teeth.
b. Fractures of teeth and restorations.
c. Mobility of teeth.
d. Tenderness and hypertrophy of masticatory
muscles,
e. Muscle pain when the patient wakes up in the
morning.
f. Temporomandibular joint pain and discomfort can
Fig 6 Parent v/ith mouth breathing 'icbit exhibiting anterior mci'ginol occur,
gingivitis.

helps in establishing' the amount of nasopharyngeal s

price, size of adenoids and also helps in diagnosing the
long face associated with mouth breathing.

Rhinomanomeir/ : It is the study of nasal air flow

characteristics using devices consisting of flow
meters'/and pressure gauges. These devices help in
estimation of air flow through the nasal passage pnd
nasal resistance.

Management ot rooatft fireaM/ng

Removal of nasal or pharyngeal obstruction: Any
nasal' or pharyngeal obstruction should be removed by
referring the patient to the E,N,T, surgeon.
BRUXISM.;'

Bruxism can be defined as the grirding of teeth for

non-functional purposes (fig 7) Some authors refer to
nocturnal grinding as bruxism while Ihe term
bruxomania is given for grinding during the day time.

Etiology
'l. Psychological and emotional stresses have been
attributed as one of the causes of bruxism.
2. Occlusal interfere nee or discrepancy between
centric relation and centric occlusion can
predispose to grinding.
3. Pericoronitis, and periodontal pain is said to trigger
bruxism in some individuals.

Clinical features
 This habit can be intercepted using lip
bumpers that not only keep the lips away but also
improve the axial inclination of the anterior-teeth due to
unrestrained action of the tongue.

Nail biting
Nail biting does not produce gross malocclusion. Minor
local tooth irregularities such as rotation, wear of
incisal edge and minor crowding can occur as a result
of nail biting. People in certain

rig 7 Pa-ient witn bruxism show rig ott.'it'on o ; teeth

Fig 8 Patieo.l Wi'h nut Uificvg habit exhibiting typical wear of ihe
leetlfand mild malalignment-
Diagnosis
-istoryand clinical examination in most cases is
sjfficiont to diagnose bruxism. Occlusal crematurities
can be diagnosed by use of articulating papers.
Electromyographic examination can be carried out to
check for hyperactivity of the muscles of mastication.

Treatment
Many cases of bruxism are associated with emotional
and psychological disturbances. Thus appropriate
psychological counseling by a psychiatrist maybe
initiated. Hypnosis, relaxing exercises and massage
can help in relieving muscle tension. Occlusal
adjustments have to earned out to eliminate
prematurities, Night guards or other occlusol splints
that cover the occlusal surfaces of teeth help in
eliminating occlusal interference, prevent occlusal
wear and break the neuromuscularadaptation, .

OTHER MINOR HABITS •

Lip biting

Lip biting and fip sucking sometimes appear after

forced discontinuation of thumb or finger sucking. Lip
biting most often involves the lower lip which is turned
inwards and pressure is exerted on the lirgucl surfaces
of the max ill o ry anteriors. The. patient may exhibit
the following features:
a. Proclined upper anteriors and retroclined lower
anteriors
b. Hypertrophic and redundant lower lip
c. Cracking of lips
 countries in middle east exhibit what :s called the nut
notch which is a wear of teeth in the form of c notch.

Orthodontics - The Art and Science

This is a result of cracking open and eating hard nuts
using the incisal edge of tne anteriors (fig 8). These
patients may exhibit mild irregularities and rotation of
teeth.

References
19. Robert z Meyers : ^ard book of Crthodon-ics, Year boo< red ccl
publishers, inc. 1908.
20. T'osk, S napi'o, arc Shcpiro : Efects cf alle'eic rh nitis on oerol
ond s<ele'ol devs opr-fir. Am J Ortnod
1967; 286-293
21. " u 11 c v : Adverse muse o forccs Their diagnostic signif'cence.
Am - Orthcd 1956 ; 80'-814
22. Ihg, <oerig, Shac'rc. Snopi'o, and Tras< : Quon-i- fied
respiration end faciei form. Am - Orthod 1990 ; 523-532
23. Vig : Masai ci-flov 'ootor tc facial morphology. Am J Orhod '98' :
263-272
2^. Women, l la rfield, and Dolstor : Nasal air//ay im- paVncv Am J
Orthod 1991 ; 3^6 353
25. Worren, Ha'neld, Seaton, fv'iorr, end Smith : Nasal si2e arc
ncscl breaking. Am J Orlhod i 983 ;259- 293
26. Worrer, Hershey, Turkey, H'nton, end Hairf'eld : Nasal airway
follov/ng maxillary expansion. Am J Orhod 1987 ;111 -116
27. Wicrren, Lehman, and H'rton : Analysis of st'rru- cted upper
air.vav breohing. An J'Orhod 1934 ■ ' 97-2C6
23. Wo be, Preston, and Wr'gr : Resislcnce ro nascl
airflow reta'ec to changes r head postjre. Am J
Orhod 1981 ; 536-5-15
29. William Chris'ie Show : Orthodontics and OCCIJSOI r-enagenen\
Wright, 1993
30. VVooc'side,Lincer-A'onson, Lundstrom, ard McWilliarr :
Murdibtlar end maxillary grov.-tn a:ter rhnngeo nods of
brecthing. Am J Orthcd 1991 .'TIS
M any organized populationsurveys have
been carried oul in different parts of the
world with the objective of
srmating prevalence of
had Angles Class I malocclusion and " 7% had Angle's
Closs II malocclusion. The zrevolence of malocclusion
among Indian —ildren has been reported to be as low
as 19.6% in Madras by Miglani D.C. et al in 1965 and as
malocclusion and high as 90% in Delhi by Sidhu S.S. in 1968. Indians
cmodontic treatment
> t 4 t« ^ t ♦ t > }> t * I .-v j j A .. j - , - •» .AI ^uyi ^^
needs. Prevalence of
T-c!occlusion is it J u ^..„yy

estimated to be higher in exhibit a low incidence of variation in molar relation both

se.eloped countries o s in the mesial and distal direction. Disto-occlusion in
compared to developing India is very low in contrast to USA (34% in Whites and
under-developed 15% in Blacks) and Europe {29%).CIass III
malocclusion is also much less prevalent in Indio

idemiology of compared lo USA, Netherlands

Prevalence of malocclusion in a sample of leboncse
and Kenya.

locclusion schoolchildren was found to be about 59.5%. A

study conducted to determine the prevalence and
countries. severity of malocclusion in Arab urban children of 13 to
A number of studies 15 years age revealed that 85 percent had Angle Class
have been conducted •xz I malocclusion, 8.5 percent had Angle Class II, Division
Mil determine the prevalence of 1 malocclusion, 1.7 percent had Angle Class II, Division
malocclusion in nrerent countrios. The 2 malocclusion, and 1.3 percent belonged to the Angle
prevalence of malocclusion ™ong Chinese children Class III category. In a study done by the Federal
was estimated to be ;oout 67.82%in a study done by University of Rio d e Janeiro, Brazil the prevalence of
Peking «^..versity. In on epidemiological survey of malocclusion in Brazilian children was estimated to be
1,028 cr-dren carried out to assess the prevalence of 75.8%.
-ciocclusion in Nigeria, it was seen that children £-1.0%

4 983 ;334-340
2. El ingscn, Vancevon'er, Shoo rc.. and Shapiro : Ten- pcol
va'ianon ii breathing. An„ Orthod 1995 ,41 1 417
3. Fields, Werner, 3lack, and Phil ips : Vertical ~icr- pholcgy and
reso'raticn in adolescenls. An J Orhod
1991 ; 147-154
4. Graber: The 'three M's': Muscles, Malformation end
Malocclusion. Am J Orthod 1963 ; 418-450
5. Gross, Kalium, Morris. Franz. Michas, Fester, Wal<er, era D is
no c : Rhine rnetry and open-mouth pestjre. Am J Onhod 1993
.-526-529
6. Hcrrukse a and Vfifinfiner : Predisposing fac'o's for nolccclLsicn
as re cted to ctccic diseases. Am J
O-thod 1987 299-303
7. Hannukselo and Vacranen : Predisposing factO'S tor
nclcccusicn as 'elotec to otco'c c'isecses. Arn J Orthod 1987 ;
299-303
8. Hnton, Warren, rird Hoirfield : U peer ci'woy pressures durinq
breathing. Am J Orthod 1986 ; 492- 493
9. Jacobscn : Psychology and ear •/ 'orthodontic t'eat- ment Ani J
O-thod 1979 ; 511-529
. 1C. Klein : P'essure hebits, etiological factors in •maloccdusion . Am
J Onhod 1952 ,- 569-58/
11. Lersson and Danlin : Prevalence end etiology of inrial djrrmy-
and nnger-scckina habt. .Am J Orthod 1985
; 432-435
12. Lcrsson and Danlir : P'evclence end otology of iri'ia dummy-
and -inger-suckine han't. Am J Orthcd 1985 ; ^32-435
13. Leiter crd Baker. Partitionlrg of vent'latior and
nasal resistance. Am J Orhod 1989 ; 432-438
14. Marks ; Bruxism r ol'ergic chidren. Am J Orthod 1 98C /8-59
15. Meyers and Hertzhe'g : Hottle-feed'ng and irclocc usion. Am J
Orhod 1988 ; 149-152"
16. Ocaarc, Lcrsson, and L'rcs'en : Effect cf sucking habits on
posterior c-ossbite. Am J Orthod 1994 ;161- 166
17. Prcfitt WR: Contemaorary Orthodontics, St Louis,
Cs'M.osby,1986.
M
18. Regan and Sublelny : Correction o ; severe Cess II
malocclusior. Am .1 Orthcd 1989 ; 192-199
110 r Orthodontics - The Art and Science
MEASUREMENT OF MALOCCLUSION The 'Handicapping La bio-Ungual Deviation Index1
(HLD Index) was developed by Harry L. Droker in 1960.
Malocclusion and dento-facicl deformity are conditions
The HLD index was proposed to select
that constitute a hazard to the maintenance of oral
subjects with severe or handicapping malocclusion and
health and interfere with the well being of the person by
dento-facial onomalies. The index is applicable only to
adversely affecting dento-fccial aesthetics, mandibular
function or speech. the permanent dentition. HLD index was the first

The measurement of malocclusion as a public orthodontic index designed to meet the administrative

health problem is extremely difficult since most needs of program planners.

orthodontic treatment is undertaken for oesthetic

reasons and it is very difficult to estimate the extent lo
which molposed teeth or dento-fccial anomalies
constitute a psychological hazard. Malocclusion has
Method
The three planes commonly used for orthodontic
orientation i.e. the sagittal plane, Ihe Frankfort

proved to be a difficult entity to define because horizontal plane and the orbital plane are the basis for

individual perceptions of what constitutes a the HLD index measurements. The main intention of the

malocclusion oroblem differ widely. As a result, no HLD index is to measure the presence or absence and

generally accepted epidemiological index of the degree of the handicap caused by the components

malocclusion has yel been devised. of the index. The HLD index is based on seven
According to Russell, an Index is defined as 'a components. All measurements are made with a Boley
numerical value describing the relative status of a gauge scaled in millimeters. The seven component
population on a graduated scale with definite upper and conditions of the HLD index are explained as
lower limits which is designed to permit and facilitate
comparison with other populations classified by the
same criteria and methods.
Jamison H.D. and McMillan R.S. have
proposed a list of requirements for an ideol orthodontic
index that can be used in the epidemiologic studies of
orthodontic problems, as follows:
1. The index should be simple, accurate, reliable and
reproducible.
2. The index should be objective in nature and yield
quantitative data which may be analyzed by
current statistical methods.
3. The index must be so designed as to differentiate
between handicapping and non- handicapping
malocclusions;
4. The examination required must be one that can be
performed quickly by examiners even without
special instruction in orthodontic diagnosis.
5. The index should lend itself to modification for the
collection of epidemiological data, regarding
malocclusion other than prevalence, incidence,
severity e.g. frequency of molpositioning of
individual teeth. •
6. The index should be usable either on patients or on
study models.
7. The index should measure Ihe degree of handicap,
if any and avoid classifying 'malocclusion1.

HANDICAPPING LABIO-LINGUAL
DEVIATION INDEX (HLD INDEX)
 Condition # 7 - La 6 ro-/in gua/ spread : To measuro
labio-lingual spread, the Boley gauge is used to
Conditions Observed determine the extent of deviation from a normal arch.
The total distance between the most protruded and the
Set pa/ate
lingually displaced anterior ismeosured.
«•.ere traumatic deviations
In the event of multiple anterior teeth
0»e*jet in mm Cvtfbite in mm
crowding, oil deviations from the normol arch should be
Vandbula' protrusion in mm
measured for labio-lingual spread, but only the most
Cpen bite m mm Eoopic
severe individual measurement should be entered on
eaiption. anteriors at/ e&tfi
tooth fcterior crpWding the index. This is done to give the patient the benefit of

Maxilla ........................ the greatest deviation.

Mandible ..............
*ok»vs:
Conditio n # ?- Cleft Pa/ate : This condition a
described as malocclusions resulting from serious
structural deformities involving growth and revslopment
ol Ihe mandible and maxilla. The presence of cleft
palate is indicated by an "X1 in ire recording chart.
Condition # 2 - Traumatic Deviations :The Toumatic
deviations referred to ore, for e.g. loss rra premaxilla
segment by burns or by accident, re results of
osteomyelitis or other gross pathology. The presence of
a traumatic deviation is also -Seated by an X' in the
recording chart.
The above explained HLD index system is a
modification of an earlier used HLD index. The HLD
index used prior to the new HLD index i.e. before 1960's
made use of weighting factors developed by trial and
error. This index system had nine component conditions
measured. The conditions observed and scores
assigned are given inTable II.
A score of 13 (tentative) and over constitutes a
physical handicap'.
The following codes are used in the HLD
index.
O : Condition absent X :
Condition present

Condition # 3 - Overjet : This condition is -veasured with

the patient in centric relationship. ~ne measurement
can be applied to a protruding angle tooth as well as to
the whole arch. The measurement is read and rounded
off to the -earest millimeter and recorded.

Condition # 4 - Overbite : This measurement ^ also

rounded off to the nearest millimeter and recorded.
Reverse overbite may exist in some conditions ond
should bo measured and recorded.

Condition # 5 - A'1anc/ibu/ar Protrusion : This is

measured from the labial of the lower incisor to the
labjal of the upper incisor. The measurement
in millimeters is recorded. A reverse overbite
if present should be shown under 'overbite'.

Condition # 6 - Open bite : This condition is defined as

the absence of occlusal contact in the anterior region.' It
is measured from edge to edge in millimeters and
recorded.
V : Mixed dentition (to be indicated if
I I
5. Tooth displacement
present) A : Clinical
6. Congenially missing teeth
approval D : Clinical disapproval
7. Unerupted central incisors
8. Mandibular prognathism
ORTHODONTIC TREATMENT PRIORITY
9. Mandibular retrognathism and
INDEX (TPI)
10. Posterior crossbite
The Orthodontic Treatment Priority Index (TPI) was TPI is based on a scale of '0 to 3", '4 to 6' and
developed by Grainger R.M. in 1967. The TPI was a 'over 6'. The TPI tends to give more consistent
revision/modification made by Grainger over the earlier percentage of prevalence, relative to age.
developed 'Malocclusion Severity Estimate1. TPI is' TPI scores can be expressed in the ranges
based on the study of interrelationships of 10 of:
manifestations of malocclusion. TPI includes seven 0-2.5 = Low 2.5-4.5 =
syndromes and quantifies oral inter-relations hips in Middle above 4.5 = High
terms of the seven syndromes. The 10 manifestations TPI serves as a guide for epidemiological
of malocclusion measured in TPI are : surveys of populations as well as an instrument for
1. Bimolar relationship screening. TPI has been used in national studies of
2. Maxillary overjet orthodontic needs of children.
3. Open bite 4: Overb/te

Count the number of teeth displaced or rotated.

Assessment of tooth displacement and rotation Is
qualitative -(all or none).

Malalignment Index by Vanklrk Tooth displacement and rotation were measured.Tooth

andPennel(1959) displacement defined quantitatively: <1.5mm or > 1.5mm.
Tooth rotation defined quantitatively: <45c or
Master and Frankel (1951)

Handicapping Lablo - Ungual
Deviation Index by Draker
(I960)
Measurements include deft
paJate (all or none), Iraumalic
deviations (all or none), overjet {mm), overbite {mm},
mandibular protrusion {mm), anterior cpen bite (mm),
arid labio-lingualspread (a measurement of tooth
displacement in mm),

Occlusal Feature Index by PouHon

andAaronson(1961)
Measurements include lower
anterior crowding, cifcpal
intendigitation, vertical overbite,
and horizontal overjet.
 ?.VS» >"••> SFIVVS'*
Malocclusion Severity Estimate by
linger (1960-61)
Occlusion features measured
and scored according to
defined criteria.
Seven weighted and defined
measurements:
Overjet 2. Overbite 3. Anterior
open Me 4. CorxjerotalJy '
missing maxillary incisors 5.
Occlusal Index by Summers (1966)
Treatment Priority Index by Grainger (1967)
Epidemiol
ogy of
Malocclusi
indices'of occlusion-continued
on
Firstpermanentmolarrelationship 6. Posterior
crossbite- 7. Teeth displacement (actual and
potential).
Six malocclusion syndromes were defined:
1 .Positive overjet and anterior open bite.
Posl1ive overjet, positive over bite, distal molar
relationship. arid posterior crossbite with maxillary
teeth buccal to mandibular
Negative oveijet, mesial molar relationship, andposterior
aossbite with maxiUary teeth lingualto mandibular teeth.
Congenially missing maxillary incisors.
Tooth displacement
Potential tooth displacement.
Nine weighted and defined measurements ;
1. Molar relation 2. Overbite 3. Overjet 4. Posterior cross We
5, Posterior open bite 6. Tooth displacement 7. Midline
relation 8. Maxillary median diastema 9. Congenitally
missing maxillary incisors.
Seven malocclusion syndromes defined:
1.Overjet and open bite.
2. Dislal molar relation, overjet, overbite, posterior
crossbite, midline diastema, and midline deviation.
3. Cor>genitalty missing
maxillary incisors; 43mdisplacement
(actualand potential).
5.Posteriofopenbite.
«.Mesial molar relation, overjet, overbite, posterior crossbite,
midline diastema and midline deviation.
7. Mesial molar .relation, mixed dentition analysis
(potential tocth displacement), and ipoth displacement.
Different scoring schemes & iorms for different stages
ot dental development; deaduousdentition, mixed
dentition, a permanent dentition.
11 weighted and defined measurements: 1. Upper anterior
segment overjet. : 2. Leaver anterior segment overjet 3.
Overbite of upper anterior lower anterior .4;Ar)ierarcpenbite
5. Congenital absence ot incisors:
6.Distal molar relation
7. Mesial molar relation
I \1
 9. Posterior crossbite (maxillary leeth lingual lo normal)
10. Tooth displacement
11. Gross anomalies.
Handicapping Malocclusion Weighed measurements consist of three parts:
Assessment Record by 1. Intra-arch deviation- missing teeth, crowding,
Salzmann{1968) rotation.
Seven malocclusion syndromes were spacing.
defined: 2.Interarch deviation - overjet, overbite, aossbite,
1. Maxillary expansion syndrome cpen bite., mesicdistal deviation.
2. Overbite 3. Six handicapping dento-faclaideformi:ies.
3. Retrognathism 4; Open bite 1. Facial and oral clefts
5. Prognathism 2. lower lip palatal 10 maxillary incisors
B. Maxillary collapse syndrome 7. 3. Occlusal interference
Congenital^ missing incisors 4. Functional jaw limitation
5. Facial asymmetry
6. Speech impairment.

This part can only be assessed on live pat

ents.
 .r-.

Orthodontic Diagnosis
■■H B

O
rrhodontic diagnosis deals with recognition b) Bite wing
of the various characteristics of the c) Panoramic
malocclusion, h involves collection of 5. Facial photographs
pertinent data in a T»stema»ic mannerto nelp in
identifying rne nature and cause of the problem.
Ormcdontic diognosis should be based on sound
scientific knowledge combined at times with clinical
experience and common sense.
Diagnosis involves development of a
comprehensive data base of pertinent information. The
data is derived from case history, clinical exomination
and other diagnostic aids such as study casts,
radiographs and photographs. A systematic opproach
to the examination is essential to ensure that nothing is
overlooked. The purpose of this chapter is to describe
and illustrate fundamentals of gathering and
interpreting clinical information yielded from a
diagnostic
exercise.
Comprehensive orthodontic diagnosis is
established by use or certain clinical implements called
diognostic aids. Orthodontic diagnostic aids are of two
types. They are the essentiol diagnostic aids and the
supplemental diagnostic aids.

ESSEWTMJL DIAGNOSTIC AIDS

They are clinical aids that are considered very important

for all cases. They are simple and do not require

wr
expensive equipment. The following are the
essential diagnostic aids.
1. Case history
2. Clinical examination
3. Study models
A. Certain radiographs
a) Periapical radiographs
 SUPPLEMENTAL
1601?" Orthodontics
DIAGNOSTIC AIDS- The Art andsocio-economic
Science status of the patient and parents. This
helps in selection of an oppropriate appliance. The
They are certain aids which are not address also helps in future correspondence such as
essential in all coses. They may require specialized to intimate appointments.
equipment that an average dentist may not possess. Chief complaint
The supplemental diagnostic aids include : The patient's chief complaint should be recorded in his
1. Specialized radiographs e.g. or her own words. This helps the clinician in identifying
a. Cep halo metric rodiogrophs the priorities and desires of the patient. Most patients
b. Occlusal intra-oral films seek orthodontic care for reasons of either esthetics or
c. Selected lateral jaw views impaired function.
d. Cone shift technique
2. Electromyographic examination of muscle activity
Medical history
3. Hand-wrist radiographs to assess bone age or Before orthodontic treatment is undertaken, a full
maturation age medical histony is recorded. Fortunately very few
4. Endocrine tests medical conditions contra indicate the use of
5. Estimation of basal metabolic rate orthodontic appliances. Most of these conditions may
6. Diagnostic setup require certain precautionary measures to betaken
7. Occlusograms prior to or during the orthodontic therapy. It is
advisable to delay orthodontic treatment in patients
CASE HISTORY
suffering from epilepsy until it is controlled. Patients
with history of blood dyscrasias may need special
Case history involves eliciting ond recording of
management if extractions are planned.
relevant information from the potient and parent to aid
in the overall diagnosis of the case. The information is 'H f
gathered from the patient and parents. i

Personal details
Nome : The patient's name should be recorded for the
purpose of communication and identification. Most
patients like being called by their name. Addressing a
patient by his or her name has a beneficial
psychological effect as well. It gets the patient to think
that the clinician is interested in his well being. In case
of children it is wise to record their pet names. Age :
The patient's chronological age should be recorded.
Age consideration helps in diagnosis as well as
treatment planning. There are certain transient
conditions that occur during development that are
considered normal for that age. Thus knowing the age
helps in identifying and anticipating these condition. In
addition, there are certain treatment modalities that are
best carried out during the growing age. Growth
modification procedures using functional and
orthopaedic appliances are carried out during the
growth period. Surgicol resective procedures are best
carried out after the cessation of growth. Sex: The
patient's sex should be recorded in the case history.
This is important in planning treatment as the timing of
growth events such as growth spurts is different in
males ond females. Females usually precede males in
onset of growth spurts, puberty and termination of
growth. Address and occupation : Recording of the
address and occupation helps in evaluation of the
 Orthodontic Diagnosis

Sex M F File No

Jddress

Phone Number

Qfef Complaint

Medical History Dental History

Profile Mesocephalic
Extraoral Examination Dolicocephalic Brachycephalicj
Convex Concave Slraight
Shape of Face
Shape of Head

Facial Divergence
Anterior Posterior Straight Round Oval Square

Lips
Facial Symmetry
Symmetrical Asymmetrical
Competent Incompetent Everted

Nasolabial Angle Mentolabial Sulcus

Normal Acuie Obtuse;. Normal Deep Shallow

WT
 1601?" Orthodontics - The Art and Science

§§§§

Tongue Size
Normal Small Large Normal Tongue thrusting

T.M.J Frenum

Norma Pain Clicking Normal Abnormal

Path ot closure Breathing

Normal Deviated'isft Deviated right Oral Nasal Oro-nasal

Intraoral Examination
Permanent dentition
8 v-' N 6 5 ' r • 3 2 1 1 2 3 4 5 6 7 8

@©©©©©©© @m@M@
B®
Dec<Juou$ dentition.

EDCBA

Gums
Palate

Overjet

ABCDB
Frenum
Overbite

Molar relation Canine relation

 Details of malocclusion present

| ___| Rotations

I I Proclination

Crowding Anterior crossbile

Posterior crossbile
.

Spaclngs
 Diagnostic aids

| J Study models j j OPG | | Lateral cephalogram: | j BHewIng radiographs

| [ Occlusal radiographs j j Pholographs | | |j

Diagnosis

Treatment Objectives

Treatment Plan

I consenf to the treatment plan described above by my

Orthodontist and have been notified of the possible side
effects and complications of the above treatment

Patient Signature Doctor's Signature

W
 120 Orthodontics - The Art wmmsmm •
and Science

Diabetic patients can undergo orthodontic therapy if it is
under control. Patients having rheumatic fever or
cardiac anomalies require antibiotic coverage. Children
who are severely handicapped either mentally or
physically may require special management.
The medical history should include
information on drug usage. The use of certain drugs
like aspirin may impede orthodontic tooth movement.
Patients who are suffering from acute, debilitating
conditions such as viraf fever should be ollowed to
recover prior to initiating orthodontic treatment.
Dental history
The dental history of the potient should include
information on the age of eruption of the deciduous and
permanent teeth, history of extraction, decay,
restoralions and trauma to the dentition. The past
dental history helps in evaluation of patient's and
parents attitude towards treatment.
Pre-natal history
The pre-natal history should include information on the
condition of the mother during pregnancy and Ihe type
of delivery. The use of certain drugs like thalidomide or
affectation with some infections during pregnancy like
German measles can result in congenital deformities of
the child.
Information should be gathered on the type of
delivery. Forceps delivery predispose to
temporomandibular joint injuries which can manifest as
marked mandibular growth retardation.
usually begins his general examination as soon as the
patient enters the clinic.
Height and weight
The height and weight of the patient are recorded.
They provide a clue to the physical growth and
maturation of the patient which may have dento- facial
correlation.
Gait
It is the way a person walks. Abnormalities of gait are
usually associated with neuromuscular disorders
which may have a dental con-elation.
Posture
Posture refers to the way a person stands. Abnormal
postures can predispose to malocclusion due to
alteration in maxillo- mandibular relationship.
Body build (physique)
It is possible to classify the physique into one of the
following three types:
a. Aesthetic : They have a thin physique and usually
posses narrow dental archos.
b. Pletoric : They are persons who are obese. They
generally hove large, square dental arches.
f-

Post - natal history

The post - natal history includes information on the type
of feeding, presence of habits and on the milestones of
normal development.
Family history
Many malocclusions such as skeletal Class II, Class
III malocclusions and congenital conditions such as
clefts of lip and palate are inherited. Thus the family
history should record details of malocclusion existing
in othor members of the family.

GENERAL EXAMINATION

The general examination comprises of the general

assessmentofthe patient. An observant clinician
 c. Athletic : They ore considered normally built being
neither thin nor obese. They have normal sized
dental arches.
Sheldon has classified the general body build
into three types :
The patient's facial symmetry is examined to determine
disproportions of the face in transverse and vertical
planes. In most people the right and left sides are not
identical (fig 2). Thus some degree of asymmetry is

B
Fig 1 Clossificotion of Head types (A) Mesocepholic head (B| Brncnycaphalic: head (C! Dolicocephalic head considered normal.

a. Ectomorphic : Tall and thin physique Asymmetries

b. Mesomorphic : Average physique that are gross and are detected easily should be

c. Endomorphic : Short and obese physique recorded. Gross facial asymmetries can occur as a
result of:
a. Congenital defects
EXTRA - ORAL
b. Hemi-facial atrophy / hypertrophy
c. Unilateral condylar ankylosis and hyperplasia
EXAMINATION Shape of the
Facial profile

The facial profile is examined by viewing the patient

head
from the side. The facial profile helps in
The head can be classified into one of the following
*hree types: (fig 1)
a. Mesocepholic: Average shape of head. They
posses normal dental arches.
b. Dolicocephalic : Long and narrow head. They have
norrow dental arches.
c. Brachycephalic: Broad and short head. They have
broad dentol arches.

Facial form
A simple way of describing the face is to classify it cs

either round, oval or square. A more scientific

classification is to classify face into the following three
types:
a. Mesoprosopic : It is an average or normal face
form.
b. Euryprosopic: This type of face is broad and short.
c. Leptoprosopic: It is a long and narrow face form.

Assessment of facial symmetry


Orthodontics - The Art and Science
diagnosing gross deviations in the maxillo- mandibular
relationship. The profile is assessed by joining the
following two reference lines :
1. A line joining the forehead and the soft tissue point
A (deepest point in curvature of upper I'P).
2. A line joining point A and the soft tissue pogonion
(most anterior point of the chin).
Based on the relationship between these two
lines, three types of profiles exist.
Straight profife ; The two lines form a nearly straight line
(fig 3.a).
Convex prof/,'e : The two lines form an angle with the
concavity facing the tissue. This kind of profile occurs
as a resulf of a prognathic maxilla or a retrognathic
mandible as seen in a Class II, Division 1 malocclusion
(fig 3.b).
Concave profile : The two reference lines form an
angle with the convexity towards the tissue.
 Orthodontic Diagnosis 123

Anterior divergent ; A line drawn between the forehead

and chin is inclined anteriorly towards the chin (fig 4.a).

Posterior diverge/if : A line drawn between the foreheod

ond chin slants posteriorly towards chin (fig 4.b).

S/roignt or orthognathic ; The line between the

forehead and chin is straight or perpendicular to the
floor (fig 4.c).
The facial divergence is to a large extent
influenced by the patient's ethnic and racial
A background. .

Assessment of antero - posterior Jaw

relationship
The antero-posterior relationship between the upper
and lower jaw can be assessed to a certain extent
clinically. Ideally the maxillary skeletal base is 2 - 3 mm
forward of the mandibular skeletal base when the teeth
are in occlusion. Estimation is done by placement of the
index and the middle fingers at the soft tissue point A
and point B respectively. This can also be done in the
same way after retracting the lips. In skeletal Class II
oatients,the index finger is anterior to the middle finger
B
or the hand points upwards (fig 5.b). In a skeletal Class
III patient the middle finger is ahead of the forefinger or
the hand points downwards(fig 5.c). In a patient with
Class I skeletal pattern the hand is at an even level.(fig
5.a)

:
ig 4 Facial divergence JA) Anterior D'vergcncc (B) fbstenor
divergence (C) Orthognathic

This type of profile is associated with a prognathic

mondible or a retrognathic maxilla as in a Class III
malocclusion {fig 3.c}.

Facial divergence
Facial divergence is defined as an anterior or posterior
inclination of the lower foce relotive to Ihe forehead.
Facial divergence can be of three types : \%3
 1601?" Orthodontics - The Art and Science

Fig 5 Assessment of antero • posterior jaw relationship by

placement of the index and ihe middle fingers at the soft tissue point
A and point B (A) Ooss I skeletal pattern the nanri is at an even
level. (B| In Class II pcticn-s, the hand points jpv/ards. |C) In Class III
patienl the hand points downwards

planes meet beyond the occipital region, it indicates a

low angle case or a horizontal growing face. If the two
planes meet anterior to the occipital region it indicates a
high angle case or a vertical growing face.

Assessment of vertical skeletal

relationship
Normally, the distance from a point between the
eyebrows to the junction of the nose with upper lip will
be equal to the distance from the latter point to the
under side of the chin. A markedly reduced lower facial
height is associated with deep bites while increased
lower facial height is associated with anterior open
bites. Fig 6 Assessment of vertical focial height
The vertical skeletal relationship can also be
assessed by studying the angle formed between the
lower border of the mandible and the Frankfort
horizontal plane (a line between the most superior point
of external auditory meatus and inferior border of orbit)
(fig 6). Normally the two planes intersect at the occipital
region. In case the two
Evaluation of facial proportions
A well proportioned face can be divided into three equal
vertical thirds using four horizontal plones at the level of
the hair line, the supraorbital n'dge, the base of the nose

Fip 3 Assessment ol the I ps (A| Compeer) ips |f)) Incornoetert lips \C\
and the inferior border of chin. With i n the lower face, Everted lips

the up pe- "locc u p ies a third of the distance while the

chin c-tupies the rest of the space (fig 7).

Examination of Hps
Normally the upper lip covers the entire labial surface of
upper antcriors except the incisal 2-3 mm. The lower lip
covers Ihe entire labial surface of the lower anteriors
and 2 - 3 mm of the incisal edge of the upper anteriors.
Lips can be classified into the following four types :

Competent Zips ; The lips are in slight contact when the

musculature is relaxed (fig 8.a).

Incompetent Zips : They are morphologically short lips

which do not form a lip seal in a relaxed state. The lip
seal con only be achieved by active contraction of the
perioral and mentalis muscles(fig 8.b).

Potenlially rncompeJenf //ps : They are normal lips that

fail lo form a lip seal due to proclined upper incisors.
Everted lips : They are hypertrophied lips with weak
muscular tonocity (fig 8.c).

IPS
 The malocclusions while recessive chins are common in
nose
to a large Class II malocclusion

Nasolabial angle
It is the angle formed between the lower border of the
nose and a line connecting the intersection of nose and
upper lip with the tip of the lip (labrale superius) (fig 10).
This angle is normally 110°. It reduces in patients
having proclined upper anteriors or prognathic maxilla.
Fig 10
It increases in Assessment of nnso-labial
patients with angle maxilla or
retrognathic
retroclined maxillary anteriors.
F'g 9 iVIantolcb al sulcus

Examination of the nose

extent contributes to the esthetic
v»
appearance of a face.

Nose size ; Normally the nose is one third of the total

fccial height (from hair line to lower border of chin).
Nose.1 contour : The shape of the nose can be straight,
convex or crooked as a result of nasal injuries.
Nostrils : They are oval and should be bilaterally
symmetrical. Stenosis of the nostrils may indicate
impaired nasal breathing.

Examination of chin
Mentolabial sulcus : The mento-labial sulcus is a
concavity seen below the lower lip {fig 9). Deep
menlo-lobial sulcus is seen in Class II, Division 1
malocclusion while it is shallow in bimaxillary protrusion.
Menfa/is activity : Normally the mental is muscle does
not show any contraction at rest. Hyperactive menlalis
activity is seen in some malocclusions such as Class II,
division 1 cases. It causes puckcring of the chin.
Chin position and prominence : Prominent chin is
usually associated with Closs III
INTRA-ORAL EXAMINATION

Examination of tongue
Abnormalities of Ihe tongue can upset the muscle
balance and equilibrium leading to malocclusion.
Presence of an excessively large tongue is indicated by
the presence of imprints of the teeth on the lateral
margins of the tongue giving it a scalloped appearance. \ M
- \
 A patient whose tongue can reach the -'o of
the nose is said to have a long tongue. The :ngual
frenum should be examined for tongue -'e. In patients
having tongue tie there is an alteration in the resting
tongue position as well •as impairment of tongue
movement.
L
Examination of the paiate
The palate should be examined for the lowing
findings : Variation in palatal depth occurs in
association with vanotion of facial form. Most
dolicofacial patients have deep polates. r Presence of
swelling in the palate can be indicative of an impocted
tooth, presence of cysts or other bony pathologies. -
Mucosal ulceration and indentations are a
feature of traumatic deep bite, i Presence of clefts
in Ihe palcte are associated
with discontinuity of the palate. = The third rugae
is usually in line with the canines. This is useful in the
assesment of maxillany anterior proclinalion.
K looked for.
Examination of gingiva
The gingiva should be examined for inflammation,
session ond other mucogingival lesions. rT5sence of
poor oral hygiene is usually associated
generalized marginal gingivitis. It is very r-mmon to
find anterior marginal gingivitis in —outh breathers due
to dryness of the mouth reused by the open lip
posture. Presence of roumatic occlusion is indicated
by. localized r-ngival recession. Abnormally
hyperplastic crrgiva is seen in patients using certain
drugs ice Dilantin.
Examination of frenai attachments
'ne maxillary labial frenum can at times be thick, "brous
and attached relatively low. Such an
attachment prevents the two maxillary central incisors
from approximating each other thereby predisposing to
midline d'astema.
Abnormal frenal attachments are diagnosed
by a blanch test wnere tne uoper lip is stretched
upwards ond outwards for.a period of time. The
presence of blanching in 'he 'egion o~ the inter-dental
pap'llc is diagnostic of an abnormal frenum.
An abnormally high attachment of
mandibular labial frenum can cause recession of the
gingiva in that area.
Examination of tonsils and adenoids
The size and degree of inflammation if any of ihe tonsils
should be examined. Abnormally inflamed tonsils cause
alteration in tongue and jaw posture thereby upsetting
the oro-facial balance !eadirg to malocclusion.
Assessment of the dentition
The dental system is exomired and the following details
are recorded :
a. Teeth present inside the oral cavity
b. Teeth uneruated
c. Teeth missing
d. Status of the dentition i.e. of teeth thct have
erupted end teeth not erupted.
e. Presence of caries, restorations, malformations,
hypoplasia, wear and discoloration.
f. The pctient is asked to close the jaws in centric
occlusion and the molar relation is determined.
This is described as Angles Class I, II or III.
g. The overjet and overbite which represent the
horizontal and vertical overlap of the upper ar.d
lower teeth are recorded. Variations such as
increased overjet, deep bite open bite and cross
bite should be recorded.
h. Transverse malrelations such as cross bite ond
shift in the upper or lower midlines should be
i. Individual tooth irregularities sucn as rotations,
displacements, intrusion and extrusion are noted.
j. The upper and lower arches are examined individually
«-h to study their arch form and symmetry. Arch forms
can be normal, narrow (V shaped] or square.
FUNCTIONAL EXAMINATION
It is now established that normal function of the
stomatognathic system promotes normal growth and
development of the oro-facial complex. Improper
functioning of the stomatognathic system can result in
vorious malocclusions.
Orthodontic diagnosis should not be restricted
to static evaluation of Ihe teeth and their supporting
structures but should include tho examination of Ihe
various functional units of tho stomatognathic system.
The functional examination should include Ihe following
:
a. Assessment of postural rest position and inter-
occlusal space.
b. Path of closure
c. Assessment of respiration
d. Examination of TMJ
e. Examination of swallowing
the
f. Examination of speech
Assessment of postural rest position and
Inter - occlusal clearance
The postural rest position is the position of the mandible
at which the muscles that close the jaws and those that
open them are, in a state of minimal contraction to
maintain the posture of the mandible. At the postural
rest position, a space exists between tne upper and
lower jows. This space is called the inter-occlusal
clearance or the freeway space. Normally the freeway
space is 3 mm in the canine region.
There are various methods of assessing the
postural rest position. During examination, the patient
should be seated upright, with the back unsupported
and asked to look straight ahead. The following are
some of the methods used to record the postural rest
position.

Phonertc mefhod : The patient is asked to repeat some

consonants like 'M' or 'C' or repeat a word like
Mississippi1. The mandible returns to the postural rest
position 1 -2 seconds after the exercise. The potient is
told not to change the jaw, lip or tongue position after the
phonation, as the dentist parts the lips to study the inter-
occlusal space.

Command mefhod : The patient is asked to perform

certain functions such as swallowing. The mandible
tends to return to rest position following this act.

Non-commond method : The patient is observed as he

speaks or swallows. The patient is not aware that he is
being examined. This is usually corried out by talking
about topics unrelated to the patient while carefully
observing him or her.
There are various methods employed to
measure the inter-occlusal clearance. The following are
some of them.

Direct infra - oral procedure r Vernier calipers can be

used directly in the patient's mouth in the canine or the
incisor region to measure the freeway space.

Drrecf extra - orol procedure : Two marks are placed

one on the nose and onother on the chin in the
mid-sagittal plane. The distance between these two
points is measured after
 -struding the patientto remain at rest position, later the either no cnange in the external nares or they may
patient is osked to occlude the teeth and —e distance
between the two points is again measured. The
Orthodontic Diagnosis 129
difference between the two -eodings is the freeway
constrict during inspiration.
space.

'"direct extra - oral procedure : The inter- occlusal Examination of T.MJ.

space is determined in a radiograph or ay The functional examination should routinely include
Kinesiograohy. Two lateral cepha log rams, at rest auscultation and palpation of the temporo-mandibular
position and other in centric occlusion can -elp joint and the musculature associated with mandibular
establish the freeway space. opening.
The patient is examined for symptoms of
Evaluation of path of closure
temporomandibular joint problems such as clicking,
~he path of closure is the movement of the —cndible
crepitus, oain of Ihe masticatory muscles, limitation of
from rest position to habitual occlusion, -bnormolities
jaw movement, hyper-mobility and morphological
of the oath of closure are seen in some forms of
abnormalities.
malocclusion.
The maximum mouth opening is determined
r
orward potk of closure ; A forward path of closure by measuring Ihe distance between the maxillary and
occurs in patients with mild skeletal zrenormalcy or
mandibular incisal edges with the mouth wide open. The
edge to edge incisor contact. In sbch patients, the
normal inter-incisal distonce is 40-45 mm.
mandible is guided to a more torward position to allow
the mandibular incisors to go labial to the upper Evaluation of swallowing
incisors.

accfev/ard path of cfosure : Class II, division 2 cases

exhibit premature incisor contact due to "^oclined
maxillary incisors. Thus the mandible s guided
posteriorly to establish occlusion.

.c'erof path of c/osure : Lateral deviation of tfee

mandible to the left or the right side is associated with
occlusal prematurities and a -crrow maxillary arch.

Assessment of respiration
-^mans may exhibit three types of breathing : -csal,
oral and oro-nasal.
A number of simple tests exist that can rx
employed to diagnose the mode of respiration.

J V.'rror tesf ; A double - sided mirror is held ae*ween the

nose and the mouth. Fogging on
the nosal side of the mirror indicates nasal breathing
while fogging towards the oral side indicates oral
breathing!

Cotton test: A butterfly shaped oiece of cotton is placed

over the upper lip below the nostrils. If the cotton flutters
down it indicctes nasal breathing. This test car be used
to determine unilateral nasal bockage.

Water test; Tne palien* is asked to fill his mouth with

water end retcin it for a period of time. While nasal
breathers accomplish this with ease, mouth breathers
find the task difficult.

Observafcon ; In nasol breathers the external nares

dilate during inspiration. In mouth breothers, there is
In a new born, the tongue is relatively large and
protrudes between the gum eads and takes part in
establishing Ihe lip seal. This kind ol swallow is called
infantile-awallowand is seen till 1 1/2 to 2 years of age.
Infantile swallow is replaced by the mature swallow os
Ihe buccal teeth start erupting. The persistence of tne
infantile swallowing can be a cau^e for malocclusion.
Thus the swallowing pcttem of the individual should be
examined. The persistence of infertile swallow is
indicated by tne presence of the "ollowing fecruries:
a. Protrusion of Ihe tip of the tongue
b. Contraction of perioral muscles during swallowing
c. No contact at the molar region during swallowing
F g 1 1 Orthodontic study models

Speech 4. They nelp in assessing the nature and severity of

Certain malocclusions may cause defects 'n spcech due
to interference with movement of the tongue and lips. 5.
This should be ooserved while conversing with the
potienl. The patieir can be asked to reac cut from a book
or asked lo count from 1 - 20 while observing the 6.
speech. Patients having toncue thrust habit tend to lisp
while cleft palate patients may have a nasal tone. 7.
ORTHODONTIC STUDY MODELS
malocclusion.
They are helpful in motivation ol the patient end to
explain the treatment plan as well as progress to
the patient and parents.
It makes it possible to simulate treatment
procedures on Ihe cast such as mock surgery.
Study models are useful to transfer records in case
the patient is to be Ireoled by another clinician.
Details on the requirements of orrnodontic

Orthodontic study models are accurate plaster study models arid their fabrication ore given in chapter

reproductions of the teeth and tncir surrounding soft 39.

tissues. They ore an essential diagnostic aid t not

Gnattiostatlc models
makes it poss'ble lo sludy the arrangement of teeth and
I hey are orthodontic study models where the base of
ihe occlusion from all directions
(fig 11). the maxillary cast is trimmed to correspond to the
Uses of study models include : Frankfort horizontal plane.
1. They enable the study of the occlusion from all
aspects.
DIAGNOSTIC SET UP

2. They enable accurate measurements to be made
in a dental arch. They help in measurement of arch
length, arch width and loolh size.
3. They he p in assessment of treatment progress by
the dentist as well as the patient.
The diagnostic setup was first proposed by H.D.
Kesling. The diagnostic set up is made from an extra set
of trimmed and polished sludy models. The individual
teeth and their associated alveolar

131
Fig 13 Extra - oral photcgxphs |A; Frontal view (BJ Profile view |C) Oblque facial view. Intra • oral pho'ogroplis (0) Left latcrcl viev/ |E; Right laterall
view 'F) Frontal view (G) Maxillary occlusal vie»- (II) Mandibular occ Lsa view

processes are sectioned off and replaced on the model
base in the desired oositions. The diagnostic set up
thus helps in simulating the various tooth movements
that are planned for patients.
Uses of diagnostic set up
1. It is usefu1 :n visualizing and testing the effect ol
complex tooth movements and extractions on the
occlusion.
2. The patient con be motivated by simulating
the various corrective procedures on the cast. 3.
Tooth size - arch length discrepancies can be
visuolized by means of a sel up.
Procedure
The cast is cut using a fretsaw blade to se pa rare ihe
individual teetn. A horizontal cut is made 3 mm apical
to the gingival margin. Vertical cuts are made to
separate the individual teeth. The individual teeth are
set in desired position using red wax (fig 14}.

131
FACIAL PHOTOGRAPHS AS
A DIAGNOSTIC AID
facial photographs offer a lot of information on •he soft
tissue morphology and fecial expression. Photographs
should be taken in a standardized manner so that they
can readily be compared with similar photographs
muscle activity. Eledromyogram is a 'eccd obtained
bysucna procedure. The adion potential is pic<ed up
by electrodes which are of two types:
Surface e.'ectrod'es : These eledrodes are used when
the muscle is superficially placed lust below tne skin.
Needle electrodes : They are used when the muscle is

taken during or after •he treatment. placed deep inside e.g. Pterygoid musdes.

Both extra-oral as well as intra-oral Having picked up the action potential with

ohotogrophs are useful diagnostic records. Three surface or needle electrodes, it is recorded either with

extra-oral views are routinely taken (fig 13): the he o of a moving pen in the form of a grapn or

a. Frontal view recorded in the form of sound with the help of a

b. Profile view magnetic taoe recorder.

c. Oblique facial view EMG is used "o detect abnormal muscle

The extra-oral photographs are token by activity associated with certain forms of malocclusion.

positioning the patient in such a manner that the .H = a. In severe Class II, division 1 malocclusion the

plane is parallel to the floor. upper lip is hypo-functional. Thus during

The intra-oral photographs that are token swallowing, the lower lip extends upwards and

include : forwards to force the maxilla labially and a strong

a. Left and right lateral view mentalis activity is seen. EMG can be used to

b. Frontol view study such a condition.

b. Abnormal buccinator activity in Class II, division 1.
c. Maxillary and mandibular occlusal view Use c. Overclosure of jaws is associated with
accentuated temporalis muscle adivity.
of photographs
d. Children with cerebral palsy.
1. They are useful in assessment of facial symmetry,
e. EMG can be carried out after orthodontic therapy
facial type and profile.
to see if muscle balance is achieved.
2. They serve as diagnostic records.
3. They help in assessing the progress of the
treatment.

ELECTROMYOGRAPHY

Electromyography is a procedure used for recording

the electrical activity of the muscles. The resting
potential of a muscle fiber is 85 - 90 mV Voluntary
muscles consists of many contracting fibres supplied
by peripheral nerve terminals. The membrane of each
fibre is electrically charged with positive charge outside
and negativity of 85 - 90 mV inside. Upon receiving a
stimulus, there is a reversal of this potontic% resulting
in muscle contraction. This is called action potential
and denotes the mechanical activity of the muscle. The
electromyog'-apn is a machine which is used to
receive, amplify and 'eco'd the action potential during
RADIOGRAPHS USED IN 2. To establish the presence or absence of supernumerary
ORTHODONTIC DIAGNOSIS teeth.
3. To determine the extant ot root resorption of deciduous
Orkhodonlics - The Ari and Science
teeth.
William Conrad Roentgen discovered X-rays in 1895.
4. To study the exlent of root formation ol the permanent
There is no aspect of the medical field that is not
teeth. '
influenced by this discovery. Orthodontics is no
5. To confirm the presence and extent of pathological and
exception. Radiographs have established themselves
trao malic conditions.
as a valuable tool in orthodontic diagnosis. Table 1
6. To study the character of areolar bone.
gives the uses of radiographs in orthodontic practice.
7. They are a valuable aid in cranio-dento-faciai analysis.
Radiographs routinely used for diagnosis in
To confirm ihe axial inclination of Ihe foots of teeth. 9.. To
orthodontics can be classified into two groups:
assess teeth that are morpholc^caJly abnormal.
Intra-oral radiographs
Extra-oral radiographs
1. Paralleling technique
2. Bisecting angle technique
INTRA ORAL RADIOGRAPHS
Paralleling technique ■: This technique is also called
Three types of intra-oral radiographs ore commonly right ongle or long cone technique. In this technique,
used. They are the periapical, bite wing and occlusal the X-ray film is placed parallel to the long axis of the
projections. teeth and the central ray of the X-ray beam is directed
at right angles to the teeth and film. This method is
Intra - oral periapical radiographs
believed to reduce geometric distortions and is
(1.0. P. A.)
therefore the preferred technique.
They ore rcdiographs that are used to view the teeth
Bisecting angle technique J In this technique, the
and their supporting structures (fig 14). Two inlro-oral
central roy is directed ot right angles to a plane
projection techniques are used for periapical
bisecting the angle between the long axis of the teeth
rcdiography. They ore :
p.* and the film.

Uses of intra-orai periapical radiographs: Full

mouth intra-oral periapical radiographs ore routinely
token prior to initiation of orthodontic treatment. The
*»iJv< v! following are some of the uses of IOPA.
:• v.-.v
If 1. To confirm the presence or absence of teeth.

P*:
m 2. To establish the presence or absence of

0$

mmmm
•N»:*'1 W" *,'

•
fm
1I1 ijfjljl

Fig 14 Inlro-oral pe?iopicol radiograph

To assBss general development ot Ihe dentition, presence,

absence arri state ot eruption ot the teeth.

I
 supernumerary teeth. 3. To assess the extent of f. To detect inte-proximal calculus.
calcification and root
formation of teeth, -i. To confirm the presence and
Orthodontic Diagnosis 135
Occ/asa/ radiographs
study the extent of periapical pathology and root
Intra-oral occlusal rodiographs enable viewing of a
fractures.
relatively large segment of the dental arch, including
5. To study the alveolar bone and periodontal
Ihe oala^c or floo' of the mouth. Occlusal radiographs
ligament space.
are also useful in parents who are unable to open the
6. To study the height and contour of alveolar bone
mouth wide enough for periapica' radiographs. It is
crest.
possible to obtain occlusal p'ojeclion of the uppe' as
7. To assess the axial inclination of roots.
well as the lower arches {fig 16). The following are the
S. To detect retained root fragments and root stumps.
uses of occlusal radiographs :
?. To determine the size and shape of unerupted teeth.

Disadvantages of IOPA : The following are smeof the

disadvantages of intra-oral periapical 3ms:
Assessment of the entire dentition requires too
many radiographs. 1 Children may not allow olccement
of intraoral films.
2. They cannot be used in patients having high gag
reflex and trismus.

Advantages of fOPA : Although the IOPA n-c:ographs

have a number of drawbacks they r-^r some
advantages as well: - Low radiation dose.
: Possible to obtain localized views of the area of
interest.
EL They offer excellent clarity of teeth and their Fig 16 CCCIJSOI rnd ograph
supporting structures.

=/fe wing radiographs

5r» wing radiographs record the coronal part of 1fre
upper and lower dentition along with their sucoorting
structures (fig 15). The following are same of the uses
of bite wing radiographs : •z. ~o detect proximal
caries, ir To study Ihe height and contour of ii

Fig 15 Bits wing radiograph

alveolar bone.
c. To detect secondan/ caries below restorations.
d. To defect overhanging proximal restorations.
e. To detect periodontal changes.
BS
 F'g 17 Pai. i c radlograp>
1. To locote impacted or unerupted teeth. 3. To study the patn of eruption of teelh.
2. To locate superrumera^ teeth. 4. To diagnose the presence and extent of pathology
3. To locate foreign bodies in Ihe jaws and stones in and fractures of the jaws.
salivary ducts. 5. To diagnose the presence or absence of multiple
4. To study bucco - lingual expansions of cortical supemumeran/ teeth.
plate due to patho'ogy of the jew. 6. They are useful aids in serial extraction
5. To diagnose Ihe presence and extent of fractures. procedures to study the status of erupting teeth.
6. They are useful in orthodontics lo study the effects 7. They are useful in the mixed dentition period to
of arch expansion procedures. study the status of uncrupted teeth.

EXTRA-ORAL RADIOGRAPHS The advantages of panoramic

radiograpn include:
Extra-oral radiographs include all views made of the
1. A oroad anatomic area can be visualized.
oro-facial region with the film positioned extra- oral I y.
2. The potienl radiation exposure is low.
They are useful whenever large areas of Ihe face and
3. It can be used in patients who are unable to
skull are lo be visualized.
tolerate intra-oral films or unable to open the
Panoramic radiographs mouth.

Panoramic radiographs enable viewing of both The following are the disadvantage of

maxillary and the mandibular arches with their panoromic radiograohs :

supporting structures (fig 17). Thus a single image

covers a major part of the facial region. Uses of
Panoramic radiograph includes I. They are useful in
assessing the dental
development by studying deciduous root
resorotion and root development of permanent
teeth.
2. They can be used lo view ankylosed and impacted
teeth.
 Fig "i 8 (A) LalS'cl cephalog'cms (B! Poste'o - aircrior cephologrcm

Distortions, magnifications and overlaoping of the
structures occur. 2. The teeth and the suoporting
oeriodontal structures are not as clear as in periapical
films.
* Inclination of anterior teeth cannot be visualized.
Requires equipment that is expensive. ■ 5
Whenever details of a particular area are needed they
have to be supplemented by otner radiographs.
Radiographs of the hand and wrist are useful in
estimating Ihe skeletal age of a person. The hand and
wrist region have a number of small bones whose
appearance and progress of ossification occur in a
predictable sequence. This enables assessment of the
skeletal age of a patient. They

Cephalometric radiographs
are specialized skull rodiographs in which p*e
head is positioned in a specially designed bead holder
called cephalostat by means of ear —cis. Thus it is a
standardized technique where - -^e head is held in a
predetermined position. Ceohalograms are also used
for comparison of serial radiographs.
Cephalometric radiograpns are of two
types:
Lateral cephalogram (fig 18.a)
Postero- anterior cephalogram (fig 18.b)
The use of cephalometric radiographs for
orthodontic diagnosis is discussed in detail in the
following chapter.

OTHER RADIOGRAPHS in
Hand - wrist radiographs
 Orthodontics - The Art and Science

ore useful in assessing growrnfor planning growth 1. It exhibits high edge contrast due to a
modification procedures and surgical resedive phenomenon called edge enhancement. Tnis
procedures. facilitates perception of anatomic details.
2. The xeroradiographs image is on paper and is
RECENT ADVANCES IN DIAGNOSTIC
viewed in refleded light. Thus no special
AIDS
illumination is needed for viewing.
Orthodontics is a rapidly growing field with 3. Choice of positive or negative image is »
developments occuring almost every day. The possible.
improvements basicoily occur in two areas. The first is
an improvement in the materials and techniques used The advantages of Xeroradiography ore :

while the other is advcnces in the diagnostic aids. 1. Reduction in exposure time

Recent innovations in medical imaging has been 2. Ease in manipulation. No need of dark rooms for

adapted to dentistry ond find some applications in developing.

orthodontics as well. Some of these recently evolved 3. Ease of viewing. No special light source is

diagnostic aids are discussed in brief. required.

4. Edge enhancement effed. Boundary between
Xeroradiography structures is clear
Xeroradiograpny is a completely dry, non-chemical 5. Cephalometric landmarks are easily identified.
process which mokes use of the electrostatic process 6. Reconstruction of the cephalometric planes and
as in Xerox machines. It was invented by Chesrer F. points can be made directly on paper.
Carlson in 1 937 shortly before the II World War.
Dlgl Graph
Xeroradiography makes use of an aluminium
plate That is coated with a layer of vitreous selenium. The Digi Graph is a synthesis of video imaging,

The selenium particles are given a uniform electrostatic computer technology ond sonic digitizing. The Digi

charge. The charged plate is placed in a light tight, graph work station equipment measures 5' x 3 x 7. The

airtight cassette. When the film is exposed it causes a main cobinet contains the electronic circuitry. The Digi
Graph enables the clinician to perform non-invasive
selective discharge of the selenium depending upon
and non-radiographic
the amount of radiation used and relative density ol Ihe
object. This pattern of electric discharge on the plate is
called latent image.
The latent image is then converted into a
visible image by a process called development in a unit
called processor. The plate is exposed to charged
particles called toner. These particles adhere to the
charged areas in amounts proportional lo the quantity
of charge present. This image is now transferred on*oa
special kind of paper called Xerox opaque paper.
The unique feature of xeroradiography is that
it is possible to have both positive and negative image.
Once the latent image is converted to a real image on
to a poper the selenium plate can be discharged,
cleoned and used again. It can be reused as many as
1000 times.
Xeroxadiographic image differs from
conventional radiographs in the following ways:
 cephalometric analysis. Cephalometric landmarks are magnetic field. If a coil is now wound around a volume
digitized by lightly touching the sonic digitizing arobe to of protons, they now progress at 90 degree around the
a point on the patient's skin corresponding it. This emits mognetic field at the same frequency and induce a
a sound, which is then recorded rv the microphone and minute current in the coil which when amplified can be
monitored as X, Y and Z co-ordinates. displayed over on oscilloscope. This energy is utilised
~he system allows cephalometric evaluation and in the scanning procedure.
-satment progress as often as necessary without The advantages of magnetic resonance
■odiation exposure. Feotures of Digi Graph system imaging are :
•xlude : 1. MRI does not have hazards as it uses non-
k ionising electromagnetic radiation.
A landmark can be identified as a point in three 2. Anatomical details are as good as in C.T. scan.
dimensions.
3. Greater tissue characterisation is possible.
A cephalometric analysis can be made independently
4. Imaging of blood vessels, blood flow, visualisation
of head position. 3 Parallelism of X-ray in mid - satgittal
of thrombus is possible.
plane and symmetry of anatomic morphology between
The disadvantages of MRI include :
left and right sides is not necessary.
1. Time taken is more.
The Digi Graph work station's hardware r-rd software
2. Not used in patients with cardiac pace maker.
i enable the performance of rsohalometric analyses,
3. Non visualisation of bone makes it useless in bony
tracing, superim position and visual treatment
lesions.
objectives. The programme pable of 14 analyses.
Measurementsforony ed analysis can be displayed on
the monitor trd the observed values are shown along
with -^e patient norm adjusted for age, sex, race and
-«cdsize including standard deviations. Optional nents
include : A consultation unit: It transports information
into the operatory, doctor's office / consultation area,
thus allowing viewing and comparison of information
ond the development of visual treatment objectives. A
high - resolution video camera with a •elephoto lens for
taking intra-oral views by ^eze framing the video
image. A light box for X - rays and a study model holder
for video imoging that will be included in the floppy
disk. * Camera and video printer for producing copies
of video monitor information.
The Digi Graph allows all patient's models,
radiographs, photographs, cephalo- grams and
tracings to be stored on one small disk, thereby
reducing storage require-ments. Furthermore it is a
valuable tool for improving communication among
clinician, patient and staff.

MRI (Magnetic Resonance tmaglng)

Magnetic Resonance Imaging makes use of two
fundamental properties of protons, i.e. spin and small
magnetic movements. The proton of hydrogen ion
which is in water (woler being the major component of
body) is utilised in M.R.I. The protons behave like
m
small spinning magnets and when placed in a
magnetic field they fend to move parallel to the field.
Because of the spin the protons respond differently
within their axis progressing obout the direction of the
Tomography 2. The computer programming makes it possible to
Conventional rad'oaraphs ore images in which oil view the images in different shades and
objects between the X-ray source and film are densities. This helps differentiate fat and blood.
superimposed. Thus the clarity of a specific
Occ/usograms
radiographic finding depends on both its location and
the degree to which its density differs from that of It is a tracing of a photograph or a photocopy of a

surrounding objects. In some situations dental arch. Occlusograms are used for Ihe following

superimposition of objects interferes with an observer's purposes:

ability to clearly discover the obiect of interest. In these a. To estimate occlusal relationships

instances tomography can be used to visualise a b. To estimate arch length & width
c. To estimate the tooth movements required in all
section or slice of the object and thereby eliminate
3 planes of space
undesirable overlap.
d. To estimate spacing & crowding
Tomographic can be conventional or
e. To estimate anchorage requirements
computed tomography.
Occlusograms can be obtained in two
Conventor?a/ Tomogroohy: Tnjs is a process by which
ways:
a layer of an image within Ihe body is produced while
1. The occlusal surfaces of the upper ond lower dental
ihe images of structures above and below that layer are
casts are photographed in a 1:1 ratio and a tracing of
made invisible by blurring. Blurring of image outside the
the photograph is made.
plane of interest is accomplished by simultaneous
2. The casts are photocopied on a xerox machine and
movement of tne X-ray lube and film during the
the occlusal photocopy is used lo obtain a tracing.
exposure. The tube and film are connected so that
movements occur around a point or fulcrum. As the Digital Subtraction Radiography
distance from the point of rotation increases, the In conventional radiographs the background structures
amount of image blurring also increases. Thus objects such as alveolar bone and adjacent
close to Ihe point of rotation are more sharp and
objects farthest are blurred. As the angle between the
source / film and tissue increases the thickness of the
image is reduced. Thus the greatest blurring is seen in
tne periphery while the sharpest image is seen at Ihe
central area near' ihe fulcrum of rotation.
The principles of tomography can be
mechanically implemented in two ways : 1 .The X-ray
tube ond film can move synchronously in opposite
directions in parallel planes. 2.The X-ray tube and film
can move synchronously and in opposite directions in
parallel p anes but with motions other than straight line
ie circular, spiral, etc.,.
Competed Tomograph/; It is also called C.T. or CAT
(computed axial tomography). C.T. systems are mainly
complex imaging systems which use thin beams of X
ray that move in a synchronous manner with an array
of detectors which calculate and attenuate the X ray
beams at different cngles and in different planes. This
data is fed into a computer which performs numerous
calculations as per the program and constructs
accurate images in the coronal and oxial planes.
The advantages of C.T. scan are :
1. Accurate visualisation of an area of interest is
possible.
-eeth may draw the examiners vision away from —e 1. Storage of study model images.
diagnostic information thereby making detection of 2. Measurement of incisor intrusions.
pathologic changes difficult. The advancement of Orthodontic Diagnosis 141
caries from an incipient lesion "rough the 3. Study the effects of high oull heodgeor traction in
dentino-enamel function is often f fficult to detect. children s skulls.
Likewise the assessment of a -ealing or expanding 4. Tooth position measurements on dental casts.
lesion after root canal therapy is a challenge because 5. To study the effect of maxillary expansion on
of the subtle —anges in the density of the lesion that facial skeletons.
may not detectable with the unaided eye. 6. To study the effect of Class II elastics on bone
The detection of initial saucering or .'fbrmotion of displacement.
angular defects around implants is difficultto visualize 7. To study the effect of cervical pull headgear on
on radiographs. Moreover the spread of bone loss maxilla.
along the thread of the -re4 form implant is often 8. To determine Ihe centres of rotation produced by
obscured by the sharp rest between the bone and orthodontic forces.
imp'ant surfoce. 9. Lower incisor space analysis.
ction radiography addresses many of the 'ations in the
10. To assess the facial and dentol arch symmetiy.
detection of these radiograohic nges by decreasing
the amount of distracting ground information and by Photocephalometry
:
allowing the eye ocus on the actual change that has Although the standard lateral and antero-posterior
occured n two images. By subtracting all anatomic cephalogram s reveal some aspects of soft tissue, they
ures that have not changed between raphic nevertheless do not give adequate soft tissue details.
examinations, changes in diagnostic ation are easier In a lateral cephalogram only the profile is seen while in
for the reader to see. Technically this is an imoae
an antero-posterior cephalogram
enhancement od that removes the structured noise
from mages. The result is Ihe area of change clearly d
either against a neutral grey background c s
superimposed on the original radiograph *. The
subtraction of original two radiographs termed an
image rather than a radiograph use it does not directly
result from exposure c radiographic film.
The digital subtraction technique ively enhances the
differences between two s. Image registration however
is found to o technical problem. It is impossible to
achieve t registration of images during digitization use
of imperfections in the radiograohic and
alignment procedures. The larger the differences in
registration, the more the visual noise present in the
subtracted image.

Laser Holography
Holography is a photographic technique for recording
and reconstructing images in such a way that the 3
dimensional aspect of an object can be obtained. The
recorded imcge is called a hologram. Loser is light
amplification by stimulated emission of radiation.
Holography is a wave front reconstruction
process in which two coherent beams converge to
produce a constructive and destructive interference
patte-n which is recorded on film. Orthodontic
applications of loser holography include:
 1601?" Orthodontics - The Art and Science

the lateral soft tissue margins are seen.

Thomas in 1978 developed photo-
cep'nalometry to better visualize the soft tissues of the
patient.
Three radio-opaque metalic markers with
holes are placed on tho patient's skin with cdhesives
and standard lateral ond antero-posterior
cepholograms are taken. Using the same position
lateral and frontal photographs are taken. The
photographs are printed to the some size as the
radiographs and are superimposed over the
radiographic tracing taking the metalic markers as the
guide.

Cineradiography
This is basically a radiographic motion picture.The
subject is oriented properly and stabilized in a modified
cepholostat. An X ray motion picture is obtained using
a cine camera which runs at 240 frames per second.
This diagnostic aid is used to visualize the swallowing
pattern OT the patient. The X ray motion picture is
studied using a movie projector.

References
1. Downs VVB : Analysis of -.KB dentofadol profi U . Angle Orthod
1956 ;26 .191
2. Hous:onWj& : Ortnodontic Diagnoses, Wright, Bristol, 1982
3. Jocobson : Introduction to Radiographic Cepnabmetry, Lea
ard Febiger, Philadelphia, 1985
4. P'cdcep CS, Vcl ctlian Ashi-na : Digital sub-radion
rcdiograpny: KDJ 1998. 20: 51-55
5. Profrtt WR: Contemporary Orthodontics. St Louis, Of Mosby,
1986.
6. Rcber 5 Mayers : Hand boo'< of Orthedon'ics, Year boo<
nedical oublishers, inc,19B8.
7. Romeo A : Ho ograms in Orthodontics : Arn J Orlhod
1995,^3-447
8. 5neholata, Vo liana n Ash i mo : Laser holography: KDJ 199b.
18: 1169-1171
9. Thomas M Graber, Robert L Vanarsdail : Onhodor-
tics.current principles and technictus, Mosby year book Inc ,
1994
10. Yen P : IdentificaHon of landmarks in osphalanelric
rcdiograpna. Angle Orthod I960 ;30-36
 «J3
L^jS^SSttij 41 ol ' jL^l i U^wli Vj

T
he assessment of cranio-facial structures Cephalograms can be of two types:
forms a part of orthodontic diagnosis. The Lateral cephalogram : This provides a lateral view
earliest method used to assess facial of the skull (fig 1 .a). It is taken with the head in a
coportions was by artistic standards with -crmony, standardized reproducible position at a specified
symmetry ard beauty as key points. Craniometry can distance from the source of the X ray.
be said to be the forerunner of cephalometry. Frontal cephalogram : This provides an
Craniometry involved -easurements of cranio-fccicl antero-posteriorview of the skull (fig 1.b).
J
dimensions of skulls of dead persons. This method
was' not practical in living individuals due to the soft
tissue envelop which made direct measurements
difficult end far iess reliable.
The discovery of X-rays in 1 895 by
•oentgen revolutionized dentistry. It provided a -ethod
of obtaining the inner cranio-facial ~easurements with
quite a bit of accuracy and •^oroducibility. In 1922
Paccini standardized the 'adiographic head images
by positioning the rjbjects against a film cassette at a
distance of 2
meters from the X - ray tube. In 1931 Boardbent in
U.S.A. and Hofrath in Germany simultaneously
oresented a standardized cephalometric technique
using a high powered X-ray machine ond a head holder
called Cephalostat. The term cepha I o metrics is used
to describe the analysis ond measurements made on
the cephalometric rodiogrophs.

TYPES OF CEPHALOGRAMS
USES OF e. Cephalometrics helps in
CEPHALOGRAM -'g 1 ;A) .cte.'cl CepMogrom (B! Frontal Cephalogram
predicting the growth related
S
changes and changes associated with surgical
Cephalometrics has established itself as one of Ihe treatment.
pillcrs of comprehensive orthodontic diagnosis. It is f. Cephalometrics is c valuable o id in research work
also a s'oluable fool irt treatment planning and follow involving the cranio- dento facial region.
up of patients undergoing orthodontic treatment. Tne
TECHNICAL ASPECTS
following are some of the applications of
c:ephotometries in orthodontics. The cephalometric radiographs are taken using an
a. Cephalometrics helps iri ortnodonticdiagnosis apparatus that consists of an X-ray source and a head
by enabling tne study of skeletal, dental and soft holding device called ccphaloslal. The cephalostat (fig
tissue structures of Ihe cranio-facial region. 2.b)consists of two ear rods that prevent the movement
b. It helps in classification of the skeletal arid dentol of the heed in the horizontal plane. Vertical stabilization
abnormalities and olso helps in establishing facial of the head is brought oboul by an orbital pointer thot
type. contacts
c. Cephalometrics helps in planning treatment for an
individual.
d. It helps in evaluation of the treatment results
by quantifying the changes brought about by
treatment.
 Cephalometrics 145

WM „

Fig 2 (A) Source- rrid sagircl plane distance o: 5 tee*. (BJ Cemdos-at used to stabilize the head and be p ii s-cndcrdizirg the teoc
orentcfioi

rhe lower border of the left orbit. The upper port of the
Anatomic landmarks

face is supported by the forehead clamp cositioned These landmarks represent actual aratomic structures
above the region of the nasal bridge, "he distance of the skull.
between the X-ray source and the mid-sagittal plane of
Derived landmarks
the patient (fig 2.o) is fixed at 5 feet (152.4 cm). Thus
the equipment helps in randardizing the radiographs These are landmarks that have been obto'ned

by use of constant Head position and source film secondorily from anatomic structures in a

distance so that serial radiographs can be compared. cephalogram.

The landmarks that are used in
CEPHALOMETRIC LANDMARKS cephalometrics should fulfill certain requirements.
a. II should be easily seen in a radiograph.
Cephalometrics makes use of certain landmarks or
b. It should be uniform in outline and should be
points on the skull which are used for quantitative
reproducible.
analysis and meosurements. The cephalometric
landmarks (fig 3) can be of
two types:

14-5
146 f Orthodontics - The Art and Science

Fig 3 (A) Impotent lateral cepha oneiric landmarks identit ed an the lateral ccuna ogrom

W;!:!;
fig 3(B) Important laterol cephalometric landmarks : N - Nas:or, S - Sel!c, O - Orbitale, ANS - Anterior nasal spine, ^S - Posterior nosal spine, A - Point A, B - Point B, Pog
- Pogor-ion, Gn - Gnathicn, We • Men'on, Go - Gonion, Ba - 9a$ior, 3o - Bolton's poinl, A r - Articolare, P - Porion, PTM - Ptm point.

c. The landmarb should permit vclid quantitative
measurements of lines and angles projected from
them.
The landmarks used in cepholometrics can
be classified as hard tissue and soft tissue landmarks.
The following are some of the mportant cephalometric
landmarks
Vosion : The most anterior point midway between the
frontal ond nasal bones on the fronto-nasal suture.
Orbitale : The lowest point on the inferior bony margin
of the orbit.
Porion : The highest bony point on the upper r-.argin of
external auditory meatus.
Sella : The point representing the midpoint of the
pituitary fossa or sella turcica. It is a constructed point
in the mid-sagittal plane. .
Point A : It is the deepest point in the midline between
the anterior nosal spine and alveolar crest between the
two central incisors. It is also called subspinale.
Point B : It is the deepest point in the midline between
ihe alveolar crest of mandible ond the mental process.
It is also called supramentale.
Bas/on : It is the median point of the anterior margin of
the foramen magnum.
Bo/fon point : The highest point at the post condylar
notch of the occipital bone.
Anterior rvasai1 spine : It :s the anterior tip of the shorp
LINES AND PLANES IN
CEPHALOMETRICS
bony process of the mcxilla in the midline of the lower
margin of anterior nasal opening. Cephlometrics makes use of certain lines or planes

Gonio.n : It is a constructed point arthe junction of (;'ig 4). These I'nes are obtained by connecting two

ramal plone and tne mandibular plane.
Pogonion : It is the most anterior ooint of rhe bony chin
in the median plane.
landmarks. Based on their orientation the lines or
planes can be classified into horizontal and vertical
planes.

iVienton : It is the rrost inferior midline point on the Horizontal planes

mandibulor symphysis.
Gnathior? : It is the most antero-inferior ooint on the
:
symphysis o the chin. It is constructed by intersecting
a line drawn perpendicularrothe fine connecting
menton ond pogonion.
Articulate : It is a point at the junction of the posterior
border of ramus and the inferior border of the basilar
part of the occipital bone.
CondyJ'ion : The most superior point on Ihe head of
the condyle.
S.N. plane : It is the cranial line between the center of
sella tursica (sella) and the anterior point of rhe
fronto-nasal suture (nasion). It represents the anterior
crcnial base.
Frankfort horizontal plane : This plane connects the
lowest point of tne orbit (orbitale) and the superior
point of the external auditory meatus (porion).
Occlusal plane : It is a denture plone bisecting the
posterior occlusion of the permanent molars and
premolars (or deciduous molars in mixed dentition)

Prosfbion : The lowest and most anterior point on the ond extends anteriorly. Pa/ato/ plane : It is a line

alveolar bone in the midline, be:ween tne upper central linking the anterior nasal spine of the maxilla and Ihe

incisors. It is also called supradenla'e. posterior nasal spine of the palatine bone.

/nf'rac/emoi'e : The highest end most anterior point on Mondiku/ar plane : Several mandibular planes are

the alveolcr process, in the median plane between the used in cephalometrics, based on the analysis

mandibular central incisors.

The key ridge : Tne lower most point on the contour of

the anterior wall of the infra-remporal fossa.

Posterior nasai spine : The intersection of a

continuation of Ihe anterior wall of the pterygopalatine
fossa and the floor of the nose, marking the distal limit
of the rnoxilla.

Broodbent registration point : It is the midpoint of the

perpendicular from Ihe center of sella tursica to the
Bolton plane.

Ptm point : It is the intersection of the inferior border of

the foraman rotunduni with the posterior wall of Ihe
plerygo-maxillcry fissure.

G.'abe/.'o : It is the most orominent point of the

forehead in Ihe mid-sagittal plane.

CbeJjon ; It is the lateral terminus of the oral slit on the

outer corner of the mouth.

Sufcncsa'e : The point where the lowest border of the

nose meets the outer contour of the upper lip.
^ 4 Cephalometric planes. (A) Sella • Nosion plane IB) Frankfort Horzonta plane (Q Pclaxl plcne {D] Occlusal plane

being done. The most commonly used ones are Facial axis : A line from Ptm point to cephalometric
gnathion.

a. Tangent to the lower borer of the mandible E. Plane : or the esthetic plane is a line between the
(Tweed). most anterior point of the soft tissue nose and soft
b. A line connecting gonion ond gnathion (Steiner). tissue chin.
c. A line connecting gonion and menton (Downs).
Boston - Nosion plane : It is a line connecting the
basion and nosion. It represents the cranial base.
Solton's plane : This is a plane that connects the
Bolton's points posterior to the occipital condyles and
nosion.
Vertical plane

A - Pog Line : It is a line from point A on the maxilla to

pogonion on the mandible.

Facial plane : It is a line from the anterior point of the

fronto-nasal suture (nasion) to the most anterior point
of the mondible (pogonion).
Fig 4 Ccplido-iiolric planes continued. • E; Mandibu ar plane (F) Basioo - Nosior plane (G) Estnetic plane (H) A - Pogonion plane |l| Fccia plane
(JJFaciol cxis
 Cephalometrics 151

DOWNS ANALYSIS A'1andiu/ar plane angle : The m and i u la r o lane

angle is formed by the intersection of the mandibu'ar
One of the most frequently used cephalorvetric
plone with the F.H.plane (fig 5.dj. The mean value is
analysis is the Downs anclysis. Downs had based his
21.9* while the range is 1 7 to 28°. An increased
findings on 20 Caucasian individuc is of 12 - 17 years
mandibular plane angle is suggestive of a vertical
age group belonging to both tne sexes. Downs
grower with hyperdivergent facial oattem.
analysis consists of 10 parameters of which five are
Y - ax.;s fgrowJ.h axis) : This angle is obtained by
skeletal and five ore dental.
joining the sol la-gnathion line with the F.H. plane (fig
Ske/eta/ Parameters 5.e). The mean value is 59° with a range of 53 to 66 s .

racial angle : It is the inside inferior angle formed by The angle is larger in Clcss

the intersection of nasion- oogonion plane and the II facial oa-terns ihon "n patients exnibiting Class

F.H. plane (fig 5.a). The average value is 87.8" while III pattern. In addition, the Y oxis indicates the growth

the range is 82 to 95°. This angle gives us an pattern of the individual. If the angle is grecterthan

indication of the antero- oosterior positioning of the normal, it indicates greater vertical growth o*

mandible in relation *o the upper fcce. The magnitude mandible. If the angle is smaller than no-mal, it
of this value increases in cases of skeletol Class III indicctes greater horizontal growth of mandible.
with orominentchin while it decreases in skeletal Class
Dentai Parameters
II cases.
Cent of occtasa' pi one ; This angle is formed between
Angle of convexity : This angle is formed by rhe
the occlusal plane and the F.H. plane (fig S.f). Downs
intersection of a line from nasion to point A and a line
constructed the occlusal plane by bisecting the
from point A to pogonion (fig 5.b). This angle reveals
occlusion of the 1 st permanent molars and the incisal
the convexity or concavity of the skeletal profile.
overbite. The mean value is 9.3" while the range is 1.5
The average value is 0° while the range is
between - 8.5 to 10°. A positive angle or an "ncreased to 14'"'. This angle gives us a measure of the slope of

angle suggests a prominent maxillary denture base the occlusal plane relative to *he F.H. plane.

relative lo mandible. A decreased cngle of convexity or /nter-mc.'sa/ ongle : This angle is formed belween Ihe

a negative angle is indicative of a prognathic profile. long axes of the upper and lower incisors (fig 5.g). The
average reading is 135.4" while the range is between
A-B plane angle : This angle is formed between c line
130 to 150.5°. The angle is decreased in Class I
connecting point A and point B ond a line joining
bimaxillan/ protrusion and Class II, division 1
nasion to pogonion (facial plane)(fig 5.c). The mean
malocclusion whereas it is increased in a Class II,
value is -4.6'' while Ihe range is -9 to 0\ This angle is
division 2 case.
indicative of the maxillo- mandibular relationship in
J.ocisor ocdusaJ pione ongle : This is the inside
relotion to the fecial plane. It is usually negative in
inferior angle formed by the intersection
value since point B is positioned behind point A. In
case of Class
III malocclusions a positive angle may be found.
Rg 5 Downs analysis (A) Facial angle (BJ Angle of convexity JC) A-B plane angle (D) Mandibular alone angle [EJ Y • ax's (growth cxisl |F| Cart of occusal plare
^g 5 Downs analysis continued ; (G! Inler-incisa cnQle (HJ Incisor occlusal plane cngle (lj Incisor mandibular plcno r^gle (JJ Upper ir.cisor to A - pcg ine

retween the long axis of lower central incisor and occlusal
plane and is read as a plus or minus deviation from a right
angle (fig 5.h). The average olue is 14.5f' while the ronge
is between 3.5 to 20°. An increase in this angle is
suggestive of rcreased lower incisor proclination.
5-j). This distance is on an average 2.7 mm (range : -1
to 5 mm). The measurement is more in patients
presenting with upper incisor proclination.
STEINER ANALYSIS

Incisor mandibular plane angle : This ongle s formed Cecil. C. Sleiner in the yeor 1930 developed this
by intersection of the long axis of the lower incisor ond the analysis with the idea of providing maximal clinical
mandibular plane (fig f i).The mean angulation is 1.4° information with the least number of
while the range •s between - 8.5 to 7°. An increase in
this angle is "dicafive of lower incisor proclination.
Upper j.ncrsor fo A - Pog /ine : This is a linear
measurement between the incisal edge of the maxillary
central incisor and the line joining point A to pogonion(fig
 1601?" Orthodontics - The Art and Science

prognathic (Class II) while a smaller value is

suggestive of c retrognathic maxilla (Class III).
S.iV.8. ongle : It is the angle between the S.N plane
Variable Mean value Range
and a line joining nasion ro point B(fic 6.b). This angle

Skeletal indicates the antero-posterior positioning of the

mandible in relation to the cranial base. Its average
Facial angle 8?.0{degi 52 - So',ceo;
value is 80". An increase in this ang.'e indicates a
A".gle of.convexity '.Oideg; • ' -S.5-ipidegj prognathic mandibie (Class III) whereas a 'ess ?hon

.A-g';piana angle. . -4.6(degV -9 - Oideg) normal angle suggests a retrusive mandible (Class II).

Mandibula' plane angle?... 2l;.9(dcg) .17-28i;d©g;<

A.N.8. angle : Tnis angle is formed by the
intersection of lines ioining nasion to point A and
Y axis 5$.4(desJ S3-S6(dec;
nasion to point B (fig 6.c). 11 denotes the relative
posrion of the maxilioand mandible to each other. The
Denial
mean value is 2C. An increase in this angle is indicative

Cant ot dcdusal plan-e 5.3(deg'/ t .5 - I 4{degj of a Clcss II skeletal tendency while ari angle that is
less than normal or c negative angle is suggestive of a
\ Lower inciscr to occlusal piano i4.5(deg) 3.5 :20
skeletal Class III relationship.
(dog)
/vlorcdfbui'ar p'one angfe : It is the angle formed
Loiv.er incisor. to. ma"dibula< plana 1..4[deg;- 4J '•;' between S.N. plane and fhe mandibular plane (fig 6.d}.

7(dag) :'•. The mandibular-plane used in this analysis is a line

connecting gonion and gnathion. The average value is
. InterincisBl angle .'.'.
32°. This angle gives an indication of the growth
130-i5G.o!d$ pattern of on individual. A lower angle is indicative of a
gj horizontal growing foce while an increased cngle
suggests a vertical growing individual.
Upper Incisor to A - pog 2.7 nn -1 • 5 mm
Occtusa/ p'one angic : The occlusal plane angle is
formed between the occlusal plane end the S.N. plane
(fig 6.e). In this analysis 'he occlusal plane represents
a line passing through the overlapping cusps of first
measurements.
premolars and first molars. It has a mean value of
The Steiner analysis in divided into three
14.5°. This angle indicates tne relation of the occlusal
parts. They ore Ihe skeletal analysis, dental analysis
plane to tne cranium and face. It also indicates the
and the soft tissue a n lysis
growth pattern of an individual.
Ske/etaf analysis
Den fa/ Analysis
S.N.A. angle : It is the angle formed by the
Upper incisor fo N'-A (angle) : It is the angle
intersection of S.N. Plone and a line joining nasion
formed by Ihe intersection of the .!ong axis of the
and point A (fig 6.a). This angle indicates the relative
anlero-posterior positioning of the maxilla in relation
to the cranial base. The mean value is 82". A
largort.nan normal value indicates that the maxilla is
 .oper central incisors and the line joining nasion •o incisor inclination. An increase in this measure-ment
point A (fig 6.f). The normal angle is 22°. Thisangle indicates proclined lower incisors. The normal value is
4mm.

inter-incisor angle : Tnis is the angle formed between

the long axis of the upper and lower central incisors

Variabl (fig 6.j). A reduced inler-incisor angle is associated

e with a Class II, division 1 malocclusion or a Closs I
Skeleta bimax. A larger than normal angle is seen in Class II,
l
division 2 malocclusion. The mean value is 130 to 131
°

Soft t/ssue ana/ys/s

02{deg
) S line : According to Steiner the lips in a well balanced
Occlusal plane angle face should touch aline extending from soft tissue

Mandibular plane contour of the chin lo the middle of an 'S' formed by the
lower border of the nose (fig 6. k). If the lips are located
angle Dental
beyond this line then the lips are believed to be
Upper incisor to NA (angle} 22{deg) upper
protrusive and is interpreted as a convex profile. If the
Irxisor to NA (linear) 4{mm)- lips arc

Lower incisor to NB (angle} 25{deg) Lower

incisor to NB (linear) 4{mm) Interincisal

angfc 131

{deg)

indicates the relative inclination of the .oper incisors.

An increased angle is seen in catients who have
proclined upper incisors as in Cass II, Division 1
malocclusion.

Upper incisor f o N-A (linear) : It is a linear Fig 7 Tweed analysis

—-easurement between the labial surface of the .oper
central incisor ond the line joining nasion ib point A (fig
6.g). This measurement also helps r determining the
upper incisor position. Normal clue is 4mm. It
increases in cases with proclined .•pper incisors.

lower incisor to N-B (angle) : This angle is ^med

between the N-B plane ond the long axis c^the lower
incisor (fig 6.h). This angle indicates —e inclination of
the lower central incisor and -es a mean value of 25°.
An increased value indicates proclamation of lower
incisors whereas a decreased value indicates upright
or retroc!ined lower incisors.

Lower incisor to N-B (linear) : It is the lineor

distance between the labial surface of lower central
incisor and the line joining nasion to point B (fig
6.i).This measurement helps In assessing the lower
 c. Long axis of lower incisor
The objectives of the analysis include the
Variable
determination of the position of the lower incisor] and

Frankfort mandibular 25{deg)i6-35(<teg) plane angle (FMPA)

evaluation of prognosis of o cose. The angles formed

Incisor mandibular 90(<teg)85-95(d<?g) plane angle (IMPAJ by these three planes are :
Franktort mandibular 65(deg)60-75(deg) Incisor angle (FMIA)
Frankfort mandibular plane angle
(FMPA)

It is the angle formed by the intersection

behind this line they are said to be retrusive and the of the Frankfort horizontal plane with the mandibular
patient may have a concave profile. plane. The meon value is 25=.

TWEED ANALYStS Incisor mandibular plane angie (IMPA)

It is the angle formed by the intersection of the long
The Tweed analysis makes use of three planes (fig 7)
axis of the lower incisor with the mandibular plane. It
that form a diagnostic triangle. The planes used are:
indicates the inclination of the lower incisor. The mean
a. Frankfort horizontal plane
volue is 90°.
b. Mandibular plone
Frankfort mandibular incisor angle
(FMIA)

It is the angle formed by the

intersection of the long axis of the lower incisor with the
F.H.plane. The mean value is 65c.

The Wits appraisal

The wits appraisal is a measure of the extent to which
the maxilla and the mandible are related to each other
in the antero-posterior or sagittal plane. The wits
approisal is used in cases where the ANB angle is
considered not so reliable due to factors such as
position of nasion and rotation of the jaws.
A functional occlusal plane is drawn through
the overlapping cusps of first premolars and first
molars (fig 8). Perpendiculars are drawn to the
occlusal plane from points A and B. The points of
contact of these perpendiculars on the occlusal plane
are termed AO and BO. The distance between points
AO and BO gives the anteroposterior relation between
Fig 8 Wits Apprise I the two jaws. In
 1601?" Orthodontics - The Art and Science

ill

Ccphalometrics

Brror mmm
1. Radiographic projection errors
A. Magnfcaiion i a certa.n
amounlofertanjemeni s seen
in cephalorretr'c rad'cgraohs.
B. Distorters : tie head being
3 dimensions' causes
dlfarerf. magnifications at d
flerent depths c t lie'd. This
may rest>1 in distortions.
Causes of
error
f-Aagrilcation enors are because
tho X ray beams are not parallel w th all points of
t"e ob;ect
Lardmaiks arid stwctires /Jbt s i„ated in the
mdsagitlal olana are usually bilateral ard
nay cajse CuaJ -mages in radiograph
By us;rg a long tocus- ob.eci distance
and a start ohect • film distance By
use ot a-gUar ratierSiar. rear
measurement.
Th's enx>r may be overcome by
record tte nucpo -t cf die vx
Images.

Rolaic n of the pafenfs tesd in ary plane of space By stardard<2ed head orerrtaicn
in the cephaiostot may prcduce linear a-d i&jjng ear rods, orbits oointe- and
angular distoricre. forehead rest

2. Errors within the measuring system

Emors may occir in tie

measu^ment of the va-iois
lines' and Tie angular
neasu-ements.
1 Errors in landmark fdenlifitalion
A. Quafffy cf
radiog, r apttc image
Human enor may creep in during tt-e iraclng and
measurements.
Blurring of the radiograph may occur as a ^sult
ot scattered radiate n frat togs the ilm
Poor contest of flm may make differentiation
between adjacent structures difficult.
Errors may occur if Bie landmark is not defined
accurately. This causes confusion in
identificalcn ol a tandma-k.
In general certain lardmaiks are drtfcult to
identify such as porior.
The use of computerized olotters and
digitizers to digitize ne Isndma-ks a^d
to carry ou- 1"e various linear and
angular measurements tas proved to
be more accurate and consistent
Good quality f&jiog'aphy ard use of
avetage values from mUfple
identification of tho same landma-k
I i3 advisable tor tte same person to
Identify and trace in patens who are
subject« serisi cephafometic
studies
Ws can be overcome by randomizing
the recorded measurements and by
adopting a double blind study pattern.

Variation f-^/e been observed in landman

identification between operators.

"Pie operators oipectafors can result <n bias of

B. Precision of landman
deinltion and reproducibility Of
landmark location
the values
Recomended t'ms snotld be used to avoid ooo r
deinition radiographs

Tris can be avoided oy stabilization of Ite object,

C. Operator Bias
Poor detrison of radiographs may
occu' tiw to use ot test iims and
intensive screens alhojgr the
raJiaton dose is reduced,
Movement of the object tube or
the Sim may CETJSe a motion
blur,
tube and tte film. By increasing tie currern, ine
exposure time is reduced, tius minimizing tiifi
possibility of motlo,-- blu',
This can be 'educed by jse of g ids.
Good contrast is obtained by using; good films
and use of sc'eqvate Kv level. Too Hgh Kv .-esulR
in poor contrast
lardmaiks have to be accurately, defined.
Certain lartimafts may require special condrtohs
to identfy wfrich should be stricty toitowp.c.
case of males point BO is ahead of AO by 1 mm, while
in case of females Ihe points AO and BO coincide. In
case of skeletal Class II tendency BO is usually behird
AO {read as a oositive reading) while in skeletal Class
III pattern the point BO is located aneod of AO {reed as
a negative reading}

ERRORS IN CEPHALOMETRY

A number o* possible errors may creep in during

cephalometry as it involves a number of steps such as
obtaining a good radiograph, use of geometric
constructions and analysis and interpolation of the
values obrained without any observer bios. Table 4
gives o summary of the sources of error in
cephalometry. Although conventional cephalomctry
may be associated with a number of sources of errors,
il slill offers vital information fortne orthodontist in
diagnosis and treatment planning.

References

1. Downs WB - Analysis of the denlofac c I profile.

Angle Ortnod 1956 ;26 :191
2. Downs WB : The no e o: cephalometry in Orhocon- tic casfl
analysis onr. diagnosos. Am .1 OrtnocJ 1952

3 Grcber T.V1 : Orthodontics : Principles and practice. W3

Saunders, 198B
4. Jacobscn : introduction to Radiographic Cepnolomelry, Leo
and Fcbigcr, Pniladclphia, 1985
5. Profitt WR: Contemporan^ Orthocoilics. St Louis, CV Mosby,
1986
6. Robsrl t Moyers : Hand boo< of Orthodontics, Yea' book
medical publishers, 'nc,1988.
7. Sazman JA : P'octice ot Orthodontics, JB Lippincott com
pony. -966
8. S'einer CC : Cephalometrics for you ond me.Am J Orthod
1953:39; 729
9. Stc nor CC : C'Bphclomet'y in clinical prcdice. Angle Orthod
1959:29; 8
10. Sleiner CC : The use o: Cepha om«try us an aid in planning
and asscssinc ortnodontic treatment. Am J Orthod 1960:46;
721
11. Thomas M Grobc, Robert L Vanarsdoll : Orthodonlics current
principles and technicues, Mosby year book Inc , 1994
12. Yen P : identification of landmark in cephalometric
radiographs. Angle Orthod 1960 ;30-3S
 1601?" Orthodontics - The Art and Science

Maturity

A n understanding of growth events is of primary

importance in the practice of
orthodontics. Biologic age, skeletal age, bone
age, and skeletal maturotion ore -early synonymous
clinical
A number o; methods are available to
assess the skeletal maturity of an individual. These
include:
A. Use of hand-wrist radiographs.
terms used to describe the stages of moturalion of a B. Evaluation of skeletal maturation using cervical
person. Due to indi- «xiual variations in timing, duration vertebrae.
and velocity cf growth, skeletol age assessment is C. Assessment of maturity by clinical and radio-
essential in ^-rmulating vioble orthodontic treatment graphic examination of different stages of
plans, '•'oturationol status can have considerable
influence on diagnosis, treatment goals, treatment
cfanning, and the eventual outcome of orthodon- -c
treatment. Clinical decisions regarding use of extraoral
traction forces, functional appliances, extraction
versus non-extraction treatment or orthognathic
surgery are, at least partially, based co growth
considerations. Prediction of both the -me and the
amount of active growth, especially n the craniofacial
complex, would be useful to —e orthodontist.
In view of the importance of growth in
orthodontic treatment, objective assessment of
moturalion is important. The chronological age based
on the date of birth o^ers little insight in determining the
developmental stage or somatic maturity of a person.
Thus the maturity indicators provide an objective
diagnostic evaluction of stage o: maturity in an
individual.
The basis for skeletal age assessment by
radiographs is thot the different ossificction centres
apoear ond mature ot different times.The order, rate,
time of appearance and progress o: ossification in the
various ossification centres occurs in a predictable
sequence. 161
 tooth development.
Althougn a number of metnods of skeletal
met jrity determination have been described, the use
of hend-wrist radiographs has been the most widely
accep'ed method.
HAND-WRIST RADIOGRAPHS
Tne hand - wrist region is made up of numerous small
bones. These bones show a predictable and
scheduled pattern of appearance, ossification and
union from birth to maturity. Thus by mere y comparing
a patient's hand-wrist radiograph with standard
radiographs that represent different skeletcl ages, we
will be able to determine rhe skeletal maturation status
ot that individual.
A number o: methods have been described
TO assess the skeletal maturity using hand- wrist
rcdiograpns. The following are the most commonly
used methods:
A. Atlas Method by G'eulich and Pyle
B. Bjork, Grave and Brown Method
C. Fishmon's Skeletal Maturity Indicators
D. Hag g and Ta ranger Met nod.
ANATOMY OF HAND - WRiST
The hand-wrist region is made up of I he following four
groups of bones (lig 1}.
1. Distal ends of long bones of forearm
2. Corpals
3. Metacarpals
4. Phalanges
Dfsts/ ends of tong bones of forearm
The distal ends of radius and ulna, which are long
bones of the forearm, form the first group of bones. In
the anatomical position with the palm focing the front
the ulna is on the mediol aspect while the radius is on
the distal aspect. The radius and tne ulna give rise to o
distol projection on their respective sides. These are
called the ulna styloid ond the radial styloid.
The carpals
They consist of eight small, irregularly snapec bones
arranged in two rows, a proximol row and a distal row.
The bones of the proximol row are scophoid, lunote,
triquetral and pisiform. The distal row of bones include
trapezium, trapezoid, capitate, and hamate. Each of
these eight carpc bones ossifies from one primary
center, which appears in a predictable pattern.
TVre metacarpals
They are 5 miniature long bones forming the skeletal
framework of the pa I m of the hand. They are
numbered I - 5 from the thumb to the little finger. Each
metacarpal ossifies from one primary center (in its
shaft) and a secondary center on the distal end (except
for the first rnetacarpol where it appeors at the
proximal end).
The phalanges
They are small bones forming the fingers. They are
three in number in each finger, except the thumb which
has only two pholanges.
The three bones are referred to as the
oroximal, middle (absent in thumb) ond the distal
phalanges. The phalanges ossify in 3 stages
(fig 2).
STAGE 1 : The epiphysis and
diaphysis are equal. STAGE 2 : The
epiphysis caps the diaphysis by
surrounding it like a cap. STAGE 3:
Fusion occurs between the
epiphysis and diaphysis.
t
 1601?" Orthodontics - The Art and Science

Skeletal Maturity

Indicators 163
1. Radius
2. Ulna
3. Distal Epiphysis of Rodius
4. Distal Epiphysis of Ulna
5. Trapezium
6. Trapezoid
7. Capitate
8. Hdmular process of Hamate
9. Hamate
10. Triquetral 11 .Pisiform 12. =
ig 1 Ana'Oftiy of hand and wrisl
lunate
] 3. Scaphoid 14 ^Sesamoid . M =
Metacarpal P ''§ Phalanx

1*3
|g4 Orthodontics - The Art and Science

in the atlas is representative o*' c particular skeletal

age. The patient's radiograph is matched on an overcll
In patiems who exhibit napr discrepancy between dental and
basis with one of the photographs in the atlas.
chronologic a$s.

2. Determination of skeletal maturity status prior to treat-

men: of skeletal malocclusion s*ch as a skelelal Class
II or Class III malocclusion.
3. To assess the skeletal age •:> a patient whose growth is
ajfeaed by rnfecton3. aplastic or fa--mate oy- cftons
4. Serial assessment cl skeletal age using hard-wrist
radiographs helps not only in assessing ihs growth of
a-, individual, but also helps predicl future skeletal
maturation rate and status.
5. To predicl the pubertal growth spurt.
6. II is a valuable aid $ research airr.ed at stuoying 1he role
of heredity, environment, nulrt.on etc., on the s-iele-.al
BJORK, GRAVE AND BROWN
They have divided skeletal development into 9 stoges.
Each of these stages represents a level of skeletal
maturity (fig 3). Appropriate chronological age for ecch
of the stages was given by Schopf in 1978.
Stage I (mates 10.6 y , fema/es 8. Iy): The epiphysis
and diophysis of the proximal phalanx of index finger
are equal. It occurs approximately three years before
the peak of pubertal growth spurt.
Stage 2 (mafes J 2.0 y, femoJes 8. J y): The epiphysis

maturation pattern.
f, It is indicated in patients wdh skeletal malocc^uson nesting
onhognathic surgery, if undertaken between :6 - 20
years so as to-assess thegrowh status.
The sesamoid bone
The sesamoid bone is a small nodular bone mosT
often present embedded in tendons in the region of
the thumb.
and diaphysis of the middle pho- lanx of the middle
finger are equal.
Stage 3 fma/es /2.6 y, f em ales 9.6 y): This stage is
characterized by presence of 3 areas of ossification:
The hamular process of the hamote exhibits
ossification.
Ossification of pisiform.
The epiphysis and diaphysis of radius are
equal.

Stage 4 (moles 13.0 y , fema/es f 0.6 y): This stage

marks the beginning of the pubertal growth spurt. It is
characterized by :
a. Initial mineralizotion of the ulnar
sesamoid of the thumb.
b. Increased ossification of the hamular

flflfl
A B
C
Fig 2 5lages in ossificot on of plia'crigcs |A)Ihu epiphysis and d
ephysis'are equal |B)The epiphysis caps -he c'iaphysis
(C)Fusion butween epiphysis and diaphysis.
GREULICH AND PYLE METHOD

Greulich and Pyle published an alias containing ideal

skeletal age pictures of the hand-wrist for different
cnronobgiccl ages pnd for each sex. Each photograph

I
 &
Fig 3 (A) S'age one - Epiphysis and diaphysis of -ne croxirrol Fig 3 (B1 Stage -wo - The epiahysis and biaohysis of 'he rriddle
pha'anx o1' index finger a'e equcl. phalonx cf the ~iidd e finger are equcl.

C D E
Fig 3 (C) Stage "hree • The homula' process of ihe homa'e exhibits os$i ication |Oj Ossification at pisiform (E) The epiohysis end diaphysis of
:

radius ere equal.

Fig 3 (F) Stage four - Initial rrheralizafion of Ihe ulnar sesamoid cf the thumb |G) Increased ossification of -he hamular process of the narrate bone.
 1601?" Orthodontics - The Art and Science

iiilli Fig 3 (H) Stage Five -

-
Capping of diophysis by the epioiysis is seen in middle pholar* of the third f nger (I) Proximol phaloru of
ha tnumb (J; Rod us

end diophysis of the distal phalanx of ihe middle f nger.

Fig 3 (I) S' O G E seven • Union of epiphysis and diophysis of the

O'oximal phalanx of the little finger
Fig 3 K) Stage Six - Un or- betweencpiohysis

n
Fig 3 (W) Srcge Eight • Fusion between the epiphysis end diophysis
of the middle phalanx of the rriddle finger,
Fig 3 (N; Stage Nine • Fusion of epiphysis and diaphysis of the
radius.
 process of the hamate bone. Stage three (Pubertal onset)
Stage 5 (ma/es 14.0y, females ?.0 y): This stage This stage is characterized by
heralds the pea'< of the pubertal growth spurt.
Skeletal Maturity Indicators beginning of calci-
Capping of diaphysis by the epiphysis is seen in : fication of ulnar
a. Middle phalanx of the third "finger sesamoid, increased width of epiphysis of proximal
b. Proximal phalanx of the thumb phalanx of Ihe second finger and increcsed
c. Radius calcification of hook of hamate and pisiform.
Stage 6 fma/es /5.0 y , femafes J 3.0 y): This stage
Stage four (Puberal)
signifies the end of the pubertal growth spurt. It is
characterized by union between epiphysis and Stage four is characterized by calcified ulnar sesamoid

diaphysis of the distal phalanx of the middle finger.
Stage 7 fma/es / 5.9 y,'/emo/es /3.3 y): Union of
epiphysis and diaphysis of the proximal phalanx of the
little finger occurs.
Stage 8 (males /5.9 y , females J 3.9 y This stage
shows fusion between the epiphysis and diaphysis of
the middle phalanx of the middle finger.
Stage 9 (ma/es /8.5 y , females 16.0 yj: This is the last
stage ond it signifies the end of skeletal growth. It is
characterized by fusion of epiphysis and diaphysis of
the radius.
SINGER'S METHOD OF ASSESSMENT
and capping of the diaphysis of the middle phalanx of
third finger by its epiphysis.
Stage five (Puberal deceleration)
This stage is characterized by fully calcified ulnar
sesomoid, fusion of eoiphysis of distal phalanx of third
finger with its shaft, and epiphyses of radius ond ulna
not fully fused with respective shafts. Stage 5
represents that period of growth when orthodontic
treatment might be completed ond the patient is in
retention therapy.
Stage s/x fGrowtft completion)
No removing growth sites seen.

Julian Singer in 1980 proposed a system of hand- wrist

radiograph assessment that would enable the clinician
to rapidly and with some degree of reliability help
determine the maturational status of the patient. Six
stages of hand-wrist development ore described. The
stages and their characteristics are :

Stage one (Early)

This stage is characterized by absence of the pisiform,

obsence of hook of the hamate and epiphysis of
proximal phalanx of second finger being narrowerthan
its dioohysis.

Stage two (Prepubertal)

Stage two is characterized by initial ossification of hook

of the hamate, initial ossification of the pisiform and
proximo' ohalanx of second finger being eaual to its
epiphysis. Stage 2 represents that period prior to the
adolescent growth spurt during which significant
amounts of mandibular growth are possible. Maxillary
orthodontic tneropy in conduction with mondibular
growth might aid correction of a Class II relationship
with considerable speed and ease.
1601?" Orthodontics - The Art and Science Fishmon s system of interpretation uses four stages of
bone maturation. They are:

1) Epiphysis equal in width to diaphysis.

S.M.I. 1 : The third lingef proximal
2) Appearance of adductor sesamoid of the thumb.
phalanx-.shows equal w.dth of
3} Capping of ephiphysis 4} Fusion of epiphysis
epiphysis and diaphysis.
Table 2 gives tne eleven skeletal maturity in-
S.M.I. 2 : V^idih of epiphysis equal to lhal of
diaphysis in Ihe middle phalanx of dicator (fig 4). Table 3 gives us the approximate

third finger. chronological age and percentage of growth that is

S.M.I. 3 : Width of epiphysis ecual to thai of completed corresponding to each of the eleven
diaphysis in the micdle phalanx of skeletal maturity indicators.
fifth finger.
MATURATION ASSESSMENT BY HAGG
S .M. 1 . 4 ; Appearance ot adductor sesmod
of the thumb.
AND TARANGER
S.M.I. 5 : Capping of epiphysis seen in distal
Skeletal development in the hand and wrist is analyzed
phalanx of third finger.
from annual radiographs, taken between the oges of 6
S.M.I. 6 ; Capprvg of epiphysis seen in micdle
and 18 years, by assessment of Ihe ossification of the
phalanx of third finger.
ulnar sesamoid of the metacarpophalangeal joint of the
S.M.I. 7 : Capping of epiphysis seen in middle
first finger (S) and certain specified stages of three
phalanx of lifth finger.
epiphyseal bones: the middle and distal phalanges of
S.M.I. 8; . Fusion of epiphysis and diaphysis in
the third finger (MP3 and DP3) and the distal epiphysis
the distal phalanx of third finger.
of the radius (R) (fig 5).
S.M.L 9 : Fusion of epiphysis and diaphysis in
proximal phalanx of third finger. Sesamoid
S.M.L 10 : Fusion of epiphyss and diaphysis
Sesamoid is usually attained during the acceleration
in the middle phalanx of third
period of the pubertal growth spurt (onset of Peak
linger.
height velocity).
S.M.I. 11 ; Fusion of epiphysis and diaphysis
seen in the radius.
Third finger middle phalanx
MP3-F : The epiphysis is os wide as the meta-
physis. This stage is attained before onset of RH.V. by
FISHMAN'S SKELETAL
about 40 percent of the subjects and at RH.V. by many
MATURITY INDICATORS
others.
A system for evaluation of skeletal maturation was /VIP3-FG : The epiphysis is as wide as the meta-
proposed by Leonord S. Fishman in 1982. This system physis and there is distinct medial and/or lateral border
of evaluating hand-wrist radiographs makes use of of the epiphysis forming a line of demarcation at right
anatomical sites located on the thumb, third finger, fifth angles to the distal border. This stage is attoined 1
finger and radius. Eleven discrete adolescent skeletal year before or at RH.V
maturity indicators (S.M.I.'s) covering the entire period
of adolescent development have been described. The
v Approximate chronological age and percentage of growth completed corresponding to the

Female
 1601?" Orthodontics - The Art and Science

SMI No. Age in Years

Percentage of Adolescent growth % of Max Growth % of Mand.
completed Completed Growth
Completed
1 9.94 ±0.96

2 10.58 =0.88 12.2 16.7 14.7

3 10.88 ±0.99 22.5 18.5 25.0

4 11.22 =1.11 32.7 20.3 33.1

5 11.64 ±0.90 39.8 28.6 38.3

6* 12.06 ±0.96 51.7 49.7 47.0

7 12.34 »0.90 73.6 69.0 58.0

8 13.10 ±0.87 86.6 83.0 72.7

9 13.90 ±0.99 91.9 89.6 84.0

10 14.77 ±0.96 96.1 92.7 90.0

11 16.07 ±1.25 100% 100% 100%

Male
SMI No. Age in Years
Percentage of Adolescent growth % of Max Growth % of Mand.
completed Completed Growth
Completed
1 11.01 ±1.22

2 11.68 ±1.06 15 16.7 15.9

3 12.12 ±1.00 21.6 18.5 19.5

4 12.33 ±1.09 28.9 20.3 26.7

5 12.98 ±1.12 34.0 28.6 30.8

6* 13.75 ±1.06 52.6 49.7 48.5

7 14.38 ±1.08 74.3 69.0 66.7

8 15.11 ±1.03 87.3 83.0 77.7

9 15.50 ±1.07 92.0 89.6 84.6

10 16.40 ±1.00 95.3 92.7 91.5

11 17.37 ±1.26 100% 100% 100%

i si
 fig 4. fisnnian's skeletal maturity indicators
Skeletal Maturity Indicators 171

MP3-G : The sides of the epiphysis h.ave thickened distally at one or both sides. This stage is attained at or
ond also cap its metaphysis, forming a sharp edge 1 year after RH.V MP3-H : Fusion of the epiphysis
and metaphy- r"s has begun and is attained after PHV
but be- ^re end of growth spurt by practically all boys
end about 90 percent of the girls. WP3-J: Is attained
before or at end of growth ssurt in all subjects except a
few girls.
Third finger dlstat phalanx
3 D 3-I ; Fusion of the epiphysis and metaphysis s
completed. This stage signifies the fusion of the
•oiphysis and metaphysis and is attained during ■he
deceleration period of the pubertal growth spurt e. end
of RH.V.) by all subjects.
Radius
8J: Fusion of the epiphysis ond metaphysis has regun.
This stage is attained 1 year before or at 1-« end of
growth spurt by about 80% of the girls rrd about 90%
of the boys. t-U : Fusion is almost completed but there
is r II a small gap at one or both margins. <-J : is
characterized by fusion of the epiphysis
metaphysis.
:
These stages were not attained before end of H.V. by
any subject.
SKELETAL MATURATION EVALUATION
USING CERVICAL VERTEBRAE
-ossel and Farman developed a system of skeletal
maturation determination using the cervical «ertebrae.
The shapes of the cervical vertebrae -ere seen to differ
at each level of skeletal devel- rcment (fig 6}. This
provided a means to deter- —fne the skeletal maturity
of a person and thereby :-exermine whether the
possibility of potential growth existed.
The shapes of the vertebral bodies of C3 and C4
changed from somewhat wedge shaped,
rectangular, followed by square shape.In addition
They became taller os skeletal maturity progressed.
The inferior vertebral borders were flat when
immature, and they were concave when mature. The
curvatures of the inferior vertebral borders were seen
to appear sequentially from C2 to C3 to C4 as the
skeleton matured. The concavities became more
distinct as the person matured.
Hassel and Forma n have put toward the
following six stages in vetribral development:
Stage I
This stage called initiation, corresponds to beginning
of adolescent growth with 80% to 100% of adolescent
growth expected. Inferior borders of C2, C3, and C4
were flat at this stage. The vertebrae were wedge
shaped, and the superior vertebral borders were
tapered from posterior to anterior.
rrd Stage 2
The second stage is called acceleration. Growth
acceleration begins at this stage, with 65% to 85% of
adolescent growth expected. Concavities were
developing in the inferior borders of C2 ond C3. The
inferior border of C4 was flat. The bodies of C3 and C4
were nearly rectangular in shape.
Stage 3
The third stage colled transition, corresponded to
acceleration of growth towards peak height velocity
with 25% lo 65% of adolescent growth expected.
Distinct concavities were seen in the inferior borders of
C2 and C3. A concavity was beginning lo develop in
the inferior border of C4. The bodies of C3 and C4
were rectangular in
to
l-H
 Orthodontics - The Art and Science

THE DISTAL PHALANX OF

THE THIRD FINGER I
THE MIDDLE PHALANX OF THE THIRD FINGER

ULNAR
SESAMOI
D Fig 5. Hond-wrist rodiogroph assessment by Hagg end Toranger
 Skeletal Maturity Indicators fj

Initiation Acceleration Transition

Completion Maturation Deceleration

Fig 6. Assessment of skeletal motu'etien using the verebral coljmr.

borders of C2, C3, and C4. The bodies of C3 and C4

s~ope.
were nearly souare to square in shape.

Stage 4
Stage 6
This stege colled deceleration, corresponds to
This stage called completion corresponds to
deceleration of adolescent growth spurt with 10% •o
completion of growth. Little or no adolescent growth
25% of adolescent growth expected. Distinct
could be expected. Deep concavities were seen in the
concavities were seen in Ihe inferior borders of C2, C3,
inferior borders of C2, C3, and C4. The bodies of C3
and C4. The vertebral bodies of C3 and Z4 were
and C4 were sauare or were greater in vertical
becoming more square in shape.
dimension than in horizontal dimension.

Stage 5
TOOTH MINERALIZATION AS AN
The fifth stage is called maturation. Final malu- trtion of INDICATOR OF SKELETAL MATURITY
the vertebrae took place during this stage, *:th 5% to
10% of odolescent growth expected. More The calcification patterns and stage of mineralization
accentuated concavities were seen in the inferior of the teeth is believed to have a close

m
relationship with the s<eletal maturation of an
individual. Seymour Chertkow has described a method
of determining -he skeletal maturity based on Ihe
mineralization of the lower canine. Demirjcln,
Goldstein and Tanner have described a similar
method.

References
1. Chctkow : loolli minerol2a'ion as on indica-o' of the pubertal
growth spurt. Am j Orhoc 19SO; vol : 79-91.
I. Coutinbo, Buscnarc and Miranda: Mcndibulor ca- rine
calcifica-icn stages end s<clcla ma urity, Am „
Orthod 1993 ; vol :?6? 968 3. Demirjiar, Buscha-ig, languoy,
arc Poters: Intsrre- Iclionshios cr-iong mp.asi.res of somatic, skc
clul, den-cl, arc saxjal malumy. Am J Onhod 1985; vol: 433-138
Grave end Brown: Skeletal oss'tication arc ccolcs- cen- crcwih
spur. Am J Orhoo 1976; vol: 69-80. I>. (■•egg ard Tamnger :
Metjrotor nd LCIOIS end Ihe pubc-ta g'owlh Spur Am j Onbodl9&2; vol
: 299- 309
6. rasscl and Fair-ai : 5<s etcl maturat'en o value- •icn. Am J
O.-tiodl 995; vol : 68-66
7. Julian Siraer : Phys'olagic timing o; O'lfodorvic •reel-Men'.
Argle Orhocont 1980; vol: 322-333
8. Leite, O'Rei ly, end Close : Skols'cl age assess me n- wrh
first, second, and tliirc tinges. Am J Orthod " 987 ; vol :
492-498.
9. (.eonorc S.Fisiman: Radiog'aphic cvaljJlio-i o; Skc c'al
matufity. Angle Ortnodcm 1982; vol: 83 - 112
10. Moore, Mover ord DuBois : Skele-al netu-etor a id crcniotccia
growth. Am J Oinod 1990; vol : 33-
40.
II. Rcve o arc P'sircr : Evaluation of ossification of mid pa lota I
suxre. Am J Or boei 1 99*- ; vol : 283- 292.
12. Rcssouw. Lomberu, aid I laris: Frortcl sinus a id mandibii.fir
growth predict on. Am J Orthod 1991; vol: 5<12-5'-6.
 (Jj Model Analysis

Determination of the discrepancy

S
tudy casts are essential diagnostic aids. The
study models provide a three dimensional The discrepancy refers to the difference between the
view of the maxillary and mandibular dental a'ch length and tooth material.
arches. Model analysis involves the study of the
^axillary and mandibular dental arches in all the three
planes of space (sagittal, vertical and ^nsverse planes}
and is a valuable tool in cfthodontic diagnosis and
treatment planning.

CAREY'S ANALYSIS

Many malocclusions occur as o result of discrepancy

between arch length and tooth material. Carey's
analysis helps in determining -he extent of the
discrepancy. It is performed on -he lower cast. The
same anolysis on the upper cast is called Arch
Perimeter Analysis.

Determination of arch length

"he arch length anterior to the first permanent -solar is
measured using a soft brass wire. The wire is placed
contacting the mesial surace of the first permanent
molar of one side and is passed over the bucccl cusps
of the premolars and along the anteriors and is
continued on Ihe opposite side in the same way upto
the mesial surface of Ihe opposite first permanent
molar. In case of proclined anteriors, the wire is passed
along the cingulum of anterior teeth. If the anterior
teeth are retroclined, the bross wire in the anterior
segment passes labial to the teeth. If the anterior teeth
are well aligned the wire passes over the incisoi edge
of anteriors.

Detez-m In a 11 on of tooth material

The mesio-distal width of the teeth anterior to the first

molcrs (second premolar lo second premolar) is
measured and summed up.

iv r
 • Carey's analysis inference

Discrepancy Inference
0 - 2.5 mm Proximal stripping
2.5 • 5 mm Ext'aclicr, of seconc premolars
> 5 mm Extract on of firsi premolars

Inference
a. If the discrepancy is 0 to 2.5 mm, il indicates
minimal loom mcrenal cxccss. In such cases,
proximal stripoing can be carried ouf to reduce the
tooth material.
b. If the discrepancy is between 2.5 to 5 mm, il
indicates the need to extract the second
premolars.
c. A discrepancy of more than 5 mm indicates the
need to extract the first premolars.

ASHLEY HOWE'S ANALYSIS

Ashley Howe corsidered loolh crowding to be due to

deficiency in arch width rather then arch lenglh. He
round a relationship between tnc total width of the 12
teeth anterior to tnc second molars and the width OT
the dental arch in the first premolor region.

Determination of total tooth

material (T.T.M.)

The mesio-distal width of cil the feefh mesial to the

second permanent molars is mecsureci with the hclo
of dividers (fig 1 .a) and al t'ne values are summed up.
This vclue is called the total loolh material.

Determination of premolar
diameter (P.M.D.)

The premolar diameter refers to the arch width from

the t'p of the bucccl cusp of one first premolar to ?he tip
o: bucca cusp of the opposite first premolar(fig 1 .bj.
h g I Ash1 ey Howe's analysis (A; Measurement cf -ne mesio-msta
width of tie ioctn cf ihe a ca o; maximum contour (3) Meosjrement of
premolar diameter (C) rreasjrerrent of premolar uasa ard 1 widlh.
esc- shows t ic oca'icn distal to tie canine prominence
 Model Analysis 177

PMBAW Inference
% Need for exfadon
37 c l$S9 44 Trealmeni by
cr more 37 nc--extraction
to 44 Borderline cases
Determination of premolar basal arch
width (P.M.B.A.W.)
The canine fossa is found dista1 to carine eminence.
Tne measurement of the width from canine fossa of
one side to the other gives us Ihe width of the dental
Determ/naf/on of sum of
arch at the coical base or the junction between the incisors (S.i.)
basal bone and o'veolc process. If Ihe canine fossa is
The mes io-d istal widtn of t.ne 4 maxillary incisors is
not clearly distirguishcble the measurement is mede
measured ond the values summed up. This value is
from a ooint that is 8 mm below the crest of the irter-
called sum of incisors (S.I.).
dental papilla distal to 'he canineifig 1 .c)

Inference
The RM.B.A.W. and the RiV,.D. are compared. If the
RM.B.A.W. is greater than the PM.D., then it is an
indication that arch expansion is possible. If on the
other hand the RM.B.A.W. is less than RM.D., then
arch expansion is not oossible.
According lo Ashley Howe, to achieve normal
occlusion with o full complement of teeth the basal
arch width ot the premolar region should be 44% the
sum of mesio-distal widths o" all the teeth mesial to the
second permanent molar (tolol tooth material). This
ratio (expressed as %) between the apical base width
at the premolar region and the total tooth material is
called the prenolor 'oosal arch width percentage. It is
determined using the formulc :

RM.B.A.W. % - PM.B.A.W. x 100

T.T.M.
a. If RM.B.A.W. % is 37% or less, it indicates a
Fig 2 ?orts analysis (A) Inte'-premolar width (B; rver-
mcla' w cfh

need for extraction.

b. If RM.B.A.W. % is 44% or more, Ihe case can
possibly be treated without extracting any teeth.
c. If RIVI.B.A.W. % is 37 - 44%, the case is referred
to as a borderline case.

PONTS ANALYSIS

Ponts in 1909 presented a system whereby the

measurement of the four maxillary incisors
automatically established the width of the arch in the
premolar and molar regions. Ponts analyst helps in :
a. Determining whether the denial orch is narrow or
is normal.
b. Determining the need for lateral arch expansion.
c. Determining how much expension is possible at
the oremolar and molar regions.
Determination of measured
premolar value (M.P.V.)
The width of the arch in the premolar region from the
distal pit of ore upper -first premolar to the distal pit of
the oppos'te first premolar is measured. It "s called the
measured premolar value.
Determination of measured
molar value (M.M.V.)
Tne width of the arch in the mo or region from the
mesial pit of one upper first molar to the mesial pi-of
the opposite first molar is measured. This value is
called the measured molar volue.
between the mesio-distal widths of maxillary and
mandibular teeth. Many malocclusions occur as a
result ot abnormalities in tooth size. The Bolton's
analysis helps in determining disproportion in size
between maxillary and mandibular teeth.
Sum of mandibular 12
The mesio-distal widln of all the teeth mesial to the
mandibular second permanent molars is measured
and summed up.
Sum of maxillary 12

Deterro/nat/on of calculated
premolar value (C.P.V.)

Calculated premolar value or tne expected arch width

in the premolar region is determined by the formula :
S.I. x 100/80

Determination of calculated
molar value (C.M.V.)
Calculated molar value or the expected arch width in
the molar region is cetermined by the formula: S.I.x
100/64

Inference
If measured value is less than calculated value, it
indicates the need for expansion. Thus it is possible to
determine flow much expansion is needed in the molar
and the premolar regions.

UNDER HARTH INDEX

This analysis is very similar to Pont'sanolysis except

that a new formula has been proposed to determine
the calculated premolar and molar value.
The calculated premolar value is determined
using tho formula : S.I. x 100 / 85
The calculated molar value is determined
using the formula : S.I. x 100 / 64

KORKHAUS ANALYSIS

This analysis is also similar to Pon^s analysis. It makes

use of the Under Horth's formu la to determine the
ideal prph width in the premolar and mo'ar region. In
addition, this analysis utilizes a measurement made
from the midpoint of the inter-premolar line to a point in
between the two maxillary incisors. According to
Korkhaus, fora given width of upper incisors a specific
value of the distance between the midpoint of inrer-
premolor line to the point between the two maxillary
incisors should exist. An increase in this measurement
denotes proclined upper anterior teeth while a
decrease in this value denotes retroc I i ned u pper a
nte ri o rs.

BOLTON'S ANALYSIS

Tooth size is ari important factor to be taken into

consideration in orthodontic diagnosis and treotment
planning. According to 8olton, there exists a ratio
The mesio-distal width of all the teeth mesial to the The sum of mesio-distal width of the mandibular
maxillary second permanent molars is measured ond Model
onteriors should be 77.2 Analysis
% o;tne T179
mesio-distal width of
summed uo. the maxillary anten'ors. The anterior rcrio is
determined using 'he following formula :

Sum of mandibular 6
sum of nand:bular 6 x 100 sum of maxillc-y 6
The mesio-distal width of all the teelh mesial to the
mondibulor first premolars is measured and summed If the anterior rat'o is less t nan 77.2% it
up. iridicctes n axil la ry anterior excess. r he
amount of maxillary anterior excess is
Sum of maxillary 6
Anterior ratio = determined by the following way:
The mesio-dista! width of all the teeth mesial to •he Mandibular 6 x 100
maxillary first premolars is measured and summed up. Maxillary6 -

l~ the anterior ratio is more than 77.2 %, it

Determination of overall ratio
indicates mandibular onterio- excess. The amount of
According to Bolton, the sum of mesio-distal widths of mandibular anterior exccss is determined usinc the
the mandibular leelh anterior to the second permanent formula :
molars is 91.3% the mesio- disfal width of the maxillary
teeth mesial to Ihe second molars. The overcll ratio is 77.2
determined using the formula :
Determination of anterior ratio

Mandibular 6 -
Over all ratio = sum of mandibular 12 x 100 sum of
maxillary 12

MOVERS MIXED DENTITION ANALYSIS

The ouraose of a mixed dentition analysis is to

evaluate the amount cf space available in the arch for
the erupting permanent canines and orernolars. In this
analysis the size of the
Maxillary 6 x 77.2 100
unerupted permanent
cuspids and premolars
are predicted from the knowledge of the sizes of

If overall ratio is less than 91.3%, it ndicates certain permanent teeth already erupted in the mouth.

maxillary tooth material excess. The amount of The Moyer's mixed dentition analysis predicts Ihe

maxillary excess is determined using "he formula combined mesio-dislal width of 3, 4 and 5 based on the
sum of the widths o* Ihe four lower permanent incisors.
The mesio-distal width of Ihe four lower
Mandibular 12 12
Maxillary x 100 91.3
x91.3 incisors are measured and summed up. The amount of
Maxillary 12 -12 -
Mandibular
Too space available for the 3, 4 and 5 crter incisor
alignment is determined by measuring

If the overall ratio is more than 91.3%. ft

indicates mandibular tooth materia! excess. The
amount of mandibular excess can be determined by
the formula :

1*9
A-XLULTLLK IKUFLLL 111 C«|ML .

\8\
 «v it/ . e>- . Vr3
192 Orthodontics - The Art and Science unerupted
•'. teeth. Radiographic measurements c-
- .a. M'- !
• .
v\ J iii iii' jtt'- nfi ■'■ •lit' '. J. .-o to ■ unerupted teeth ore by themselves unreliable due to
U at. J-. ''■M
i'- Ihe distortion that can occur. It is possible to determine
xi m ■ ><~ !■<•: m m: '.
JNO 1yl 3.1
•'.
. HS.
.-.V the measurementsofthe unerupted teer by studying
f'
•5 »> XI :</
:u . }if i: JiJ a» tne teeth that have already eruptec in a radiograph
■:
.i SI
and on a cast. The following formula is used: Y1 = XI x
A-
<5 .3! :iv M'. y>. ■ ii.' .11 '..u -4i ■'' :• ii Y2
<- JI: J i. >. IL*. •.
' X2
si 'M H? iV. >1 s< >1 JI 'l ii i .>). JO ' iU- a »
- S 9. >• .
?>
."t- . •»> : !>i •\0 a» SM •
' U' widlh of unerupted tooth whose measurement is
ll.V
M' II > IM Y!A Iff. m 5>- •a . iu JIJ 4 to be determined, width of unerupted tooth on
:' ■ l -
II JU . 11 u: H. IH ••■>/ ■
a:. U'. >u iii
the radiograph.
-.
1- S width of a tooth that has erupted, measured on
i M n? . m II? u ii i . v> • .
iy> |IA • .1) the cast, width of a toolh that has
tl'MM «
o )> »■)
HA .•l .l' nt ]■•■
»y. . erupted, measured on the radiograph.
>'
' 'i'/..'
where
>» : Y1 = References
'■'.
•
u •.*».
JI ■'. SU c/ J)! Y2 =
;•-J
.
>
■
1! )»» :xr. iCt ii». i.) r s r. . Cl •'U;
3K V.
XI =
l< . M . f a i-'. iii J» JI. •'t» SI 3l>
uv ' >'•' * -
» i»'. .i». :JJ i»« 3V . >:)
31 ;I.I ju . ill- • X2 =
'/. . > » ' 31
5
v.- u; ■W Mi ' ■
11 i» :i i ll>'.
/ y>j
!
X n UI 'M I<I 'n/' ■'• ■■ •'.»»•
/.•
,.T.> •'•-. .'.JI
j.' '. J- ■.v .- . T.» .')'.
»•
m •■l' :
i> i • IV S IX ' yr 31*
lt. ' n> HA . ."
.
• IM ■■ 1- .V Kl >J 1« •..I . lO ;
'J'- .1 5 f ■ >- H i»-
:1.
: 1. »
II. MIDI.R/ ILI-U.1.

• •
Si'i UI i'/ A'! :i f,; 1M
5
l -''
« 3. •! S jn n't: iiii a 4 131 a» Kl'
1 M' •'»' •
.
E it i M- m. ai • ' W- ILL . '.Ii .i. .
JI» >-t
.
»-
u. M JJ iu Hi: ■:::+ Ii.' •3) . -
V- .i>>
M .
v m . Ji i-». * a) i;» .
J. 3-> -15
JC
'
x .ii". ■ . JO .JJ
i.1 i JU' - v.'
■ .
n i«; m 1»t 5M
s:> . .''L-l- J.V
'
5 954
J? i» ■ M r 40: 811. -• Ji •U ji.r i'. ;..>.'. " '-■>. '.ii'"
4. i',Hunter
M S >. of arc lysis
H-: Application v * ■
of crowding and SpOC'ng-.
1 - North Am 1978; 563-578.
cf Ihe teeth. Derf Clin
19 IH n.J n». XV J M .i. - :>>J i--'. ".
5. Jaondeph . DR, ftiedei RA, Moore V: AW : Pcnrs .:'index-: Cl'nical
il*'
UT. Orrhod '•
1 /i* IH Angle
y u:
evaluation. '.It- 1970J>l ; 40W'.
: 12 «.«.;
6. Profil! WR:
. Contemporary Orthodontics, . '."'.V :
'. OJ'S. CV 5" L
Mosby,1986. irkitri
1- v'i c MoyersJI:. Hand book■ittof ■'o
7.«i Robert Orthcdon-ics, Year book Vi'v
i
.medical
I u- < .inc, 1988. -
publishers, ■
»
V j; 'i.« lu • ■ !7.l ' a<
8. "anaka MM, I.Johnston Jit
l£:J.The prediction of tho sizeof Ihe
. 3H
uneiupted Cannes : ar-d O'premolars in a contemporary
p M •i» v > • ll? iij- :i> W.': v -
COr'hadontic Population. .1 Am Den" Assoc 1974 ; 88 •.:«.: 798
iSi
*.••
'A >1 x; :»>■ M I'l ■JI v; .'-v
'.
1 /-. ></■
'/
H i<» . ■J •'. i •-■>
»'
>u... M.'
11 j '. .
,
)» ■ • ■yt 15 • : >«. '
'
IH. JO 1 W' v 35"
.
U K • "'y r.t LLI -M' >0 - JIL ■
m.; A 'S; •'. • .-
'•' >•
»;.
-.
■
IS -■ . )««'.
•'y/ • > . I' V M' •' -V' -J
J. i») -'- r/. 11.
. 1.
.-.» IV !>I II • !>-. ILL >I 1«/. IM .III »1
the distance between the distal surface of lateral
incisor arid Ihe mesial surface of first permanent molar.
Based on the mesio-distal width of the four
mandibular incisors, the expected width of the canines,
first and second premolars are predicted by referring
the probabilily cnart (Tcble 3). While doing so, the 75%
level of probability is considered reliable.
The predicted tooth size of 3,4 and 5 is
cornpored with the arch length available for them so as
to determine the discrepancy. If the predicted value is
greater than the ovailable orch length, crowding of
teeth can be expected.

MIXED DENTITION ANALYSIS

- RADIOGRAPHIC METHOD

This technique makes use of a radiograph as well os a

study cast to determine Ihe width of Ihe

\8\
 rthodontic treatment is made possible by the c. Changes in tooth position during mastication

O 194 Orthodontics - The Art and Science

Tooth

fact that teeth can be moved through the alveolar bone

by opplying appropriate forces. Orthodontic tooth
movement is o unique process where a solid object
(tooth) is made to move through a solid medium
(bor.e). The ability of independent movement of the
teeth is unique to humans in particular and mammals in
general. The earlier primitive animals such as reptiles
had teeth that were ankylosed or fused to the bone.
This did not allow independent movement of the teeth.
During the process of evolution, the periodontal
ligoment appeared between the tooth and the alveolar
socket. The appearance of this periodontal tissue
enabled independent tooth movement.
Orthodontic treatment is possible due to the
fact that whenever a pfolonged force is applied on a
tooth, bone remodeling occcurs around the toolh
resulting in its movement. As a rule of thumb it can be
said that bone subject to pressure as a result of
compression of periodontal ligament resorbs while
bone forms under tensile force asa result of stretching
of the periodontal ligament. The aim of the present
chapter is to study the various biological tissue
changes that occur during tooth movement.

PHYSIOLOGIC TOOTH MOVEMENT

Physiologic tooth movements are naturally occurring

tooth movements that take place during and after tooth
eruption. Physiologic tooth movements include :
a. Tooth eruption
b. Migration or drift of teeth
Tooth erupt/on
Tooth eruption is the axial movement of the tooth from
its developmental position in the jaw to its final position
in the oral cavity. A number of theories have been put
forward to explain how the eruption process takes
place. The following are some of the theories :
A) Blood pressure theory : According to this
theory, the tissue around the developing end of the root
is highly vascular. This vascular pressure is believed to
cause the axial movement of the teeth.
B) Root growth ; According to the proponents of
this theory, the apical growth of roots results in an
axially directed force that brings about the eruption of
the teeth. This theory has not been accepted for a
number of reosons. Teeth move a greater distance
during eruption than the increase in root length. In
oddition, the onset of root growth ond eruption do not
seem to coincide. Teeth that are malformed and lack
roots also erupt in a number of cases.
Q Hammock ligament: According to Sicher, a band
of fibrous tissue exists below the root apex spanning
from one side of the alveolar wall to the other. This
fibrous tissue appears to form o network below the
developing root and is rich in fluid droplets. The
developing root forces itself against this band of tissue,
which in turn opplies an occlusally directed force on the
toolh.
D) Periodontal ligament traction : This theory
states that the periodontal ligament is rich in fibroblasts
that contain contractile tissue. The contraction of these
periodontal fibers (mainly the oblique group of fibers)
results in axial movement of the tooth.
Migration or drift of teeth
Migration refers to the minor changes in tooth position
observed after eruption of teeth. It is generally beleived
that the direction of tooth migration vanes from species
to species. The human dentition shows a natural
tendency to move in a mesial and occlusal direction.
This is largely true in case of the maxillary dentition.
However the lower jaw could show certain variations.
Tooth migration is usually a result of proximal anc
occlusal wear of teeth. As the teeth undergo occlusal
and proximol wear, they move in a mesial and occlusal
direction to maintain inter-proximal ond occlusal
contact.
Tooth movement during mastication
During mastication, the teeth and periodontal
structures are subjected to intermittent heavy forces
which occur in cycles of one second or less and may
range from 1 - 50 kilograms based on the typo of food
being masticated. Atootn subjected to these heavy
forces, exhibits slight movement within its socket and
subsequently returns to its original position as soon as
the load is removed.
When a tooth is subjected to such heavy
forces, the tissue fluid present in the periodontal space,
being incompressable, prevents major displacement of
the loolh within the socket. Therefore the forces arc
transmitted through the tissue fluids to the adjacent
alveolar bone. Recent studies hove shown that the
alveolar bone can bend in response to heavy
masticatory forces.
Whenever the forces of mastication are
sustained and are more than the usual one second
cycle, the periodontal fluid is squeezed out ond a pain
is felt as the the tooth is displaced into the periodontal
ligament space.
HISTOLOGY OF TOOTH MOVEMENT
When force is applied on a tooth to bring about
orthodontic movement, it results ir -ornrat'on of areas
of pressure ond "ension around the tooth. Areas of
pressure are formed in 'he direction of the tooth
movement, while ceas of tension form in the ooposi'e
direction.
Bone is a living tissue which rcacts to
oressure and tens'en in a certain denned manner.
Bone surface subjected to pressure reacts by bone
'esorption while bone subjected to -ension exhibits
deposition.
When a tooth is moved due to application of
an orthodontic force, there is bone resorption on the
oressure sice and new bone -'ormation on the s'de of
tension.
The hYologic chcrgesseen during tooth
movement (fig 1) vary according to tho amount and
duration of fo-ce appl:ed. The histologic changes seen
during tooth movement can be studied under two
neadings as :
1) Changes following cpplico'ion of mild force.
2) Charges following application of extreme force.
Changes following application of
mild force
When a force is applied to a tooth, areas cf pressure
and tension are produced.
Changes on pressure side : The periodcrlol ligament in
the direction of the tooth movement gets compressed
to almost l/3rd of its original thickness. A marked
increase in the vascularity of periodontal ligament on
this side is cbsen/ed due to increase in capillary blood
supply. This increase in blood supply helps in
mobilization of cells such as fibroblasts and
osteoclasts.
Osteoclasts are bone resorbing cells that
line up along the socket wall on the pressure side.
They lie within shallow depressions ir bone ca 'ed
Howship's lacunae. A change in orientation of the bor y
trabeculae is seen several weeks after continued
orthodontic force application. Tne trabeculae which
are usually oarallel to Ihe long axis of the teeth become
norizontc; y oriented i.e. pcrallel 'o the direction of
orthodontic force. The trabecular oattern revers bock
to rcrmal pattern during re'ention phase of the
treatment.
The osteoclcsts that lie within Howship's
locunce start resorb'ng bone. When the forces applied
are within physio ogic limits, the 'esorp^on is seen in
the alveolar plate immediately aciacent to the
i
ligament. This kind o resoration is cal ed fror.'al
resorotion.
Changes on tension s.:a'e : The arec of the tooth
Biology of Tooth Movement 183 ,
opposite to tne direction of force is colled -he tension
;
side. On application of orthocomic orce, the
periodontal membrane on the tension side gets
stretched. Thus the distance between the o veolar
process and the toctn is widened.
In addition to stretching of the periodontal
fibers, a raised vascularity is seen on the tens:on sice
just as on Ihe pressure side. Tne raised vascularity
causes mobilization of cells such as fibrobias-s and
osteoblasts in this area. In response lo th's traction,
osteoid is laid down by osteoblasts in the periodontal
ligoment immediately odjacent to the lamino dura, "his
lightly calcified bone in cue course of time matures to
form woven bone.
Secondary rcmode.'irjg changes ; Whenever a force is
applied to move teeth, the bone immediately adjacent
shows osteoclastic ond osteoblastic activity on tne
pressure and tension side respect'vely. Ir addi*ior,
bony changes also take place elsewhere to-mc'ntcin
the width or thickness of the alveolar bone. These
changes are called secondary remodeling changes (fig
2). For example, if a tooth is being moved in a abial
184 Orthodontics - The Art and Science

Orthodontic
force

Applic
ation of
mild
Tension Pressure
Side Side
forces

Normal
Application of
extreme
forces Periodontal Ligament Dentin

z •; Bone resorption

Pulp ; Cementum

Bone deposition

Fig I Histology oi looti -novemert


:
5 2 (A Secondary rcmode ing changes seen following the application of a bodily fo'ce in o lirguol direction r Secondary remodeling cHangos
seen following fhe application o; o lipo'ng ?orce in o linguol direction
direction there is compensatory deposition of new
bone on the outer side of the labial olveolar bony pfate
:
and also a compensator/ resorption on the ngual side
of the lingual alveolar bone (fig 2). "«nese
compensatory structural alterations maintain •^e
thickness of the supporting alveolar process »ren
though the tooth may be moved over a r stance
several times greater than the thickness :f the alveolar
bony plates.
Changes following application of
extreme forces
Whenever extreme forces are applied to teeth, it Its in
crushing or totol compression of the Jontal ligament.
On the pressure side, the "cot closely approximates
the lamina dura, compresses the periodontal ligament
and leads t> occlusion of the blood vessels. The
ligament s hence deprived of its nutritional supply
leading ■o regressive changes called hyolinizalion.
In this case, the bone cannot resorb in ■Se
fronlol portion adjacent to the teeth. Rather bone
IIS
Biology of Tooth Movement 185 ,
resorption occurs in the adjacent marrow spoces and
in the alveolar plate below, behind and above the
hyalinized zones. This kind of resorption is called
undermining or rearword resorption.
On the tension side, the periodontal ligament
gets over-stretched leading to tearing of the blood
vessels and ischemia.
Thus when extreme force is applied there is
a net increase in osteoclastic activity os compared to
bone formation with the result that the tooth becomes
loosened in its socket.
In addition, pain and hyperemia of the
gingiva may occur due to application of extreme forces
during orthodontic tooth movement.
OPTIMUM ORTHODONTIC FORCE
Optimum orthodontic force is one which moves teeth
most rapidly in the desired direction, with the least
possible damage to tissue and with minimum patient
discomfort.
186 Orthodontics - The Art and Science

Oppenheim and Schvvarz following 3] The compressed collagenous fibers graduc f j

extensive studies slate that the optimum force is
equivalent to the capillary pulse pressure which is
20-26 cm/ sq. cm of root surface areo. From a clinical
point of view, optimum orthodontic force has the
following characteristics :
a. Produces rapid tooth movement
unite into a more or less cell free mass.
4] In addition certain changes olso occur in the
ground substance.
5) There is a breakdown of the blood vessel v.'Ci
leading to spilling of their contents.
6) Osteoclasts are formed in marrow spaces arc

b. Minimal patient discomfort adjccenl areas of Ihe inner bone surface afre- a

c. The iag phase of tooth movement is minimal period of 20>30 hours.

d. No marked mobility of the teem being moved The presence of a hyalinized zone indicates

From a histologic point of view Ihe use of that the ligament is non-functional ar.0 therefore bone
resorption cannot occur The tooth is hence not
optimum orthodontic force has the following
capable of further movement until the local damaged
characteristics ;
tissue has been removed and tne adjacent alveolar
a. The vitality of the tootn and supporting periodontal
bone wall resorbs.
ligament is maintained
The elimination of hyalinized tissue occurs
b. Initiates maximum cellular response
by two mechanisms.
c. Produces direct or frontal resorption
1) Resorption of the alveolar bone by osteoclasts
HYALlNiZATlON differentiating in the peripheral intact periodontal
rnembronc and in odjocent marrow spaces.
Hyalinization is a form of tissue degeneration 2) Invosion of cells and blood vessels from the
characterized byformationofa clear, eosinophilic periphery of the compressed zone by which the
homogenous substance. This hyalinization can occur necrotic tissue is removed. The invoding cells
in organs such as kidneys, lungs, etc.,. Hyalinization of penetrate the hyalinized tissue and eliminote the
the periodontal ligament denotes a comoressed and unwonted fibrous tissue by enzymatic action and
locally degenerated periodontal ligoment. phagocytosis.
The conventional pathologic process of Greater the forces, the wider is Ihe area of
hyalinization is on irreversible one, however, hyalinization. Thus larger areas of the ligament
hyalinization of the periodontal ligament is a reversible become functionlcss, thereby showing large areos of
process. reorvard resorption. If lighter forces ore used, the
Experimental evidences show that hyalinized zones are smaller and a larger area of
hyalinization of the periodontal ligament on the functioning ligament is available. This frontal
pressure side occurs in some areas during almost all resorption predominates in case lighter forces are
forms of orthodontic tooth movement. But the areas used.
are wider when the force applied is extreme. The location and the extent of the hyclinized
The changes observed during formation of tissue largly depends upon the nature of tooth
hyalinized zones are as follows : movement (fig 3). In case of tipping tooth
1) There is a gradual shrinkage of periodontal
ligament fibers.
2) The cellular structures become indistinct.
Some nuclei become srnoller (pycnotic) whie
some nuclei disappear.
 B

r
c 3 Areas of hycl:nizaHon during foo>h movemert.fA) Tipping tooth move me n- causes hyalinizalion close -o -he alveolor I Tbyirg v.rh excessive
forces 'esult in two areas of hyol'nization. one in the cpical region arc tnc ot'ner in the jincl ores. |C) Bodily foolh movement results in
hyaliniza'ion closer 'o the middle portion of "he rod

/ement, the hyalinization would be close to t-e alveolar
crest while in case of bodily tooth jment it would be
closer to the middle portion r-he root. Whenever
excessive forces are cppl'ed ing tipping tooth
movement, it can result in 8wo areas of hyalinizalion,
one in the apical region the other in the marginal area.
The form and outline of the adjacent [areolar bone
also plays a role in location of :!inized areas. Areas of
the same extent during this initial phase of tooth
movement.
The tooth movement in the initial phase is
between 0.4 to 0.9 mm and usually occurs in a week's
time.
Lag Phase
During this phase, little or no tooth movement occurs.

bony prominences or jles usually result in areas of This phase is characlerized by formation of hyalinized

hyalinizalion. tissue in the periodontal ligament which has to be

resorbed before further tooth
ISES OF TOOTH MOVEMENT

lies have shown thot tooth movement jesses

through three stages (fig 4). Burstone jories the sieges
as : Initial phase r Lag phose i 3ost lag phase
initial phase
During the initial phase, very rapid tooth movement is
observed over a short distance which then stops. This
movement represents displacement of the tooth in the
periodontal membrane space and'probably bending of
alveolar bone to a certain extent. Studies have shown
thct both light and heavy forces displace the tooth lo
movement can occur. The duration of the lag phase
Pressure tension theory

depends on the amount of force used to move the Oppenheim in 1911 was the first person lo study the
188 are
tooth. If light forces Orthodontics - The
used, the area of Art and Science
hyalinization tissue changes in the bone incident to orthodontic tooth
is small and frontal resorption occurs. If heavy forces movement. Schwarz (1932} is so id to be the author of
are used, the area of hyalinization is large. Resorption this theory. According to

2mm Undermining Frontal

Resorption Resorption

1 mm

f Initial phasa Lag phase

Fig 4 Graph showing phoses of tooth movement.

in this case is rearward and a longer lag period occurs

to eliminate Ihe hyalinized tissue.
Post lag phase

The lag phase usually extends for 2-3 weeks

but may at times be as long as 10 weeks. The duration
of the lag phase depends upon a varied number of
factors including the density of alveolar bone, age of
the patient and the extent of the hyalinized tissue.

Post tag phase

After the lag phase, tooth movement progresses
rapidly as the hyalinized zone is removed and bone
undergoes resorption. During this post lag period,
osteoclasts are found over a large surface area
resulting in direct resorption of bony surface facing the
periodontal ligament.

THEORIES Of TOOTH MOVEMENT

The mechanism of movement of a tooth by an

orthodontic force is a subject of ongoing research for
decades. Numerous theories have been put forward to
explain the same. The theories thot are accepted and
have stood the test of time are

1} Pressure tension theory by Schwarz 2}

Blood flow theory by Bien 3) Bone bending
piezoelectrictheory
Schwarz, whenever a tooth is subjected to an
orthodontic force, it results in areas of pressure end
tension. The area of the periodontium in the Erection of
Biology of Tooth Movement 189
tooth movement is under pressure -hile the area of
periodontium opposite the tooth -ovement is under
tension. According to him, —e areas of pressure show
bone resorption while rr'eas of tension show bone
deposition.
Fluid dynamic theory
~-'s theory is also called the blood flow theory as
coposed by Bien. According to this theory, tooth
-ovement occurs os a result of alterations in fluid
rynamics in the periodontal ligament. The iodontol
ligament occupies the periodontal ircce which is
confined between two hard tissues -amely the toolh
ond Ihe alveolar socket. The :eriodontal space
contains a fluid system made JO of interstitial fluid,
Bone bending and pehroe/ectr/c f/teo- rles of
tooth movement
A century ago, Farrar (1876) first noted deformation or
bending of interseptal alveolar walls. He was the first to
suggest that bone bending maybe o possible
mechanism for bringing about tooth movement.
Piezoelectricity is a phenomenon observed
in many crystalline materials in which a deformation of
the crystal structure produces a flow of electric current
as a result of displacement of electrons from one part
of the crystal lattice to the other. A small electric current
is generated when bone is mechanically deformed.
The possible sources of the electric current are :
a. Co/fagen : In bone, collagen exists in a crystallized
state ond can thus be a source of piezoelectricity
when deformed.
b. Hydroxy apa tr'te : It also is crystalline in form and

cellular elements, blood vessels and viscous ground therefore can produce electricity when deformed.
substance in addition -c *he periodontal fibers. If is a
confined space r~d the passage of fluid in and out of c. Coliagcn-hydroxyapottte interface : The

this space s 'imifed. The contents of the periodontal junction between the collagen and hydroxyapatite

icament thus creates a unique hydrodynamic lition crystals when bent can be o

resembling a hydraulic mechanism and r shock

absorber. When the force is removed, -"•e fluid is
replenished by diffusion from capillary •c'ls and
recirculation of the interstitial fluid. Aren the force
apolied is of short duration such s during mastication,
the fluid in the periodontal rrcce is replenished as soon
as Ihe force is -=snoved. But when a force of greater
magnitude md duration is applied such as during
orthodontic ■roth movement, the interstitial fluid in the
r-eriodontal space gets squeezed out and moves
"chords the apex and cervical margins and results r
decreased tooth movement. This is called Ihe scueeze
film effect' by Bien.
When an orthodonticforce is applied, it i?sults
in compression of the periodontal ligament.
Blood vessels of the periodontal ligament get trapped
between the principal fibers and this results in their
stenosis. The vessel above the stenosis then balloons
resulting in formation of an aneurysm'. These
aneurysms are minute flexible walled sacs of fluid.
Bien suggest that there is an alteration in the
chemical environment at the site of the vascular
stenosis due to a decreased oxygen level in the
compressed areas as compared to the tension side.
The formation of these aneurysms and vasculor
stenosis causes blood gases to escope into the
interstitial fluid thereby creating a favorable local
M
environment for resorption.
 source of piezoelectricity.
190 f d. The mucopolysaccharide fraction of the ground
200
substance Orthodontics
although - The
not crystalline may Art
alsoand
possess the ability to generate electric current
when deformed.
When a crystal structure is deformed,
electrons migrate from one location to another
resulting in an electric charge. As long as the force is
maintained, the crystal structure is stable and no
further electric effect is observed. When the force is
released the crystals return to their original shape and
a reverse flow of electrons is observed. This rhythmic
activity produces a constant interplay of electric
signals whereas occasional application and release of
force produces occasional electric
Piezoelectric signals have two unusual characteristics
: reaches a certain maturity, parts of it get reorganized
a. Quick decay rate: When a force is applied, a
piezoelectric signal is produced. This electric charge
commited osteoprogenitor cells. Whenever there is a
stress or strain due to orthodontic force, these
Science
osteoprogenitor cells undergo increase in nuclear
volume and form the G1 stage preosteobiasts. With
further DNA synthesis the G1 stage preosteobiasts
transform into G2 stage preosteobiasts. As a final step
the G2 stage preosleoblasts undergo mitosis and form
the osteoblasts or bone forming cells.
The bone formed posses through three
stoges. They are the osteoid, bundle bone and the
lamellated bone. The new bone formed by the
osteoblasts is the osteoid which is lightly calcified. As
more and more osteoid is formed the deeper layers
undergo more calcification and form the bundle bone.
signals. The fibers of tne periodontal apparatus also get
attached to the bundle bone. When the bunndle bone
into moture lamellated bone.
Osteoid tissue, deposited on the tension side,

quickly dies away to zero even though the force is gels calcified resulting in the formation of

maintained.
b. When the force is releosed, electron flow in the
opposite direction is seen.
On application of a force on a tooth, the
adjacent alveolar bone bends. Areas of concavity in
bone are associated witn negative charges and evoke
bone deposition. Areas of convexity are associated
with positive charges and evoke bone resorption.
When a force is opplied, compression of the
alveolar wall occurs resulting in the alveolar and
medullary cortical plates of bone being moved closer
together. In this manner, the bone becomes less
concove ond an electric signal associated with
resorption is established.
BONE DEPOSITION

Bone formative cnanges are observed on t tension

side. As a forerunner to the process bone deposition,
there seems to be on increa in tne number of
osteoblasts which are the bo forming cells. They are
ovoid cells with basophil" cytoplasm and have an oval
nucleus. They lie against the bone surface where
active bone formation is in progress i.e. periosteum .
endosteum and help in the formation of Ihe organic
matrix and also control Ihe deposition o* mineral soils.
Osteoblasts increase in number by proliferation of their
precursor cells (fig 5).
The osteoblasts are derived from
paravascular connective tissue cells, closely
associated with the blood vessels. These precursor
cells undergo mitosis and DNA synthesis and form the
 Biology
of Tooth
Moveme
nt
Ifi'tos^
DNA
synthe
sis
Committed
Osteoprogenitor
cells

Paravascular
precursor cells

Gt Stage
Preosteobiast
s

DNA
synthesi
s

G2 Sage
Preosteobiast
s

mosis

Osteoblasts

;
Fig 5 Summary o osteoblast nistogenesis.

n»
 182 /' Orthodontics ■ The Art and Science

bone lamellae. The
periodontal fibers readapt to the new position of the
tooth by proliferation of the intermediate zone.
BONE RESORPTION
Bone resorption is brought about by cells called
osteoclasts. They are multi-nucleated giant cells and
may have 12 or more nuclei. Osteoclasts are
irregularly oval or club shaped with branching
processes. They occur in bay like depressions in bone
called Howship's lacunae and have prominent
mitochondria, lysosomes and vacuoles. Each of their
nucloi has a single nucleolus. The port of the
osteoclast in contact with the resorbing bone has a
ruffled border. The osteoclasts are derived from :
a. Activation of previously present inactive
osteoclasts.
b. Migration from adjacent bone.
c. Formation of new osteoclasts from local
macrophages of periodontal ligament.
d. Influx of monocytes from blood vessels.
and resorption. However, tnecha that occur at the
cellular level in response to force arc not totally
understood.
When a force is applied onto a tooth, results
in a number of biophysical events such compression
of periodontal ligament, bone deformation and tissue
injury. These biophysicc events in turn lead to certain
biochemicc reactions at o cellular level which bring
abc bone remodeling. Tnus a process of transductio-
occurs where mechanical energy (orthodontic force) is
converted into a cellular response.
Bone deformation and compression & the
periodontal ligament leads to the release a- some
extra-cellular signaling molecules called tirr
messengers. They include hormones such as PTH,
local chemical mediators such as prostaglandins and
neurotransmitters such as substance P one
vasoactive intestinal polypeptide (VIP).
The first messengers bind to receptors
present on the cell surface of target cells and initiate a
process of intra-cellular signaling. The intra-cellular
signalling results in formation of second messengers,

During bone resorption three processes which include cyclic amp, cyclic gmp and calcium.
The formation of second messengers inside
occur in more or less rapid succession. They are:
the cclls is believed to initiate formation of bone cells
1) Decalcification
namely osteoclasts and osteoblasts which are
2) Degradation of matrix
responsible lor bone remodeling.
3) Transport of soluble products to the extracellular
An alternative biologic pathway for
fluid or blood vascular system.
orthodontic tooth movement has been suggested by
Organic acids such as citric acid, ond lactic
some workers. According lo them, orlhodonlic force
acid and hydrogen ions are secreted by Ihe ruffled
results in certain amount of tissue injury.
border of the osteoclasts which increases the solubility
Subsequently, hydrolytic enzymes are released
of hydroxyapatite leading to decalcification.
The degradation of the matrix is brought about by the
activity of Cothepsin B-l (lysosomal acid protease).
Finally, the breakdown products of bone are
transported to the extracellular fluid and blood
vascular system.
BIOCHEMICAL REACTION TO
ORTHOD TIC TOOTH MOVEMENT

It is known that bone cells i.e. osteoclasts

osteoblasts respond to an orthodontic force
proliferation in order to bring about b deposition

Mi
 Biology of Tooth Movement 193

Summary of Biochemical Reactions

Orthodontic Force

m
 194 Orthodontics - The Art and Science

Orthodontic Tooth Movement

which activote enzyme collagenose that contributes to
bone resorption.

References
 of Tboth
>

FORCE

E Mecnamcs
Movement

very body continues in its state of rest or of uniform motion

in a straight line, unless it is compelled to change that state
by forces mpressed upon it (Sir Isaac Newton) - and teeth
are no exception.
Physics, Mathematics and Engineering ere 3
importantdisciplines thotcan effectively be applied to the
study of orthodontic tooth movement.
Mechanics is defined as that branch of
engineering science that describes the effect of force on a
body. A cleor understanding of the •heories of mechanics
have potential applications in 3 areas:
1. Precise application of forces.
2. A better understanding of clinical and histological
response to various magnitudes of force.
3. Improving the design of orthodontic appliances.
The response of a tooth to an applied force can
be at 3 levels i.e. clinical, cellular and stress-stroin level of
activity within the investing tissues which is the least
understood. There exist no stress-strain gauges, at
present, which can be placed within the periodontium to
evaluate the stress-strain activity. Therefore, the
importance of the study of mechanics cannot be over-
emphasized as olmost all the assumptions made about the
stress-strain activity in the periodontium are based on
several mathematical formulations and conclusions.
Fora better understanding of mechanics one
should be familiar with the terminology used.
H195
 Force can be delined as an act upon a body that
changes or tends to change the state of rest or of
206
uniform motion Orthodontics
of that - Theforce
body. Being a vector, Art has
anda Science
termec centre of gravity.
definite magnitude, a specific direction and o point of
application. In clinical practice it is eithor a 'pusn' or a 'Pjll.
In •he metric system Ihe unit of force is expressed in
'grams.
Orthodontic correction is based on application of
aopropriate force on the teeth .Tne forces are generated
by a variety of ortnodontic cppliances.
STRESS AND STRAIN
Stress is tne force applied per unit area while strain can be
defined as the internal distortion per unit area.
Stress and strain are inre'-related terms as
stress is an externcl fcrcc acring upon a booy while strain
is the resultant of stress on that body. Strain can be
expressed in tne form of a change in either the external
dimension or internal energy of the body.
50 Grams
10 mm
COUPLE
calculation, this point can ae taken cs the point where
the whole body weigh* is concentrated and can be
However, teeth cannot move in a free
manner within the jaws. They are restricted by the
investing tissues around rheir roots. In such a situation,
a point analogous to the centre of gravity is mace use
of and is called the centre of resistance.
Centre of resistance of a tooth can be
denned as that point on the tootn when a single forcc is
passed through it, would bring about its translation
alone the line of action cf the force.
Generally the centre of resistance of a tooth
is constant. In a single-rooted tooth it lies between one
third and one half of the roo*, cpical to Ihe alveolar
crest while in a multi-rooted tooth the centre of
resistance lies between the roots, 1 - 7 mm apical to
rhe furcation {fig 2). The centre of resistance exis's for
single tooth, units of tooth, the entire dentoi arch and
the jaws. Knowing the Ideation of the centre of
resistance is thus very important in planning
appropriate mechanotherapy.
Two factors which can change the position
"of Ihe centre of resistance are the root length and
alveolar bone neighl. Longer the root, the centre of
resistance will be placed more

Couple is c pair of concentrated forces havin; equal

magnitude and opposite direction wi parallel but
non-collinear line of action (fig 1).
A couple when ccting upon a body bring; a bot t
pure rotation.

CENTRE OF
50 Grams RESISTANCE

A Every body or tree objec:

Fig 1 »A) Couple two forces of same magnitude, parallel to each

otnc and acting h opposite direction. |3) Clinicol aaplica'ion or a
C C U J B in treatment of rotators

behaves as if its mass is concentrated a* a single point on

which it ccn be perfectly balanced. For physical
h 2 Certre o- 'esistcncc cf
magnitude o*' force and the distance from the centre of
resistance (fig 4). Eithe' one of these two variables can
be manipulated to produce the desired force systems.
Mechanics of Tooth Movement

mu'tirooted end sirg'e -cotec teeth

A B C
Fig 4 Moment is calculated by ruhiplying lie mogiitjde of
Rg 3 Certre o; resistance force by tie psrperdicula' distance of the lire cf action to ihe
rfluenced by the alveola' rone cen ire of resistance
height and the rool length. (A)
Normal clvsola' sone (B) Alveo cr
bone loss resu'fs in oplccl shift of CENTRE OF ROTATION
cen're r* 'esislar.ee. (Q -oot 'csorption and shorening results in —ore
corona centre of
Centre of rolotion is a point, obout which o body
resistance
appears to hove rotated, as determined from its initial
and final positions.
apically. Likewise if
The centre of rotation is a voriable point and
the olveolor crest is
changes according to the type of tooth movement. It
higher, -he centre of
can be at any position on or off
resistance will be
placed rrore
coronally (fig 3)
Similarly the
morphology and ■he
number of roots also influence Ihe location of •fie centre of
resistance.

MOMENT

Moment can be defined as the measure of rotational

potential of a force with respect to a specific axis.
Orthodontic forces are most commonly applied at the level
of the crowns of the teeth. Therefore the forces are
seldom applied through the centre of resis'ance of the
crowns. Thus these forces not only produce a lineor
motion, they also produce a rotation. Tne moment of the
force is therefore the tendency for a force to produce
rotation.
Moment = Magnitude of force xdistorice
:
(perpendiculor distonce from *he centre o resis'ance of the
body *o *he line of action of Ihe force). The unit of
measurement of moment is gram millimeters. The two
variables that determine Ihe moment of force ore the
<n-
 Fig 5 Centre o* ro-ction (AJ A' ihe incisat edge
during torqung \B) At tne rcot acex dur'ng
controlled tipping (Cj Away from the root epcx
curing jncort'olled tpping (D) Outside the roorh
djriny intrusion o' extrusion

the tooth (fig 5).

E.g. In case of controlled crown tipping, the
centre of rotation will be at the root apex while in case
of a perfect translation it will be at infinity.
In clinical practice, the tooth usually follows
an irregular path to reach its final position, thus
changing the centre of rotation several times.

y TYPES OF TOOTH MOVEMENT

Tipping is a simple type of tooth movement where a
single force is applied to the crown which results in
The prime motive of orthodontic treatment is to move
movement of Ihe crown in the direction of tne force and
the teeth into more favorable and corrected positions.
the root in the opposite direction. Tipping is considered
In the process of achieving this goal, the teeth undergo
to be the simplest among the tooth movements. It can
a variety of movements in all the 3 planes of space i.e.
be of two types :
sagittal, coronal and transverse. Tooth movements
within the oral cavity can be listed as follows :
1. Tipping
2. Bodily movement
3. Intrusion
4. Extrusion
5. Torquing
6. U prig h ting

Tipping
Controlled Tipping : Controlled tipping of o tooth
occurs when o tooth tios about a centre of rotation at its
apex. Here there is a lingual movement of the crown with Mechamcs of Tooth Movement 189
minimal movement of the root in labial direction.
Uncontrolled tipping : Uncontrolled tipping of a tooth
describes the movement of a tooth that occurs about o
centre of rotation apical to ond very close to the centre of
resistance. It is characterized by the crown moving in one
direction while the root moves in the opposite direction.
Bodily movement
:
the line of action of an applied force passes trough the
centre of resistance of a tooth, all the coints on the tooth
will move an equal distance in the same direction
signifying a bodily displacement. This is called translation.
Intrusion
Intrusion is the bodily displacement of a tooth along its
long axis in an apical direction.
centre of resistance of a tooth. Pure translation con be
of three types:
1. Intrusion
2. Extrusion
3. Bodily movement (mesio-distal, labio- lingual)
Pure rotation
A displacement of the body, produced by a couple,
characterized by the centre of rotation coinciding with
the centre of resistance i.e. the movement of points of
the tooth along the area of a circle, with the centre of
resistance being the centre of fhe circle. Pure rotations
con be divided into 2 types :
Transverse Rotation : Those tooth displacements
during which the long-axis orientation changes. E.g.
Tipping and torouing. Long-axis rotation : Here the
angulation of the long-axis is not altered. E.g. Rotation
of a tooth around its long axis.

Extrusion Generalized rotation

Extrusion is the bodily displacement of o tooth clong its
Any movement thai is not pure translation or rotation
long axis in an occlusal direction.
can be described os a combination of

Rotation
'otations ore labial or lingual movements of o tooth around
its long axis.

Torqulng
lorquing can be considered os a reverse tipping
characterized by lingual movement of the root.

Uprlghtlng
During orthodontic treatment, the crowns of certain teeth
will be tipped in a mesio-distal direction with -He roots
tipped in the opposite way. Tipping these roots back *o get
a parallel orientation is termed uprighting.
Although these are the commonly encountered
movements within the oral cavity, in a more scientific
approach the tooth movements can be classified basically
into three :
1. Pure translation
2. Pure Rotation
3. Generalized Rotation

Pure translation
It occurs when all points on tne tooth move an equal
distance in the same direction. This is brought about when
the line of action of an applied force passes through the

m
Fig 6 Types
of loolh move men- (A} Uncontrolled tipping S3) Controlled tipping <C| Trans ot on (D; Torqjing i[) Upiighing (G) Intrusion (H) fx-rusian
[F! Rota I or
 Interrupted Force

<i>
o

Duration
Fig 7 Grooh showing tne d fferent types force

roth translation and rotation end can be termed the activation must be done to a relatively low force level.
:eneralized rotation. This type of movement can re This is because continuous forces are expected to bring
seen during routine clinical practice. about direct resorption of the root socket. They should
hence not occludc more than a small percentage of blood
TYPES OF FORCE
vessels within the periodontal ligament and not

As is well-stated by the pioneers in Ihe subjecr, if substantially interfere with their nutritional supply.

-olocclusion is the disease in orthodontics, force s Moreover, Ihe continuous force cycle includes no 'rest

definitely its medicine. It is therefore very '-loortant for period'ond little interference with normal biologic

the clinician to use his knowledge r-d experience in functioning within the soft tissue can be tolerated.

determining the type, amount rid direction of force

/ntorm/ttent force
required to bring about ■efficient treatment results.
8ased on the d u roti on of application, It is an active orthodontic force that decays to zero

-orce con be divided into : '. Continuous force magnitude or nearly so prior to the next appointment. E.g.

2. Intermittent force Removable active plates.

3. Interrupted force For an appliance to deliver intermittent force,

the appliance components should have high stiffness and
Continuous force the initio I activation should be twice
- is an active orthodontic force that decreases
- e in magnitude between appointment periods.
E.g. Light wire appliance.
For an appliance to deliver continuous force,
the appliance components should be highly flexible and

<M
the expected corresponding soft-tissue deformation.
Due to a relatively high activation, a greater force is
212teeth.
exerted on the Orthodontics
This leads to- The Art and
undermining Science
resorption and corresponding tooth movement. Once
the tooth has moved, the force will decay considerably
so that repair of the necrosed soft tissue and
resumption of blood supply occurs within the
periodontium.

Interrupted force
Il is on orthodontic or orthooeadic force that is inactive
for intervals of time between appointments. It often
exhibits, cyclic, long-term magnitude-time pattern, e.g.
Force exerted by an exlra-oral appliance worn only at
night.
For an interrupted force lo be delivered, the
pro-requisites include:
a. It should deliver heavy forces.
b. There should not be any force decay.
c. There should be a specific magnitude-time pattern
for example, 200 - 300 gms of force 10-14 hours a
day.
d. The inactive period of each day must be sufficient
to keep the periodontal ligament healthy over the
total period of time of use of the appliance.
Thinking in tne normal way, it might occur to
us that a continuous forcc may bring about a
continuous movement or an increased force may lead
to an increased tooth movement. But, tnese
assumptions ore far from reality both in the clinical and
cellular context. The rate of tooth movement is highly
dependent upon the complex biologic responses to the
various types of forces which are yet to be clearly
understood.
References

.More ; The terms interrupted ond jntermrffent

forces are interpreted in different ways by
different authors. The above menf/oried description
is based on Robert J. Nikolai's description of the
terminology.
 ooth movement during orthodontic therapy is

T brought about by forces generated by the

active components of an
ropliance. The force used to move teeth is derived
orthodontic

~om certain anatomic areas which act as cnchors.

According to Newton's third law of r-otion, for every
action there is an equal and coposite reaction. In
accordance with this law, forces used to move teeth
may induce an equal and opposite force on the
anchorage units -«ending to cause their movement
which is not Desirable. The resistance that the
anchorage areas r*er to these unwanted tooth
movements is called ' cnchorage.
Graber has defined anchorage in r'thodontics as
the nature and degree of ••sistance to displacement
offered by an anatomic .nit for Ihe purpose of effecting
tooth movement. According to White and Gardiner,
'Anchorage is —e site of delivery from which a force is
exerted.'
SOURCES OF ANCHORAGE

Anchorage during orthodontic therapy is mainly

obtained from two sources.
1] Intra-orol sources
2] Extra-oral sources

tntra-oral sources
The intraoral sources of onchoroge include the teeth,
alveolar bone, the basal jaw bone, and the
musculature.

The teeth : Whenever some teeth are moved

orthodonlically, the remaining teeth of the oral cavity
can act as anchorage or resistance units. This is due lo
the fact that the teeth themselves can resist movement.

2?3 The anchorage potential of teeth depends on a number

of factors such as root form, root size, number of roots,
I
root length ond root inclination.
J. Roof iorm : The anchorage potential of a tooth Extraorat sources
depends largely on its root form. Cross sections of Certain extraoral areas can be utilized as sources of
204
roots can be of threeOrthodontics
types; round, flat -and
The Art and Science
triangular. anchoroge TO bring about orthodontic or orthopaedic
Round roots as seen in bicuspids and palatal root of changes. They are mainly used when adequate
maxillary molars can resist horizontally directed forces resistance cannot be obtained from intraoral sources for
in any direction. Flat roots, for example those of the purpose of anchorage. The extraoral sources of
mandibular incisors and molars and the buccal roots of anchorage include the cranium, the back of the neck and
maxillary molars, can resist movements in the the facial bones.
mesio-distal direction but have little resistance to Cranium (occipital or parietal anchorage):
movement on Ihe thin edges found on thoir buccal and Extrooral anchorage can be obtained by using head
lingual sides. Triangular roots of canines ond maxillory gears that derive anchorcge from the occipital or parietal
control and lateral incisors offer the maximum region of the cranium. These devices are used along with
resistance to displacement compared to round or flat o face bow to restrict maxillary growth or to move the
root forms.
dentition or maxillary bone distally.
2. Size and number of roote : Multirooted teeth with
Back of the neck (cervical anchoroge) : Extraoral
large roots have a greater ability to withstand stress
anchorage can alternatively be obtained from the neck or
than single rooled teeth.
cervical region. Such a type of head gear is called
3. Root length : In physiologic conditions, the root
cervical head gear.
length indicates the depth to which the tooth is
embedded in bone. The longer the root, the deeper it is
embedded in bone and the greoleris its resistance to
displacement.
4. inclination of tooth : The axial inclination of a
tooth is important in assessing its value os a source of
anchorage. A greater resistance to displacement is
offered when the force exerted to move teeth is
opposite lo that of their axial inclination.
5. Anfcyfosed teeth : Ankylosed teeth are directly fixed
to the alveolar bone and hence lack a periodontal
ligament. Orthodontic movement of such teeth is not
possible and they can therefore serve as excellent
anchors whenever possible.

Atveolor bone : The alveolar bone that surrounds a

tooth offers resistance to tooth movement upto a
certain amount of force. When the force applied
exceeds a certain limit, the alveolar bone permits tooth
movement by bone
remodeling
Basa/ bone : Certain areas of the baso I j bones are
available intraorally as sources anchorage. These
areas include the hard palcre and the lingual surface of
the mandible in the region of the roots. These intraoral
hard areas basal bone can be used to augment
intramaxillcr. or inter-maxillary anchorage.

Muscu/oture : The normal tonus of the fade and

masticatory muscles plays an important ro!e in the
normal development of dental arches Abnormal
hypotonic musculoture causes florinc ana spacing of
teeth while hypertonic muscles exert restrictive forces
in a lingual direction. Dentc anchorage may be
increased by making use o: hypertonic lobiol
musculature as in the case of c lip bumper.
 According lo the manner of force application : are to be moved within the
TYPES OF
1) Sirrple anchorage same dental arch (fig 1).
ANCHORAGE
2) Stationary anchorage
The combined root surface
3) Reciprocal a^orage According to
area of the teeth forming the anchorage unit must be
|aws Involved :
double that of the leelh lo be moved. Thus the
1) htramaxillary
2) Intermaxillary resistance offered by the qgchorage unit is greater
According to the site of anchorage: than that offered by the tooth or te$j> being moved. An
1) Intraoral example of simple anchorage -is given in fig 5, ' where
2} Extraoral : a pa lata I ly placed premolar is pushed bucally with
A. Cervical
the rest of the leelh in Ihe dental arch' as Ihe anchor
B. Occipital
units.
C. Cranial
D. Facial
Stationary anchorage
3) Muscular
According to the number of anchorage unils : II is defined as dental anchorage in which the manner
t) Single or primary anchorage & application of force lends to disploce the anchorage
Compound anchorage unit bodily in the plane of space in which the force is
Multiple or reinforced anchorage
being applied. The anchorage provided by a tooth
resisting bodily movement is considerably greater than
:
ocia/ bones : The frontal bone and the -randibular one resisting tipping force.
symphysis offer anchorage during face -^ask therapy
in order to protract the maxillo. Head gears that makes Reciprocal anchorage
use of anchorage from •he foreheod and chin are The term generally refers to the resistance offered by
colled reverse -!eadgears. two malposed units when the dissipation of equal and
Simple anchorage
opposite forces tends to move each Unit towards a
It is defined as dental anchorage in which the more normol occlusion. Here two teeth or two groups
manner & application of force is such that it tends to of teeth of equal anchorage value are made to move in
change the axial inclination of the tooth or teeth that opposite directions. Examples of reciprocal anchorage
include closure

Fig 1 Simple onchorage - removable cppliance incorpomting n screw

for buccal movement of a pala fa II y placed premolar

if form the anchorage unit in the plane of space in

which the force is being applied. Thus the resistance
of the anchorage unit to tipping is utilized to move
another tooth or teeth.
Simple anchorage is obtained by engaging
with the appliance a greater number of teeth than
,205
 Fig 2 Reciprocal anchorage : (A) Correction o: midline diastema us.ng elastics. \B) Finger springs used to close c midline
diastema (C) Cioss bi'e elastics to' correction of single tooth posterior cross brc. (D) Arch expansion using a
removable app'.iance incorporating a Coffin spring

of a midline diastema by moving the two central incisors towards each otner. The use of crossbite elastics and
dental arch expansion ore other examples of reciprocal anchorage (fig 2).

Intraoral anchorage
Anchorage in which all the resistance units are situated within the oral cavity is termed intraoral anchorage. The
teeth to be moved ond the anatomic areas that offer anchorage are all within the oral cavity. Various intraoral
anatomic units that maybe employed are the teeth, palate and lingual alveolar bone of mandible.

Extraoral anchorage
Anchoroge in which the resistance units are situated outside the oral cavity is termed extraoral anchorage. Various
extraoral anatomic units

Fig 3 Examples of extruoral anchoroge |A) Face mask ;or prolraciion

of maxilla - anchorage fromfare head and chin \8J Occipital head
geor - oncnoroge from the cranium
h

Anchorage in which the resistance units

Fig A Lip bumper utilizing musculor onchorgc

used as sites of resistance are occiput, back of *he

neck, cranium and face. Examples of extraoral
anchorage include the use of head gears that derive
anchorage from the cervical or cranial regions and
face mask that derives anchorage from the facial
bones (fig 3}.

Muscular anchorage
certain cases the perioral musculature is employed as
resistance units. Muscular anchorage makes use of
B
Fig 5 Bakers anchorage : (AJ Class 51 i-item-iax i J a ry anchorage.
|B) Closs III intermaxi'lary anchorage.

forces generated by muscles to aid in the movement of situated in one jaw are used to effect tooth movement
teeth. An example of muscular anchorage is the use of in the opposing jaw is called intermaxillary anchorage.
a p bumper to distalize molars (fig 4). It is also termed Bakers anchorage. Class II elastic
fraction (fig 5.a) applied between the lower molar and
Intramaxlllary anchorage
upper anteriors as well as Class III elastic traction
'•'/hen all the units offering resistance are situated
applied between the upper molar and lower anteriors
within the same jaw the anchorage is described cs
(fig 5.b) are types of intermaxillary anchorage.
intra maxillary. In this type of anchorage the teeth to be
moved and the anchorage units are ell situated either
entirely in the maxillary or the •mandibular arches.
Intermaxillary anchorage
 Reinforced or multiple anchorage

Anchorage in which more rhan one type c: j resistance

unir is utilized is termed reinforced anchorage.
Reinforced anchorage refers "o the . augmentation of
anchorage by various means sucn as extraoral
appliances, upper anrerior i inclined plane or a
rranspatotal arch connecting the two mo xi I lory
molars.
A. tx.Vcrorai forces TO augmen.'
anchoroge: Forces generated from extraoral areas
such c= cranium, back of the neck and face can be
used to reinforce one nonage.

B. Upper anterior inclined p.'one ;

A removable appliance incorporating an upper anterior
inclined plane resu'ts in forward glide of the mondible
during closure of the jaw (fig 6.a). This results in
stretching of the retractor muscles of Ihe mordib e
which subsequently contracts and forces the mandible
against Ihe upper inclined plane. Thus a distal force is
applied on the maxillary teeth thereby reinforcing
maxillary anchorage. A modification of the anterior
inclined plane is the 5ved appliance the* hos on
additional upper inciso capping Jfig 6.b).

Single or primary Banchorage C. Trarcspa/ofcri arch : This is a wire that spans Ihe
pciale in a transverse direction loss'.
Fig 6 Examples of reinforces anchorage (A) Uppsr a irerior ind nad
pla-ic (B) Svcd appliance

Cases wnerein the resistcnce provided by o single

tooth with greateralveo ar support's used lo move
another tooth with lesser sue port is refered to as single
or primary ancnoraae.

Compound anchorage

Anchoroge where the resistance provided by more

than one tooth with greater support is used to move
leelh with lesse.' support is called compound
anchorage.
Fin 7 Traispa rra' arc n
connecting the first permanent mo ars of either side
(fig 7).They are used in fixed mechanotherapy to
ougmenl onchorace.

ANCHORAGE PLANNING

Anchorage planning is of utmost i m po ranee •he

success of orthodontic treatment. Prior to initiation of
orthodontic therapy, it is essentia! to carefu'ly assess
the anchorage demands o: an individual case so that
appropriate treatment modalities car be executed. The
anchorage -equirement deoends on a number of
factors which are listed below :

1. Number of *eot.h being moved : The create' the

number of teeth oeing moved, the crecte' is the
demand on the anchorage.

2. Typo of feefh be.'.na moved : The movement of

slender anterior teeth offers lesser strain on the
anchorage than robust multirooted teeth.

2. Type of ,'ooffc movement ■' Whenever bodily tooth

movement is required, there is a greater, strain on tho
anchorage. In contrast, -pping tooth movements offer
a relatively 'cssor rrain on the anchorage units.

Duration of tooth movement ; Treatment cx a

prolonged duration oloces an undue strain on the
anchorage.

Based on the above mentioned factors, the

anchorage demand of a particular patient is
determined. Cases that have a high anchorage
-equirement need reinforcement of the anchorage by
one or more of Ihe various means mentioned earlier. In
spite of the precaution ta'<en in p annirg anchoroge, a
certain amount of unwanted movement of the
ancho'teetn invariably occurs during orthodontic
treatment. Such unwanted movements of anchor teeth
is called 'anchorage
H g 6 Classification o; andiccgc demand : (A) Maximum cncho'agc
(B) .NAode'a'fi ancnorcge (C) Mln mum anchorage

loss'.
 Based on the anchorage loss that is permissible,
the anchorage demand of an extraction case can be of
three types i.e. maximum anchorage, moderate
anchorage and minimum anchorage case (fig 9).

Maximum anchorage cases

In cases where the anchorage demand is very
high, not more than 1 /4 tn of the extraction space
should be lost by forward movement of the anchor
teelh. The anchorage in those patients should be
augmented to avoid unwanted movement of the
anchor teeth.

Moderate anchorage cases

In these cases, the anchor teeth can be permitted to
move forward into 1/4 th to 1/2 of the extraction space.

Minimum anchorage cases

In these cases, the anchorage demand is very low.
More than hoff the extraction space can be lost by the
anchor teeth moving mesially.

References
 ^uaUw 4JS
U^^I^iSiliJ J^JI J^j^
P—C Iff-J U^Wtli V j

Age Factor in
Orthodontics

n important consideration in Orthodontic The chronological age of the patient may

A diagnosis and treatment planning is the age of

the patient. In addition age factors influence
the treatment mechanics and prognosis.
sometimes be misleading and may not reflect the exact
growth status. Thus skeletal and dental ages of the
patient should be ascertained for a more accurate
diagnosis. The skeletal age or bone age as it is
DIAGNOSIS AND AGE sometimes called is determined by studying a
hand-wrist radiograph. The hand- wrist region has a
Diagnosis forms a vital part of successful rrthodontic
number of carpal bones. The ossification and union of
therapy. In order to diagnose abnormalities of the
these skeletal centers follow a definite time table and
dento-facial complex, the orthodontist should know
pottem. Thus by ascertaining the status of these
what constitutes -ormalcy. Normalcy in the dento-facial
ossificotion centers ond comparing them with
region r^ers from age to age. There are certain
standards for different skeletal ages, one can
features rrthe developing dento-facial complex which
determine the exoct skeletal
are "ormal in a child, however if present in an adult
*ould constitute malocclusion. These are referred 'o as
self-correcting malocclusions or transient
-alocclusions. Some of the transient
clocclusions are : a. Open bite seen in
the gum pads o Spacing in deciduous
dentition
c. First deep bite
d. Flush terminal plane
e. Ugly duckling stage
f. Second deep bite
These malocclusions are considered normal
for that age and need no treatment as they get
corrected automatically as the age advances.
W
maturity status o* an individual. The dentci age ot an armamentarium that include growth modulation,
individual is determined by assessing -he stage of guidance of eruption, use of notura'. ^orces etc.,.
222
calcification andOrthodontics
root develooment. - The Art and Science
However, in an adult patient the treatment options are
limited to moving teeth and surgery.
Considering the fact that orthodontic and
Compromise on treatment objectives : In an adult
dento-facial orthopcedic oopl'ances are most effective
patient in whom growth has ceased, it may not be
during growtn, the assessment of skeletal maturation
possible to achieve all the objectives of function,
in young patients is of utmost importance for the
esthetics and stability tnat represent ideal dentition
success of tne therapy.
and occlusion. In many adult patients compromises
TREATMENT AND AGE might have to be made in the treatment. While sealing
trectmenl objectives for cduit patients the orrnodontist
Early treatment
should set goals that are realistic, attainable and which
Most orthodon-'s-s believe in the concept of 'ca'ch strike the best possible balance in function, esthetics
them young'. Treating a patient at cn early cge when and treatment stability.
derto-focial growth is act've has numerous benefits.
TOOTH MOVEMENT AND AGE
Scope for growth modification : Skeletal
malocclusion that occurs as a resut o* altered growth
direction and amount ccn be intercepted by modulating
further growth. These procedures that modify growth
should be in'tiated at an earfy age before cranio-facial
growth ceases.

Scope for prevention ond m Perception ; One of the

advantages that early treatment offcs is the possibility
of preventing or intercepting a malocclusion. Even if
tne malocclusion ccnnot be totally eliminated, its
severity can be reduced so that complex orthodontic
trealment involving extraction and surges can oe
minimized.

Harnessing natural growth forces : The humon

dentition has a natural tendency lo move in a mesial
and occlusal direction. These natural tendencies con
be used to guide the erupting teeth to more favorable
positions.

Minimize psycho/ogrcai distress : Trealment carried

out at an early age avoids psychological disturbances
as a result of coping with a full- fledged malocclusion.
Late treatment
Roie of growth : Orthodontic treatment car r out
during adolescence or still later in adu~ cannot make
use of the growth potenticl. Altho working with growth
potential has numero advantages as enlisted earlier,
certc malocclusions are best treated offer growr-
completion. Most skeletal malocclusion indicated fo'
orthognatnic surgery arc to be treatec aftergrowth
completion so as to avoid recurre~ growth changes
associated with continuation o: abnormal growth
pattern.

Limited treatment options : In a growing patient, the

orthodontist has a numbe' of options in his
 Vitality of tissue ; orthodoritis1 merely relics on tooth movement o"
Orthodontic tooth surgery.
movement is Diagnosis : Most of the routine diagnostic aids can be
Age Factor in Orthodontics 213
used in both young as well as adult patients. An adult
most effectively
ccrried out in young patients. Young patients ex'nibir patient shows greater possibility of dormant octhosis,
increased vascularity and cellularity of the periodontal impaction, periodontal problems, wear of dentition,
membrane and bone as compared to older patients. faulty restoration, bone ioss, loss of teeth due to
Patients of younger age ere nence more responsive to decay, etc.,. The diagnostic exercise in an cdult
ortnodontic ;orces which makes is possible to move should hence consider these factors as some of them
Teeth faster. may homoerthe success of the orthodontic therapy.

App.'ionce se'ech'oft ; Younger patients who, are

Role of growth : Most orthodontic and orthooaedic
growing can benefit from orthooaedic and
corrections are effectively carried out during the growth
myofund'onal appliances that nelp modulate growth in
period. This is due to tne fact that younger growing
case of abnormal growth amount and direction. In or
patients reoct more favorably to orthodontic and
adult paliert the options are restricted to orthodontic
orthopaedic forces.
too'h movement and surgery.
Although it is desircble to carry out
It is a fact that younge' patients tolerate most
orthodontic treatment at a younger age, it is
appliances ard are not botnered by the appearance of
nevertheless possible to move teeth in older oatients
l
he appliance. Incase of adults, the appliance
by altering 'he force magnitude and duration.
tolerance is much lesser than a child. Adults are often
Sole of op i co / foramen : In an adult patient the
bothered by tne looks of the cppliance. Ir such
apical foramen is narrow. Force application during
patients, removable aoplrances ard fixed appliances
treatment may pose a greater chance of non-vitality,
that are more esthetic or inconspicuous are advoccted
root resorpt:on and ankylosis of teeth occuring. In a
whenever feasible.
young patient, the apical foramen s wider thus there is
Per/odo.oto/ problems ; Presence of periodontal
lesser cnance o6" ptipcl damage.
involvement and bone loss is mora common in an
Density of bone : As adults exhibit greater density of adult patient. Periodontally involved teeth move more
bore, orthodontic tooth movement is much slower. readily and offer poor anchorage.

YOUNG VERSUS ADULT PATIENTS Patient motivation and cooperation : Most

adult patients seeking orthodontic therapy are well
in recent times there has been an ircrease in the motivated as compared to children. Thus the
number of adult patients who desire orthodontic orthodontist can expect more co-ooeration in an adult
correction of their malocclusion. Numerous differences patient.
exist between adult orthodontics and orthodontics for
Tissue vitality : The tissue vitality and
the young child. The following ore some of the
responsiveness to force is much greater in a child than
important areas where the difference is seen :
in on adult patient. This is because of
Growth to work wi.'h ; One of vhe important differences
in treating a child and on adult is the fact that in a child
the orhodontist has growth to work with. Most
orthodontic and orthopcedic treatment is efficiently
carried out using the growth potential of the pctient. In
comparison, an adult lacks growth. Thus the

6 1. Special Considerations for Adult Orthodontics : : J.clinical

orthod : 535-545,1976
12. Tayer : Adults' at-itudes toward orthodontic therapy :
A.J.0:305-315, 1981
13. Thomas M. Graber ond Robert L VanansdaJ: Mosby , 199S'
14. Vare o ond Ga'cia-Camaa: Impact of orthodontics or ad jit
patients ; A.J.O: 142-148, 1995
15. Warren Harnjla : Orthodontic Office Design Designing Ad u t
.Areas : J.clinical ortnod 1992 : 355-360
reduced vascularity and cellulahty in an adult patient.

Treatment objectives ; In an adult patient, many

Orthodontics - The Art and Science

compromises might hove to be made. The 3 objectives
of function, esthetics and stability may not be achieved
in an adult patient and the orthodontist should thus
strike the best possible balance between the various
objectives.

Treatment appreciation : Adult patients ore more

appreciative of tne treatment results than a child
patient.

References

'Ml
i
 w

UimWiiliWftWWWW

Preventive Orthodontics

reventive orthodontics is that part of 1. Parent education

P orthodontic practice which is concerned with

the patient's ond parents' education, •
supervision of the growth and development of the
2.
3.
4.
Caries control
Care of deciduous dentition
Management of ankylosed tooth
dentition and the cranio-facial structures, the d 5. Maintenance of quadrant wise tooth shedding time
agnostic procedures undertaken to predict the table
ropearance of malocclusion and the treatment 6. Checkup for oral habits and habit breaking
s-ocedures instituted to prevent the onset of appliance if necessary
Talocclusion. 7. Occlusol equilibriation if there are any occlusal
Preventive orthodontics is a long range prematurities
roprooch and it is largely a responsibility of the 8. Prevention of damage to occlusion e.g. Milwaukee
general dentist. Many of the procedures ore common
braces
in preventive and interceptive orthodontics but the
9. Extraction of supernumerary teeth
:
timings are different. -eventive procedures are
10. Space maintenance
undertaken in znticipation of development of a
11. Management of deeply locked first permanent
problem, 'rterceptive procedures are undertaken
molar
when the :'oblem has already manifested. For e.g.
12. Management of abnormal frenol attachments
extraction of supernumerary teeth before they cause
r splacement of other teeth is a preventive cocedure,
while their extraction ofter the signs of
malocclusion have appeared is an interceptive
procedure.
The following are some of the procedures
undertaken in preventive orthodontics :
EDUCATION OF THE PARENTS

Fig' (A) Ihres'orec caries in dseciducjs oertition can ead to less o; arch length Note how ihe cones in deciduous molor has resU'ed in ihe
ceciducjs second molar mo'/irg mesiolty into -ha spoce". (B| pi- and fssure sealants

Preventive dentistry should ideally begin much before
the b'rtn of the child. The expecting mother should be
educated on matters such as nutrition to provide an
ideal environment for the developing fetus. Soon after
birth, the mother should be educated on proper nursing
and care of the child. In case tne child is being bottle
fed the mother is advised on the use of physiologic
CARIES CONTROL
material when the bigger permanent teern erupt into
the oral cavity. Caries should be detected by clinical
and radiographic examination. Bitewing radiographs
are a valuable aid in detection of caries. Once caries is
de~ectec. proper restoration of the affected teeth
should be undertaken immediately to prevent loss of
arch length.

nipple and not the conventional nipple. The

CARE OF DECIDUOUS DENTITION
conventional nipples are non-physiologic and do not
permit suckling by movement of tne tongue and the Preventive orthodontics includes care of the dcciduous
lower jaw. They rather cause sucking of the milk which dentition by way of prevention and timely restoration of
moy lead to various orthodontic problems of the teeth. carious teeth. The deciduous teelh are excellent
The physiologic nipples on the other hand are designed natural space maintained until tne developing
to permit suckling of the milk which more or less oermanentteetn ere reedy to erupt into the oral cavity.
resembles the normal functional activity as in breast Thus all efforts should be taken to prevent early loss of
feeding. The mother is also adviced against the the deciduous teeth. Simple preventive procedures
prolonged use of pacifiers which car have a detrimental such as application of topical fluoride and pit and
effect on the denrition. The young mothers arc o I so fissure scalcnts (fig l .b} help in preventing caries.
adviced on matters pertaining to prevention of nursing
bottle syndrome.
The parents should oiso be educated on the
need for maintaining good oral hygiene. The parents
should be taught the correct method of brushing the
child s teeth.
Ccries involving the proximal surface of deciduc teeth if
not restored leads to loss ot arch length I movement of
adjacent leetn into that space l .A} Such loss of arch
lengrn by mesial movement of teeth can result 'n
discrepencies between the arch length and tooth
 Preventive Orthodontics 217

G 2 ;A) And (B) Presence c>f supernumerary leelh has restl'ed in delay ii erjption OF the rncxillary incisors |C| and (D) Mesiodons causing rrcculari'-Y o :
R

the developing dcnlrion. JE; end \z\ Supplemerlo la'e'cl incsors

EXTRACTION OF
SUPERNUMERARY TEETH

-Vesence of supernumerary arid supplemental •®eth

can interfere with the eruption of nearby -ormal leelh (:ig
2). They can deflect adjacent teeth lo erupt in abnormal
positions. Presence o* an unerupted mesiodens
prevents the two maxillary central incisors from
approximating each other. Thus supernumerary teeth
snould be identified and extracted before they cause
disolacement of o'he' tee'h.
Fig 3 (A) Ankylosed primary second molar in int'raocdusion (submerged! (BjRodiog-cph of 'he same patent
ELIMINATING OCCLUSAL INTERFERENCE

All functional prematurities should be eliminated as they

can lead to deviations in the mandibular path of closure
and also predispose to bruxism. Using articulating
paper, the premature contact area is detected and
selective grinding is carried out. Sometimes abnormal
anatomical features like enamel pearls, may couse
Fig 4 (A) Midline diastema due to thick maxillary frcntm (B)
premature contact. They should be eliminated by Radiographs s h o w i n g interdental bono nolching
grinding.

MAINTENANCE OF
TOOTH SHEDDING TIME
TABLE

There should not be more than 3 months difference in

shedding of deciduous teeth and eruption of permanent
teeth in one quadrant as compared to other quadrants.
Delay in eruption may be due to one of the following
factors :
a. Presence of over-retained deciduous teeth roots
b. Presence of unresorbed deciduous root fragments.
c. Supernumerary tooth (fig 2)
d. Cysts and tumors
e. Over-hanging restoration in deciduous teeth
f. Fibrosis of gingiva
g. Ankylosed primary teeth
MANAGEMENT OF ANKYLOSED TEETH

Ankylosis is a codition characterized by absence of the

periodontal membrane, in a small area or
 and possible deformities. Whenever such an appliance
is used, occlusion should be protected using functional
appliances or positioners made of soft materials.
Preventive Orthodontics 219
DEEPLY LOCKED PERMANENT
FIRST MOLARS

The deciduous second molars occasionally have a

=
ig 5 Arkylcglossio or tongue tie
•he whole of the root surfcce. Ankylosed deciduous
^eth do not get rcsorbcd and therefore either
creventthe permanent teeth from erupting (fig 3} or
deflect them to erupt in obnormol locations. These
prominent distal bulge which prevents the eruption of the
first permanent molars. Slicing the distal surface of the
second deciduous molar helps in guiding the eruption of
the first permanent molars.
SPACE MAINTENANCE
Premature loss of deciduous teeth can cause drifting of

ankylosed teeth should be diagnosed and surgically the adjacent teeth into the space. It can result in

removed at on appropriate time to permit 'he abnormal axial inclination of teeth, spocing between
permanent teeth to erupt". teeth ond shift in the dental midline. Premature loss of
deciduous anteriors leads to very little orthodontic
MANAGEMENT OF ABNORMAL F RENAL changes. If the deciduous first molars ore lost
ATTACHMENTS prematurely, lateral

The presence of a thick and fleshy maxillary labial

^enum that is attached relatively low prevents the
maxillary control incisors from approximating each
other producing a midline diastema. This kind of
cbnormal fronol ottachment in most patients is caused
due lo hereditary factors. They should Hence be
diagnosed and treated at an early age. A blanch test
helps in diagnosing a thick frenum. h addition notching
of interdental bene in a ceriapical radiograph confirms
a thick frenal attachment
Presence of ankyloglossia or tongue tie (fig
4.b) prevents normal functional development due to
lowered position of the tongue and cbnormalities in
speech and swallowing. This condition should be
surgically treated to prevent full-fledged
malocclusions.
ORAL HABITS CHECK-UP AND
EDUCATING PATIENTS AND PARENTS

Habits such as finger and thumb sucking, nail biting,

tongue thrusting and lip biting should be identified and
stopped. Prevention starts with proper nursing and use
of a physiologically designed nursing nipple and pacifier
to enhance normal functional and deglutational activity.

PREVENTING MILWAUKEE
BRACE DAMAGE

Milwaukee brace is an orthopaedic appliance used for

the correction of scoliosis. This appliance exerts
tremendous force on the mandible and the developing
occlusion leading to retardation of mandibular growth
 According lo Hilchcock
Advantages of removable space
Removable or fixed cr s?irifwed VVIh ma/ntainers
bands ot without bands Rational or non 1. They are easy to clean arid permit mointoinance of
Lrcrional Active ot pass v? C^rla n
prooero'al hygiene.
CQTibinaiions ot the above
2. They maintain or restore the vertical dimension.

According to Raymond C. Thurov;

3. They can be worn part time allowing circulation o:
Ihe olood lo the solt tissues.
Removable Complex a-ch .
A. They serve other important functions I ke
rgu3l arch cx'ra-oral ar.corag
ndivdual toot- masticat on, esthetics and p.noretics. 5. Dental
check-up for caries detection can be undertaken
Acccrdng to Hinrlchsen easily.

rixed spa:* maintains: Class I

aj Nor. f.naicnal types i| 2ar lype i I iwp type O) F
n ""ic nal lypes i; Pontc type i) lingual arch lype Class I
• C^riileve' :yp«s (distal shoe. ba'C & ■OOP)
Ra-ncvaolo spacc nain:airers : Ao-y-'C pan si dentu'$s

shift of anteriors takes ploce. In case of oremalune loss

of deciduous second molars, the first permanent molars
migrate mes "ally "hereby leaving insufficient space for
the erupting second premolors wh'ch can get impacted
within Ihe jew or get ceflected and erupt in on abnormal
ocalicn. Soacc mainta ne' is a device used -o maintain
the space created by the OSS of a deciduous tooth.
A space mainto'ner should fulfil! the following
reouirements: I. It shou d mc'ntain tne entire mesio-distal
scoce created by a lost tooth.
2. t must restore the function as far as pos and
prevent over-eruption of opposirg te«
3. :t should be simple in construction.
4. It should be strong enough *o withstand v
functional forces.
5. I* shouid not exert excessive stress adjoining
teeth.
6. It mus* oermit maintenance of ore1 hygier
7. I* must not restrict normal growth ar development
and natural adjustments whic take ploce during
the transition fro* decid jous to permanent
cemition.
8. The space rnaintainer should not come id Ihe woy
of other functions.

REMOVABLE SPACE MAINTAINERS

They are spcce maintained which can be removes and

reinserted into the oral cavity by the patient Removable
soace maintained can be classifiec as funct:onal and
non-functional space maintainers. Funct or.al space
maintainers :ncorporale -eeth lo aia in masticat or,
speech and esthetics whereas non-functional space
maintainers hove only an acrylic extension over the
edentulous area to prevent space closure.
Jc 6 Arcyl'c poriol cen'tro used as spare martoinc
1. Lack of patient co-opera r ion.
|c Room con be mode for permanent teeth to erupt 2. In patien's who are allergic to acrylic matericls.
without changing the appliance. 3. Epilept'c patients wno have uncontrolled seizures.
| ~ They stimulate eruption of permanent teeth.
5. Some commonly used removable space
tS. Band construction is not necessary.
maintainors
11 They help in preventing development of tongue
thrust habit into the extraction space. Acrylic Partial Denture s .' Acrylic pcrtial dentures
have been used success*'ully in patients who have
Disadvantages of removable space 6.
undergone multiple extractions (fig 5). Tnis apoliance
-alntainers
con be readily adjusted to allow the eruption of teerh.
f T h e y may be lost or broken by the patient. The inclusion of artificial 4eeth in ihe denture restores
12. Unco-operative patients may not wear the mas*:catory function. Clasps can be -abricated on
apoliance. deciduous canines and molars for retention.
B. Lateral jaw growth maybe restricted, if clasps are
inco'porated.
i^. They mcy cause irritation of the underlying so^
tissues.

id/cations of removable space nalntalners

i'T. Removable dentures are indicated when aesthetics
is cf importance.
BZ. In case the abutment teeth connot suppori a fixed
appliance it is recommended to use a removab'e space
maintained 1 In cleft palate patients who require
obturation
of the palatal defect. 4. In ccse the rodiograph
reveals thot the unerupted permanent tooth is no* going
to
erupt in loss than five montns time, a removable
space maintainer can be given. If the permanent teetn
have not fully erupted it rncybe difficult to adapt bands.
Thus it ;s advisable to 'use removable space maintained.
Multiple loss of deciduous teeth which may require
functional replacement in the form cf either partial or
comp'ete dentures.

Contra/jjd/cat/ons of removable type of space

malntalners
 Space mainlainers which are fixed or fitted ontc the
Fig 6 Band and loop space maintainer toeth are called fixed space maintainers.
Full or Complete dentures : Sometimes all the
primary teeth of a pre-school child may require
extraction due to rampant caries of teeth that cannot be
restored. Although this procedure was more common in
the pre-fluoridation era, even today some children may
require complete extraction of their deciduous teeth.
These cases are managed by the use of a complete
denture. These dentures not only restore masticatory
function and esthetics, but also guide the first permanent
molars into their correct position. The posterior border of
the denture should be placed over the area
Fig 7 Band and loop spaco moimainer •
approximating the mesial surfoce of the unerupted first
permanent molar. The denture will hove to be adjusted
and a portion of it cut away as the permanent incisors
erupt, and the posterior border contoured to guide the
first permanent molars into position. When the
permanent incisors ond first permanent molars hove
erupted, a partial denture space maintainer can be used
until the remaining permanent teeth erupt.
Removab/e Dfsia^ Shoe space Maintainor: An
1
'immediate acrylic partial denture with an acrylic distal
shoe extension has been used successfully to guide the
first permanent molar
into position when the deciduous second mc is lost
shortly before the eruption of the fir permanent molar.
The tooth to be extracted is < away from the stone
model and a depression i cut into the stone model to
allow the fabricatic of the acrylic extension. The acrylic
will i into the alveolus after the removal of the prime»
tooth. The extension maybe removed after the | eruption
of the permanent tooth.

FIXED SPACE MAINTAINERS

Advantages of
Fig S (A Uinguol arch space maintaire' (B- Nance held rg arch Crown and foop appliance :
fixed space
malntalners Crown and loop apoliances are similar to band end loop

1. Bands and crowns are used which require minimum space maintainers in all respects except that a stainless

or no tooth preparation. steel crown is used for the abutment tooth. The crown is

2. They do not interfere with passive eruption of used in preference to the band when the abutment tooth

abutment teeth. is highly carious, exhibits marked hypoplasio or is

3. Jaw g rowth is n ot ha m pered. pulpotomized.

The succedaneous permanent teeth are free to Trie fongua/ arch space maintainer : The lingual arch is
erupt into the oral cavity. the most effective appliance for space maintenance in
5. They can be used in unco-operative patients. Ihe lower arch. The classical mandibular lingual arch
5. Masticatory function is restored if pontics are placed. consists of two bands cemented on the first permanent
molars or on the second deciduous molars, which are
Disadvantages of fixed space joined
malntalners
1. Elaborate instrumentation with expert skill is
needed.
2. They may result in decalcification of tooth material
under the bands.
3. Supra-eruption of opposing teeth can take place if
pontics are not used.
4. If pontics are used it can interfere with vertical
eruption of the abutment tooth and may prevent
eruption of replacing permanent teeth if the patient
fails to report.
Examples of fixed space malntalners
Bond and loop space /naintorner : Bond and loop
space mointainers are one of the most common spoce
controlling oopliances used in dental practice. The tooth
distal to the extraction space is banded and a loop of
thick stainless steel wire is soldered to it with its mesial
end touching the tooth mesic! to tnc extraction space (fig
6 & 7). It is a unilateral fixed appliance indicated for
space maintenance in the posterior segments when a
single toolh is lost.
 Fig 9 Transpalatal arch anterior palate (fig 8.b). h incorporates an ocrylic
by a stainless steel wire contacting the lingual
button in the anterior region that contacts the
surface of the four mandibular incisors (fig 8.a). The
polatal tissue.
appliance is usually indicated to preserve tne spaces
Transpa/otai1 arch : More recently, the transpalatol
created by multiple loss of primary molcrs. If helps in
arch has been recommended for stabilizing the maxillary
maintaining the arch perimeter by preventing borh
first permanent molars when the primary molars require
mesial drifting of tne molars and also lingual collapse of
extraction (fig 9}.The transpalatal arch consists of a thick
the anterior teeth.
stainless steel wire that spans the palate connecting the
Pa/cfa. 7 arch oppfionces : They are similar to the
first permanent molar of one side with the other. The
lingual arch described above. Palatal arches are
best indication for transpalotcl arch is when one side of
designed to prevent mesial migration of the maxillary
the arch is intact, and several primary teeth on the other
molars. They are constructed using
side are missing.

0.036 inch diameter hard stainless steel wire. The

F g 10 Disfcl shoe space r-ia rtniner

Nance nolding arch is a maxillary lingual arcn that does

not contact the anterior teeth, but approximates the

7 Time elapsed since loss of tooth : It is usually

advisable to place a space maintainer as
 Fig 1 1 |AJ Band and bar space maintainer (BJ Crown and be r spacic ncintoiner

Distoi shoe space maintainer : Distal shoe appliance
is otherwise known as the intra-alveolor appliance (fig
10). The distal surface of the second primary molar
guides the unerupted first permanent molar. When the
second primary molar is removed prior to the eruption of
the first permanent molar, the infra-alveolar appliance
provides greater control of the path of eruption of the
unerupted tooth ond prevents undesirable mesial
migration. The applionce which is used in practice now is
Roche's distal shoe or its modifications using crown and
band applionces with a distal intra-gingival extension.
rsf/iefrc anterior space mainioiners : It ■vas
described by Steffen, Wilier and Johnson in 1971. Its
method of construction is simple and clso provides on
esthetic component. The spoce maintainer consists of a
plastic toolh fixed onto a ' ngual arch which, in turn, is
attached to molar bands.
Bond ond Bar type spoce maintainer : This is a
fixed space maintainer in which the abutment teeth on
either side of the extraction space are banded and
connected to each other by a bar (fig 1 1. a).
Alternatively stainless steel crowns can be used on the
abutments. This type of space maintainer is called crown
and borspacc maintainer {fig 1 l.b).
fabricate the appliance prior to extraction of the primary
toolh and insert the appliance soon after Ihe extraction.
2. Dental age of fne patient : The dental age of the
patient should always be considered ralherthon the
chronological age. This is because too much variation in
eruption of teeth is observed. It is usucily observed that
the permanent teeth erupt once 3/4th of their root
development is complete. This criteria can be used lo
predict the age of eruption of the permanent teeth.
Early loss of teeth can cause a delay in
eruption of the successor. For example early loss of the
deciduous molars before 7 yecrs of age results in a
delay in eruption of the oremolar.
3. Thickness ol bone covering the
unerupted teeth: The more the bone covering the
unerupted tooth, the more would be the time it would
take to erupt, and therefore space maintenance is ;
indicated. Normally premolars take 4 - 5 months to erupt
through a bone of 1 mm.

PLANNING FOR SPACE MAINTANANCE

The following factors should be considered when space

maintainer is planned following the early loss of primay
teeth.
soon as the primary teeth are removed. Studies indicate
that the maximum loss of space occurs within 6 months
of exlraction of the teeth. It would be a good idea to

,225
 236 Orthodontics - The Art and Science

4. Sequence of eruption of teeth : Whenever a

space maintainer is planned, adequate consideration
should be given lo the adjacent deveioping and
erupting teeth. The neighbouring dentition can greatly
influence the closure of the extraction space. For exam
pie when the deciduous second molar is lost early, we
should study the d evelopm e nt of the perm anent
second mola rand the successor second premolar. In
case the second molar is ahead of the second
premolar in its eruption, it is likely to exert a mesiol
force on the first molar which can move mesially. This
may result in insufficient space for the second
premolar.

5. Congenita/ absence of permanent tooth: If

permanent teeth are congenitally missing, ihe dentist
should decide if he is going to retain the space until a
replacement can be given or allow the other erupting
teeth lo drift and close the space.
 Orthodontics

f 1. Serial extraction

T here ore a
number of
2. Correction of developing crossbite
Control of abnormal habits I 4. Spoce regaining
; 5. Muscle exercises . 6. Interception of skeletal ma I re
lotion \7. Removal of soft tissue or bony borrier to
enable eruption of teeth

procedures that can be undertaken by the orthodontist,

so as to intercept a malocclusion that is developing.
Unlike preventive orthodontic orocedures that are
aimed at elimination of fcctors that may lead to
malocclusion, interceptive orthodontics is undertaken
at a time when the malocclusion has already
developed or is developing. Thus interceptive
orthodontics basically refers to measures undertaken
to prevent o potential malocclusion from progressing
into o more severe one.
The terms preventive and interceptive
orthodontics are sometimes used synonymously. But it
should be understood that preventive orthodontic
procedures are undertaken when Ihe dentition and
occlusion_are perfectly normal, while the interceptive
procedures are carried out when the signs and
symptoms of a malocclusion have
appeared. Some of the procedures carried out in
preventive orthodontics can also be carried out in
interceptive orthodontics but the timings are different.
Interceptive orthodontics has been defined
as that phase of the science and art of orthodontics
employed to recognize and eliminate potential
irregularities and malpositions of Ihe developing
dento-facial complex.
The procedures undertaken in interceptive
orthodontics include :
SERIAL EXTRACTION Malposilioned or impacted loterol incisors that erupt
palataily out of the crch
Serial extraction is an interceptive
228 Orthodontics - Theorthodontic
Art and Science
Markedly irregular or crowded upper anc lower
procedure usually initiated in the early mixed dentition
anleriors
when ore can recognize end anticioate potential
Localized gingival recession in the lower anlerfor
irrecuarities in the dento-facial complex and is
region is a characteristic feature of arch .'ength
corrected by a procedure *hat includes the planned
deficiency
extraction of certain deciduous teeth and later specific
Ectopic eruption of teeth
permanent teeth in an orderly sequence and
Mesial migration of buccal segment
pre-determined pattern to guide the e.'upting
n. Abnormal eruption pattern & sequence i. Lower
permanent teeth into a more favorable position.
anterior flaring j. Ankylosis of one or more teelh
3. Where growth is not enough to over come the
History
discrepancy between tooth material and basal bone
Kjellgren in i 929 used 'he term serial extraction to
4. Patients with straight profile and pleasing
describe a proced jre where some deciduous teeth
appearance
followed by permanent teelh were extracted to guide
the rest of tne teeth into normal occlusion. Nance Contra-/ndJcat/ons of serial extraction
during the 1940's popularized rhis technique in the
Serial extractions are contra-indicated in a number of
United States of America and termed it planned &
conditions which include :
progressive extraction'. Hotz in 1970 called suc.n c
Class II & III malocclusion with skeletal
procedure active supervision of teeth ay extraction'.
abnormalities
Spaced dentition
Rationale
Anodontia/oligodontia
Serial extraction is based on two basic principles.

Arch length - teeth materia/ discrepancy: Whenever

there is an excess of toolh material as compared to Ihe
arch length, it is advisable -o reduce the tooth ma'erial
in order lo achieve stable results. This principle is
utilized in sericl extraction procedures where tooth
material is reduced by selective extraction of teeth so
that the rest of the leelh can be guided to norma!
occlusion.

Physiologic foofb movement : Human dentition shows

a physiologic tendency to move towards an extraction
space. Thus by selective removal of some teeth the
rest of the teeth which are in the process of eruption
are guided by the

natural forces into the extraction spaces.

Indications
Serial extraction is indicated in the following cases
1. Class'I malocclusion snowing harmo between
skeletal and muscular system.
2. Arch length deficiency as compared to the tooth
material is the most important indicator for serial
extraction. Arch length deficienc. is indicated by
the presence of one or more of the following
features:
Abserceof physiologic spacing
Unilateral or biiatercl premature loss o* deciduous
canines with midline shift
 Open bite ond deep bite h. Tneaxia' inclination of leeth at *he termination of Ihe
Midline diastemo serial extraction procedure may require correction.
Class I malocclusions with minimal space This necessitates short *erm fixed aopliance
deficiency
Interceptive Orthodontics
therapy.
Unerupled malformed teeth e.g. dilaceration
Extensive caries or heavily filled first permanent Dtognost/c procedure
molars The diagnostic exercise orior to treatment snould involve
Mild disproportion between arch length and tooth comprehensive assessment of the dental, skeletal and
maten'al thot con be treated by proximal stripping soft tissues. A tooth material - arch length discrepancy
mus4- ideally exist. According to most authors, an arch
Advantages of serial extraction
length deficiency of not less than 5 - 7 mm should exist to
Serial extraction carried out during the mixed dentition undertake this procedure. Study model analysis should
and early permanent dentition periods has 0 number of be carried out to determine the arch length discrepancy.
advantages : 0. Treatment is more physiologic as it Carey's analysis in the lower arch and orch perimeter
involves guidance of teeth into normal positions analysis in the uppe' arch should be carried out. Mixed
making use of the physiologic forces. deration analysis helps in determining Ihe spoce required
b. Psychological trauma associated with for the erupting buccal teeth. The eruption status of ihe
malocclusion con be avoided by treatment of Ihe dentition is evaluated from an O.RG.
malocclusion ot an early age. The skeletal tissue assessment should involve
c. It eliminotes or reduces the duration of comprehensive cephalometric examination to study the
multibonded fixed treatment. underlying skeletal relation. Serial extraction produces
d. Better oral hygiene is possible thereby reducing the best results in a Class I skeletal pattern. Presence of
the risk of caries. 0 Class II or a Class III skeletal pattern are
e_ Health of investing tissues is preserved. - Lesser contraindicationsforseriol extraction procedure.
retention period is indicated at the
completion of treatment, g. More stable results
are achieved as the tooth material and arch length are
in harmony.

Disadvantages of serial extraction

a. Serial extraction requires clinical judgement.
There is no single approach that can be
universally applied to all patients. Each patient
has to be ossessed and a suitable extraction time
table planned.
b. Treatment time is prolonged o s the treatment is
corned out in stages spreod over 2-3 years.
c. It requires the patient to visit the dentist often.
Thus patier+ co-operation is needed.
d. As extractior spaces are created that close
gradually, the patient has a tendency of
developing tongue thrust.
e. Extraction of Ihe buccal teeth can 'esult in
deepening of the bite.
f Ifthe p roced u res a re not earned out properly there
is a risk of arch length reducing by mesial
migrator, of the bjccal segment. Thus a poorly
executed serial extraction progremme can be
worse than rone at all.
g. Ditching o' spoce can exist between tne canine
and second premolar
F'g 1 Dewel's method o: sercl ex-radion (A) Step one • extroct'on of dcddcous canines to crecte space for the alignment of tho incisors.(B; S- ec
two ■ ex-radion of deciduous f rst molars to accelerate rhe eruction cf fi'st o'emolars.fO Step throe • extradion of 'lie erjptina *irs- prornola's to
permit tne pe'manenl canines 'o erup\ (D} Se'ial extraction completed
 A B

z
g 2 "weed's neihod of serial extraction (A) S'ep one • isoduaus
carine and first premolar
The soft tissue assessment by clinical
examination and cephalograms help in the ciagnosis.
Serial extraction is generally .-dertaken in patients
exhibiting harmonious soft *ssue pattern.
Procecfure
A number of methods or sequence of extraction -eve
been described. Three of the popular —ethods are:
space for the alignment of the incisors. This step is
corried out at 8-9 years of oge. A year later, the
deciduous first molars are extracted so that the
eruption of first premolars is accelerated. This is
followed by the extraction of the erupting first
premolars to permitthe permanent canines to erupt in
their place.
In some cases a modified Dewel's technioue
is followed wherein the first premolars are enucleacted
at the time of extraction of the first deciduous molars.

c. Dewel's method b. This is frequently necessary in the mandibular arch

Tweed's method c Nance where the canines often erupt before the first

method premolars.

Tweed's mefhoaf ; This method involves the extraction

f
Oewe/'s method ; Dewel has proposed a 3 s'ep serial
of the deciduous first molars around 8 years of age.
extraction procedure (fig 1}. In the first rep the
This is followed by the extraction of the first premolars
deciduous canines are extracted to create
racrion o cec'duous first r^olar (Bj Slep two • extraction of
: and Ihe deciduous canines

,231
simultaneously (fig 2).
Ma nee mefhod : This is similar to the Tweed's
4
echnique end involves the extrcction of the deciduous
first molors followed by the extraction of the first
premolars and the deciduous canines.
Post serial extraction fixed therapy
Most cases o1 seria1 extraction need fixed appliance
therapy for the correction of axiol ;nclination and
detailing of the occlusion.
posterior bite plate (Refer chapter 34). Funcf.io.na/
anterior crossbile: Some anterior cross bites are
referred to as functional crossbites. This type of
crossbite is the so called pseudo Class III
malocclusion where the mandible is compelled to
close in a oosition forward of its true centric relation.
Functional crossbites occur os a result of oculusal
prematurities that cause a deflection of the mandible
into a forward position during closure. These are to be
treated by eliminating the occlusal prematurities.

DEVELOPING ANTERIOR CROSSBITE S.kefetof anterior crossbite ; Skeletal anterior

crossbites are usually a result of skeletal
Anterior crossbite is a condition characterized by
discrepencies in growth of maxilla orthe mandible.
reverse over jet where in one o- more maxillary anterior
Anterior crossbites can be a result of maxillary skeletal
teeth are in lingucl relation to the mandibular teeth.
retrognathism or hypoplasia or mandibular
Anterior crossbites should be intercepted ond
prognathism. These are best treated during growth by
treated at an early stage so as to prevent o minor
growth modification procedures by use of
orthodontic problem from progressing into o
myofunctional or orthopaedic appliances
majordento-facial anomaly. An o'd orthodon*-c maxim
states " The best time to treat c crossbite is the first INTERCEPTION OF HABITS
time it is seen."
Habits in the orthodontic sense refer to certain actions
Anterior crossbite should be treated eariy
involving the teeth and other oral or perioral structures
-'orthe following reasons :
which are repeated often enough by some patients to
a. This type of malocclusion is self-perpetuating i.e. if
have a profound and deleterious effect on the positions
the cross bite is present in the deciduous dentition,
it may manifest in the mixed and permanent of teeth and occlusion. Some of the habits that can

dentition as well. affect the

b. Simple anterior cross bites that are not treated

early have the potential of growing into skeletal
malocclusion thct later need complicated
orthodontic treatment combined, at times, with
surgical procedures.
Anterior cross bites can broadly be classified
as:
a. Dento-alveolar anterior crossbites
b. Skeletal anterior crossbite
c. Functional anterior crossbites
Denfo - a/veo/ar anterior crossb/te : Anteriorcrossbite
in which one or more moxillary anterior teeth ore in
lingual relation to the mandibular anteriors is termed
dento-alvelolar anterior crossbite. This kind of anterior
crossbite is often manifested as single tooth crossbite
and usually occurs due to over-retained deciduous
teeth thot deflect the erupting permanent teeth into a
pa'atal position. These dento-alveolar crossbites can
be effectively treated using tongue blades,
Catalan'saoplianceand double conti lever spring s with
Thumb sucking

One of the habits that patients, the space lost

Fig 4Habit breakers (A) Removable hafctf o'eaker (6) F'.xed nabit breaker
is most frequently by mesial movement of

orol structures ore thumb sucking, tongue thrusting Mouth breathing

and mouth breothing.
practiced by children and is capable of producing
damaging effects on the dento-clveolar structures is
the thumb sucking habit. The presence of this habit
upto 2 1/2 - 3 years of age is considered quite normal.
Persistence of this habit beyond 3 1/2 - 4 years of age
can have a damaging influence on the dento-alveolar
structures and should hence be intercepted (Refer
choper 9). Thumb sucking is intercepted by use of habit
breakers that could be of removable type or one that is
fixed (fig 4).
Tongue thrust
Tongue thrust is defined as o condition in which the
tongue makes contact with any teeth anterior to the
molars during swallowing. This is a deleterious habit
that can clinically present with open bite and anterior
proclination.
The tongue thrust habit should
intercepted by using habit breakers. The potient should
be trained and educated on the correct technique of
swallowing.
If a primary molar is lost early and space maintainors
arc not used, a reduction in arch length by mesiol
movement of the first molar can be expected. In such
Mouth breathing habit has a profound effec on the
dento-facial region. It can be obstructive or habitual in
noture. Obstructive mouth breathing is usually a result
of nasal obstruction such as nasal polyps, nasal
tumors, chronic nasc; inflommotory conditions and
deviated nasal septum. Habitual mouth breathing is
one where oral breathing persists as a habit after the
removal of the nasal obstruction.
Mouth breathing affects the oro-facial
equilibrium due to lowered mandibular and tongue
posture and can therefore produce severe
malocclusion.
Interceptive procedures should involve
identification and removal of the cause. Persistence of
habitual oral breathing is an indication to use a
vestibular screen to intercept the habit.
the molar con be regained by distal movement of the
be
SPACE REGAINING
first molar.
 Not oil patients who haveF'g 5 Gerber"s soaca regainer
lost arch length by mesial molar
movement are ideal candidates for space regaining.
The space regaining procedures are preferably
undertaken at on early age prior to the eruption of the

A B

Fig 6 (A) Space re gainer using jack screw !3) Space regainer using anti eve' springs

second molar. The following are some of the commonly

used space regainers.
Gerber apace regainer
237 Orthodontics
A seamless orlhodontic band or a crown is-selected
The Art and
for the
tooth to be distalized. This space regainer consists of o 'U
shaped hollow tubing and o 'U' shaped rod that enters the
tubing. The tube is soldered or welded on the mesial
aspect of the first molar to be moved distally. The 'U'
shaped wire or rod is fitted into the tube, in such a way that
the base of the 'U' rod contacts the tooth mesial to the
edentulous area. Open coil springs of adequate length are
placed around the free ends of the 'U' shaped rod and
inserted into the tubing assembly. The forces generated
by the compressed open coil springs bring about a distal
movement of the first molar.
Space regalners using jack screws
Space regaining can be brought about using jack screws
placed in such a way that an increase in arch length is
obtained by distolizotion of the mojgr. The appliance
consists of a split acrylic plate with a jack screw in relation
to the edentulous space and is retained using Adam's
clasps.
Space regaining using cantilever spring
b. Patients can be asked to stretch the upper lip in a
Science
downward direction towards the chin.
c. Holding and pumping of water back and forrr behind
the lips.
d. Massaging of the lips.
e. Button pull exorcise : A button of I 1/2 inch diameter
is taken and a thread passec through the button hole.
The patient is asked to place the button behind the
lips and pul the threod, while restricting it from being
pulled out by using lip pressure.
f. Tug of war exercise : This is similar to the button pull
exercise. This involves use of two buttons, with one
placed behind the lips while the other button is held
by another person to pull the thread.
Exercise s for the tongue
One elastic s wo Mow : This exercise is used for
correction of improper positioning of tne tongue. A 5/16
inch intra-oral elastic is placed on the tip of the tongue and
the patient is asked to raise the tongue and hold the
elastic against the rugae area and swallow. Tongue ho/d
exercise : A 5/16 inch elastic is positioned over the
tongue in o designated spot fora prescribed period of time

The molar can be distalized to regain space by using with the lips closed. The patient is then asked to swallow

removable appliances that incorporate simple finger with elastic

springs.

MUSCLE EXERCISES

The dental tissues are blanketed from all directions by

muscles. Normal occlusal development depends upon the
presence of normal oro-facial muscle function. Muscle
exercises help in improving aberrant muscle function.

Exercise for the masseter muscie

An exercise to strengthen the masseter muscle involves
the clenching of teeth by the patient while counting to ten.
The patienr is asked to repecr tnis for some duration of
rime.-

Exercise for the Hps (clrcum-oral

muscles)

A number of exercises have been suggested far tne lip

and cheek muscles.
a. Stretching of the upper lip to maintain I p seal is an
important therapeutic measure in patients having
short hypotonic lips. To aic in the stretching, the
patient is asked to hold a piece of paper between the
lips.
 Skeletal Class III Face mask therapy and
severity of the malocclusion thot may occur. These growth
238 ' f Orthodontics - The Art and Science modulation procedures are aimed at normalizing the
skeletal relationship.
Ske-elaJ Class Restrict m axil; ary growth
ma'oeclusion due to us'mg headgears
Interception of Class II malocclusions
maxillary'prognathic
malocclusion due to cttn cap to .restrict Class II skeletal malocclusion usually occurs as a result of
Skeletal Class II Myotu actional applances either excessive maxillary growth, deficiency in
ma'occtusion due to to promote rnardibular mandibular growth or a combination of both. Moxillary
mandibular grcvrfh retrogna'.hlsm
growth can be restricted by use of face bow with headgear.
maxillary retrc$nathisn mandibular growth Class II malocclusion due to deficient mandibular growth is
usually treated by myo-functfonal appliances.
Skeletal Class II Myofunctional appliances
malocclusion due tc to promote mandibular
mandfbular growth and iveadgear to Interception of Class III malocclusions
re'rognathlsm a-"d restrict maxillary g-owth
maxillary prognathism Class III malocclusion occurs as a result of mandibular
prognathism, maxillary retro- gnanthism or a combination
Skeletal- Class III
of both. Chin cup with head gear helps in restriction of
mandibular growth while FR III or face mask therapy is
Skeletal Ciass 111 Chin cup therapy to
used for cases of maxillary deficiency.
malocclusion due to restrict mandibular
mandibu'ar growlh prognathism
REMOVAL OF SOFT TISSUE AND BONY
BARRIERS
malocclusion due to
INTERCEPTION OF
maxillary ; Whenever a permonenl tooth fai's to erupt at the
retrognathisn and SKELETAL
appropriate time, its eruption may be stimulated by
mandibular
MALRELATIONS surgically exposing the crown. Over-retained primary
prognaihisn
Myofunctional appliance
teeth, ankylosed primary teeth and supernumerary teeth
to promote maxillary Ske'etal malocclusion if
growth and face mask are other possible causes of non-eruption of
diagnosed at an early
therapy succedaneous teeth, which should be ruled out prior to this
age can be intercepted
procedure.
so as to reduce the
The surgical procedure involves excision of the
soft tissue and removal of any bone overlying the crown of
the unerupted tooth. The extent of tissue removal should

n place and lips apart. be such that the greatest diameter of the crown of the tooth
is
"Wo e/astic swo/low r Two 5/16 inch elastics ere placed
over the tongue, one in the midline and the other on the
tip and the patient is asked 'o swallow with the elcslics in
position.

Ihe hold pull exercise : The tip of the tongue end the
midpoint are made to contact the palate -nd the mandible
is gradually opened. This exercise helps in stretching the
lingual frenum.
exposed. In other words the surgically created opening in
the tissue is sligntly larger than the greatest dimension of
the tooth. The surgical wound is given a cement dressing
for a period of 2 weeks. References
 m

thods of ing
Space

he correction o: many

T
1. Proximal stripping is usuolly indicated when the
malocclusions requi'es space required is minimal i.e., 0 - 2.5 mm. In these
space in order to move coses, it is possible to avoid extraction of teeth by
teeth into more ideal locations. Space is required for performing reproximation.
rrection of crowding, 'etradfor of proclined ;th, leveling a 2. If the Bolton's analysis show mild tooth
steep curve o: Spee, derototion zt anterior teeth and for
correction of unstable Correlation.The orthodontist is
often faced with •be dilema of how to obtain space
required for -^ese corections. Planning space is an
important rsoect of treatment planning.
Some of the methods of gaining space nclude :
z. Proximal stripping c Expansion r.
Extraction r. Distalization r
Uprightinaof moles : Derogation of
posterior teeth z Proclfnation of
anteriors
PROXIMAL STRIPPING

•Voximal stripping is a met nod by which the proximal

surfcces of tie teeth are sliced in order to reduce the
mesio-distol width of the teeth. It is also known by the
synonyms, rearoximation, slenderization, disking and
proximal slicing. Although this procedure is routinely
carried out on the lower ameriors it can olso be done on
the upper anteriors and buccal segments of the upper
ond lower arches.

Indications for proximal stripping

9J9
 240 Orthodontics - The Art and Science
material excess in either o- the arches, it is
possible to reouce the tooth material by proximal
stripping. 3. It can be underraken in the lower anterior
region as an o:d -o retention.
Contra • indications for proximal stripping
1. Proximal stripping is not carried out in young
patients as they possess large pulp chamber
which increases the risk of pulpol exposure.
2. Patients w.no are susceptible to caries or those
who nave a high caries index.
Advantages of proximal stripping
1. It is possible to avoid extraction in borderline
cases where space requirement is minimal.
2. A more favourable over b.'te and overjot relation
can be established by eliminating tooth material
;
excess in c ther of the arches.
3. More stable results can be established by
broadening the contact area thereby eliminating
small contact points which can slip arid cause
rotation of teeth.
Diagnostic aids for proximal stripping
Arch perimeter cnc'ysfs : Arch perimeter or Careys
analysis showing a tooth material excess of 0 - 2.5 mrn
over the arch length is o diagnostic criteria favoring
reproximation.
BoJton's analysis : Bolton's an o lysis revealing an
excess of tooth materia! in either of the arches is an
indication to reduce tooth material in that arch. Minimal
inter-arch tooth material discrepancies can also be
corrected by proximal strip ping, (fig 2)
Intro - oral periapical radiographs : It is
advisable to carefully analyze an accurately taken
intra-oral periapical radiogroph of the region.
This would give an idea of tne enamel thick and a
rough estimate of the amount of ena that can be
removed from the proximal surfo without exposure of
the pulp chomber.
Amount of proximal stripping
Not more than 50% of the enamel thickness shou'c! be
reduced by proximal stripping. Whenei reproximation
is undertaken in a segment of arch, it is advisable to
equally distribute them ove~ j all the teeth.
Disadvantages of proximal stripping
The procedure of proximol reduction has a number of
drawbacks which include :
a. The stripping procedure creates roughenec
proximal surface that attracts ploque.
b. Caries susceptibility is increased-as part o* thc
enamel Is removed, leaving behind c roughened
area.
c. Patients may experience sensitivity of teeth.
d. Improper procedure at the hands of inexperienced
operators can result in alteration of morphology of
the teeth, creating an unnatural appearance of the
teeth.
e. Loss of contact between adjacent teeth moy result
in food impaction.
Procedure of proximal stripping
Proximal stripping is carried out in one of the following
ways (fig 1) :
1. Use of metallic abrasive strips
2. Safe sided carborundum discs
3. Long thin topered fissure burs
Fluoride application
The increased caries susceptibility after slenderizalion
is managed by a comprehensive fluoride progromme
following the procedure.
 Fig I Proximal striap'ng usir g (A)
Lc-ig -Kin -cpered -Issure burs (BJ
Safe sided carborundum d'scs •Q
Metallic abrasive strips

Fig 2 (A) Pretreatmcnt pholograoh of a

patient having mandibular Bolton's
excess toolh mater'al. (B) P'oximal
stripping was oerormed to reduce the
mandibular anteriors end t'ea-cd with
fxed applicnce (C) Post- t'eafment
cno-ograph after a'ignmert of lower
anteriors
 ;'.'v ' '-'Att

Jljgg.:,
•;, v ' ' ^^

vx&fy-v'
m.

B %L

F<g 3 Arch expansion os o method of gaining spcce in patients presenting witn narrow constricted arches.

EXPANSION AS A METHOD OF GAINING gained by their

SPACE

Exponsion is one of ihe non-invasive methods of

gaining space (fig 3). It is usually undertaken in
patients having constricted maxillary arch or in patients
with unilateral or bilateral cross bite. Expansion can be
skeletal or dento-alveolar. Skeletal expansion involves
splitting of the mid- palatal suture while dento-alveolar
exponsion produces a dental expansion with no
skeletal change. Expansion is brought obout by
'V/iV
various appliances that incorporate jack screws or by
use of springs. A more detailed account of various
expansion procedures and devices is given in the
ensuing chapter.
confronting problem (crowding or proclination) without
unduly hampering function and esthetics (fig 4).In cdoition,
the location of premolars in the arch is such that the space

EXTRACTION AS A METHOD OF GAINING

SPACE

One of the frequently resorted methods to gaining

space for orthodontic purposes is by extraction of one
or more teeth. Extraction that is undertaken as a part of
orthodontic treatment is called therapeutic extraction.
Premolars are the most frequently extracted
teeth as part of orthodonlic treatment. Extraction of one
premolar from eoch quadrant of the jaw provides Fig 4 (A! Extraction of some teeth is required >o goin space in
pc- errs having arch length cefficiency and crowding. |B)
sufficient space to correct the
P'oclination is also an indicclion for extractor o" some 'eetn
extraction can be utilized for correction in both ■fie
anterior as well as the posterior segments of the arch.
It is not uncommon to extract molars or iower
incisors during orthodontic therapy, -iowever,
extraction of canines and upper incisors s usually
avoided.
The answerto the question of which teeth t>
extract for a patient should be based on a sound
diagnosis. More details on therapeutic extractions zre
given in chapter 23.
In order to overcome the drawbacks of extra-oral
appliances, various intra-oral appliances to distalize
molars were introduced. These appliances are fixed on
to the teeth and therefore produce a continuous effect.
The following are some of the intra-oral devices used.
Sagittal appliance : Molar distalization can be
brought about by removable appliances incorporating
jack screws. The appliance consists of a split acrylic
plate joined together by a jack screw.(fig 5) The acrylic
plate is sectioned in such a way that the tooth that is to

DISTAUZATION be distalized is isolated, while the rest of the arch is

used for the purpose of anchorage.
One of the technioues that has gained popularity n These appliances are retained using Adam's
recent times is distolization of molars. Distalization clasps on the molars and premolars. The jack screws
procedures are aimed ct moving the molars in a distal are positioned in such a way that their long axis is
direction so as to gain space. This approach is parallel to the occlusal plane as well as the buccal
becoming popular due to the ■bet that extraction can surface of the molars. This
be avoided. Distalization cf maxillory molar assumes
significant value in -ne treatment of mild to moderate
Class II molar -=!ation associated with a norma!
mandible. Thus ry distalizina the maxillary molars in
these cases, fraction o* teeth can be avoided. The
ideal ^ming for d istal ization is during the mixed
dentition reriod prior to the eruption of the second
cermanent molar.
Distalization can be brought about by ~e
following methods
1. Extra - oral methods
distalizoMon
2. Intra - oral methods

Extra - oral methods

Head gears deriving anchorage from the cervical c
cranial region can be used to distalize molars. The
head gear assembly consists of a face bow which is
made of an inner and an outer bow. The nner bow is
fixed to buccal tubes present on the —olars. The outer
bow is attached to the extra- oral head cap or neck
strap. The use of extra- oral forces for distalization has
the following disadvantages:
\. Patient coo peration is essentia I for ti mely wea r
of the appliance". 2. The appliances are usually not
worn continuously. Thus they ore intermittent in their
action resulting in prolonged treatment time.

Intra - oral methods

Fig 6 (A) ond ;3)Pre aid post distolizction (bilateral) occlusal photographs of a pat'ent ireoled using coil springs (Q (DJ Pre end uos! d'slol'/alicn (cniloteral)
occlusal photographs of o polen- healed using pendulum appliance

type of appliance can be used for distalization of only one tooth at a time to avoid undue strain on
th e a n chorag e. iTj^J^^^^^&V'i»
DistaJization using rnfra ■ ora/ magnets : Intra-oral repelling magnets con be used to
dislalize molars. These devices consist of repelling vT^ff* WP'Ty
magnets placed on the molar to be distalized ond
the tooth anterior to it. The anterior anchorage 'A |
can be reinforced using a Nance holding arch.

Use of open coif springs to a'isfafize /fV'lfc'S^^

motors: Mo lar distal izatio n ca n be b ro ught a bout p^"' _
using open coil nickel titanium spring compressed
bctween the rnolar and the anterior segment. The f ^IK ^^fs^v
anterior anchorage is reinforced by use of a Nance ^felsl ^^Sfli
button that rests against the anterior port of the S-iTVjBifc». •f

Pendulum appliance : It is an intraoral

Fig 7 Pencu-un appliance
^g 8 Open coil springs used (o dislolize mo ors. Shown nere's cn aoo iancc called Jones ig 'hot inccporxres a coen cc I soring ond a Nance buton for anterior
anchorage.

defalcation appliance that incorporates a modified r^f^^OlY^T^TT

Nance button for purpose of anchorage.In A J\- AA^A /\V
addition it consists of a stainless steel wire with a' f \ f ' \ \ \ ! \ ! \ i if;
rrelix, the distal end of which is inserted into o KWV"j
sleeve on the palatal aspect of the molars to be j \ J\
distalized (fig 7). Distalization is produced by I j ~~~~ -------- —|
opening the helix and forcefully engaging the ^ ---- J__________ ____________ —J
distal ends into the sleeves. ^ ____ ^

UPRIGHTING OF MOLARS Cf\ .O^H^CT Tij'

-remature loss of a second deciduous molar or extraction of a second

premolar can cause mesial tipping of the first permanent molor. A
mesially -oped molar occupies more space than an „oright molar (fig 9).
Thus by uprighting these -'oped molars, certain amount of space can be
-^covered. Molars can be uprighted using molar

Fig 9 A tilted too'h occjpies more arch space thai an upright one
 5. Graaer Tfvi : Orthodontics : Princio es and era; WB
Saunders,!988
6. Hcas : Palatal exparsion: Just the beginning
dantofaciol orthopedics. A~i J Or hoc 1970 ;2' 255
7. Hass : Raa c exrans on ot 'he rcxillary dcivcl and "he
r.ascl cavity by opening the rnia pc! «ulure. A-i^lc
Orthod 1961; 31 : 73-90
8. Hciss • lone term cost trea-ment Bvcljatian ct rcc*: calatol
excansion. Angle orthod I960; 5C ; 189- 217.
• v'-.,- .V,'-.--..
9 Hass : Trca'rront of rraxi la'y deficiency by Open "he midna atel
Hg i D A footed posterio' tooth occupies r.ore scoce •ha n a suxre. Angle Crthcd 1965; c5 : 20C- 217.
norrral cne 10. "O'Z : Guidance of cructors versus serial extraction. Am J
Orhoc 1970 ; 1-20
11. Johr v. sheridor : Air-Rote Srpphg Ucda-e. Am j Orhoc 1987
uorighting springs or some fonrt of space regainer. ; 781-783
12. Julie n Phiiope : A Method of fcrcrriel Rodtctior fcr
Correction of Adj t Arcli-.ongth Discrepcrcy. Am J Orthod
1991 ; 484-^89
13. Profitt WR: Contemcorary Orthodontics, S' Louis,
CVMosb/,1986.
14. Robert : Moysrs : Herd book of Crthodon-ics, Yeoi book
r-ed cnl publishers, inc. 1988.
15. Sazrran ..A : 3racrice o: Orthodort cs, JB Lpphcott company.
1966
mmm^mmmm

DERQTATION OF POSTERIOR TEETH

Rotated posterior teeth occupy more soace thon

normally p aced posterior teeth. Derotation of these
"eeth hence provides some amount of arch length (fig
10).Derotution is best achieved with fixed cpplianccs
incoroorating springs or elastics usinc a force couple.

PROCUNATION OF ANTERIOR TEETH

References

1. Ackins, N anda, aid Curie : Arc n perimeter cha. on

'cpic pelalai expansion . An J Ortnod 1 ;194-19?
2. Bemsre n : Edv/orc H Angle vests Ca v'n S. Ex'roction
vc'sus nonextractior
3. Dev/ol : Prcrocuis tes in ser o I extraction Am J 1969;
87-93
4. Dewel : Se'ial ex-rac'ion iri o-friedcn-ics: hdic
objectives arc -roctmen- procedures . Air» J O 1954;

Procl i nation of a retruded anterior tooth results in gain

of arch length. This is usually indicated in cases where
the teeth are retrod ined or in those cases where
protracting tne anteriors will not affect the soft tissue
profile of the patient.

906-926
 n appcrently complex yet relatively simple

procedure in orthodontics is palatcl expansion. Its

versatility s unique for respite the many con'roversies
surrounding it, desirable results are achieved when
used in the :oprooriate s'tuation by a skilled clinician.
Expansion of the palate was first achieved ~f
Emerson C. Angell in 1860. Palatal expansion •ran be
carried out in different ways which are broadly
classified as rc o i o' & slow.
the first time in 1 860, used a jack screw *ype of device
between the maxillary premolars in a 1A year old girl
and achieved an increase in orch width by "/4 inch in 1 A
days (fig 1). Wolter Coffin in 1877 introduced a soring
called Coffin spring rorthe purpose of expanding fhe
orch. These efforts however were not accepted by the
orthodontic community at that time.

RAPID MAXILLARY EXPANSION (R.M.E.)

'coid mcxillan/ exponsion is also known by the ^s rap'd

palatal expansion or split palate. It is skeletal *ype of
expansion that involves the arotion of the mid - pcilotal
suture ond movement of the maxilla0/ shelves away
from each

Emerson C. Angell is considered the -ner of

rap'd maxillan,! expansion. Angell, for
 It was the oral surgeons and E.N.T. narrow maxilla. Relative maxillary deficiency is
surgeons who pooularized this technique during characterized by norma maxilla but oversized
the early part of this century. E.N.T. surgeons mandible.
Orthodontics - The Art and Science
used this technique in treatment of nasal
insufficiency and constricted naso-maxillary complex
with great success.
Korhkaus and Andrew Hass during the 1950's
reintroduced raaid maxillary expansion to the
orthodontic community. They popularized the concept
with excellent reseorch publications on animals and
humans using a variety of techniques ond methods.

APPLIED ANATOMY

The maxilla together with the palatine bone forms the

hard palate, floor and greater part of the lateral walls of
the nasal cavity. The maxilla is c paired bone that
articulates with its opposite member and various other
bones including frontal, ethmoid, nasal, lacrimal, vomer,
zygomatic and the palatine bones. Most of the sutural
attachments of the maxilla to the adjoining bones are ot
its posterior and superior aspects leaving the anterior
and inferior aspects tree, which makes it vulnerable for
lateral displacement.
Fig 2 (AJPostcrior cross bite. (B| Occlusal view of narrow arcn
The inter-maxillary and the inter-palatine
sutures arc collectively called the mid-palatal suture.
Rapid maxillary expansion should be initiated prior to
the ossification of the mid - palatal suture. Various
studies nove been done to ascertain the age at which
the mid - palatal suture ossifies. Melsen reports that the
transverse growth of the mid - palatal suture continued
upto 16 years in girls and 18 years in boys. Most studies
report a broad range of ossification timetable i.e.
between 15-27 years. The clinician should hence
ascertain that the suture is not ossified by using
appropriate diagnostic aids to be described later in this
chapter.
The sphenoid and the zygomatic bor,s |
nave c buttressing effect resisting mid - palctai suture
opening.

INDICATIONS FOR R.M.E.

Rapid maxillary expansion hes been carried c-_r for

dental as well as medical purposes. The following are
some of the indications for rape maxillary expansion:
(1) Posterior crossbite (fig 2) associated with rez or
relative maxillary deficiencies. A rec maxillary
deficiency is associcted with cr undersized /
 A B
Fig 3 (AjTriangjIar spli' of the nc*il c in fcnsverse view (BlTriangiJar split of the moxi la in fronlal view

(2) Class III malocclusion of dental or skeletal cause.
Improvement is seen in both anterior as well as
posterior crossbites.
(3) Cleft palate pationts with collapsed maxillary arch.
(4) In cases requiring face mask therapy, R.M.E. is
used along with face mask to loosen the maxillary
sutural attachments so as to facilitate protraction.
(5) The medicol indications for ropid maxillary
expansion include nasal stenosis, poor nasal
airway, septal deformities, recurrent ear ond nasal
infection, allergic rhinitis, D.N.S., e.t.c.,.
DIAGNOSTIC A/DS
The routine diagnostic aids such as case history,
clinical examination and study models are useful in
diagnosis. The mid - palatol suture can be visualized in
a maxillary occlusal view radiograph.
reciprocal force so as to open the mid - palatal suture.
Since the force employed for the procedure is very high,
not much of orthodontic changes can be obsen/ed. The
appliance on activation comoresses the periodontal
ligament and bends the alveolar process bucally and
slowly opens the mid • palatal suture. The opening of
the mid - palatal suture is fan-shaped or triangular with
maximum opening at the incisor region and gradually
diminishing towards the posterior part of polatc (fig 3 a).
This can be appreciated in a post R.M.E. occlusal
radiograoh. Similar fan - shaped or non-parallel opening
is also seen in the superio-inferior direction. The
maximum opening is towards the oral cavity with
progressively less opening towards the nasal aspect
(fig 3 b).
According to Krebs, the two halves of the
These maxilla rotate in the sagittal and coronal

radiographs are also useful during treatment to check

for mid - palatal split ond also to estimate the amount of
maxillary expansion achieved. RA. cephalogram is
another valuable diagnostic aid in rapid maxillary
expansion procedures to estimate the omount of
exponsion that has taken place.
THE EFFECTS OF R.M.E.

Though R.M.E. is essentially a dento-facial orthopaedic

apoliance used by orthodontists, it finds application in
other fields such as oral surgery, E.N.T. ond plastic
surgery.

Moxilhry skeletal effect : The maxillary posterior

teeth are used as handles to apply a transverse
 planes. Inrne coronal plane the two nalves of the
maxilla 'otate away from each other. The point at wn'ch
the rotation takes place is abound the fronto- maxii an^
suture. In the scgittal plcne, the maxilla is found to
rotate in a downward and forward direction.

Amount of expa.os/on achieved : An increase in

mcxilary width OF J oto 10mm can be achieved by rapic
maxilla^ expansion. Tne rare of expans'on is ooout 0.2
to 0.5mm per day.

Effect on o/veo'or borre : The areolar bone in the area

adjacent to the anchor teeth bends slightly. This is due
to the resident nature of the alveolor bone.

Effect on morxiffaiy onferror fee?.1) ; The apoearanee

of a midline spacing between tne two maxillary central
incisors is the most reliable clinical evidence of tne B
maxillary separation. The incisor seoaration is about Fig 4 (A) Normal axiol inclination of the onchor molars (BJ
half of the distance the screw is opened. By tnree to five Buccol y tipped anchor molars

months, the midline diastema closes as a result of the

trans- septa I fibre traction.
Effect on maxillary posterior teeth : The
maxillary posterior teeth arc used as anchors during
rapid maxiilary expansion. Tnese teeth show buccal
tipping (fig 4) and are also believed to extrude to a
limited extent.
Effect on mandible : Most authors have observed a
downward and backward rotation of the mandible
following rapid expansion. This is accompanied by a
slight increase in the mandibular plane angle. The
reason attributed for the mandibular rotation is the
extrusion and buccal tipping of the maxillary molars.
Effect on adjacent crania.1 bones and sutures :
Rapid maxillary expansion not only results in opening of
the mid - palatal suture but also has for reacning effects
on adjacent cranial
structures. In addition to the effects on those bones
directly articulating with the maxilla, bones of the
cranium such o s parietal and occipital were also
found to be displaced.
Effects of R.A/I.E. on n as a/ cavity : Following rapid
maxillary expansion an increase in intranasal spoce
occurs due to the outer walls of nasal cavity moving
apart. This increase in nasal cavity width is maximum
in the inferior region of the nasal cavity and gradually
decreases towards the superior aspect. Similar
gradient is also found in an anterio-posterior direction
with the greotest increase being in the anterior region.
Air flow resistance is believed to reduce by
45 - 60 %, thereby improving nasal breathing.

\
TYPES OF APPLIANCE USED

Numerous appliances have been used for rapid

maxillary exponsion. Broadly they can be classified as :
1. Removable appliances
2. Fixed Appliances
a. Tooth borne
b. Tooth and tissue borne

Fig 5 Rerrovab e appliance incorcoroting jock screw for arch

REMOVABLE APPLIANCES
expansion

The reliability of these appliances in producing skeletal

Derfcfcswe//er type
expansion is highly questionable. Although it is possible
to split the sutures using removable plates, it The first premolars and Ihe first molars are banded.

nevertheless is unpredictable. Treatment during the Wire tags are soldered onto the palatal aspect of the

deciduous or early mixed dentition is considered more bands. These wire tags get inserted into a split palatal

favorable in producing appreciable skeletal effects. acrylic plate incorporating a screw at its center (fig 6.a).

A removable type of rapid maxillary

Hass type
expansion device consists of a split acrylic plate with a
The first premolor and molar of eithe' side are banded.
midline screw. The appliance is retained using clasps
A thick stainless steel wire of 1.2 mm diameter is
on the posterior teeth. The disadvantages of a
soldered or the buccal and lingual aspects connecting
removable rapid expansion applionce is the need for
the premolar and molar bands. Tne lingual wire is kept
patient co-operation and the difficulty in retaining the
longer so as lo extend past the bands both anteriorly
plate inside the mouth.
and posteriorly. These extensions are bent palatally to
FIXED APPLIANCES gel embedded in the palatal acrylic. The split palatal
acrylic has a midline screw. The plpte does not extend
Appliances that are fixed onto the teeth are more
over the rugae area (fig 6.b).
reliable and found to produce consistent skeletal
effects. These fixed rapid expanders con be classified Isaacson type
into tooth and tissue borne appliances and tooth borne This is a tooth borne anpliance without any acryl'c
appliances. Two of the commonly used tooth and tissue
palatal covering. This design makes use of a
borne oppliances ore :
1. Derichsweiler type
2. Hasstype
Examples of tooth borne appliances
include :
1. Isaacson type
2. H y rax type
 adapted to follow the palotal contour and are

Fig 6 (A) Derichsweiler type of expansion appliance (BJ Moss type a: exnansion appliance (C) Isonr.son type of exponsion apoliance
using Minne expander (D) Hyrax ^ype cf oxpans on appliance
spring loaded screw called a MINNE expander soldered to bands on premolars and molars {fig 6.d).
(developed at the University of Minnesota, Dental
Bonded R.M.E
5chool).
The first premolars and molars are banded. Most of the rapid maxillary expansion appliances

Metal flanges are soldered onto the bands on the described earlier are banded appliances. They

buccal and lingual sides. The expander consists of a incorporate bands on the first premolars and

coil spring having a nut which can compress the spring.

This coil spring is made to extend between the lingual
metal flanges that have been soldered. The expander is
activated by closing the nut so that the spring gets
compressed (fig 6.c).
Hyrax type
This type of appliance makes use of a special type of
screw called HYRAX (Hygienic Rapid Expander). The
screws have heavy gauge wire extensions that are
Fig 7 ;A; Removable appliance Tncorporalmg a jack screw for slow exponsion (B) Hyrax appliance used for rapid expois'or
(C!& (D) Prelrea'ment end posl-t'eatr-en- photograph of a pctient Irsa-ed with hycx -cpid axaa-idcr (EJ & (FJ
Ptelrea'rren! Or d post-treatnen" occlusal radiographs of th« same potient
 254 Orthodontics - The Art and Science

molars. An alternative design of the appliance would be

to have a splint covering variable number of teeth on
either side to which the jack screw is attached. Splints
can be of two types :
1. Cast Cap Splints
2. Acrylic Splints
The cast cop splints are made of silver-
copper alloy. The acrylic splints are mode of
polymethyl-methocrylate. A wire framework may be
adapted around the teeth to reinforce the acrylic. These
splints are bonded to teeth using oither glass ionomer
or other bonding adhesives, after adequate etching.

DESCRIPTION OF A TYPICAL
EXPANSION SCREW B
Fig 8 (A) Typical expansion sere?/ JB) <ey jsad tor activation of
A typical expansion screw consists of an oblong body the appliance

divided into two halves. Each half has a threaded inner Schedule by Zlmrlng and Isaacson
side that receives one end of a double ended screw.
In young growing patients, they recommend two turns
The screw has a central bossing with four holes. These
if each day for 4 - 5 days and later one turn per day till the
holes receive a key which is used to turn the screw (fig
desired expansion is achieved. In case of non growing
8). The turning of the screw by 90 degree (i.e. one turn)
adult patients, they recommend two turns each day for
brings about a linear movement of 0.18 mm. The
first two days, one turn per day for the next 5- 7 cays
pattern of threading on either side is of opposite
ond one tum even/ alternate doy till desired expansion
direction. Thus turning the screw withdraws it from both
is achieved.
sides simultaneously.
TREATMENT EVALUATION
ACTIVATION SCHEDULE
DURING R.M.E.
Various authors have advocated different activation
Clinically, the most noticeable feature during rapid
schedules to achieve the desired results.
maxillary expansion is the appeoranee of o midline

Schedule by Tlmms diostema. Studies by various authors show that the

amount of incisor separation is roughly half the amount
For patients of upto 15 years of age, 90° rotation in the
of jack screw separation. But the amount of diastema
morning and evening. In patients over 15 years, Timms
should not be taken as o reliable factor iri estimating
recommends 45" activation 4 times a day.
the amount of expansion. Maxillary occlusal radiograph
and
 cephalogram are more reliable in estimating -he
amount of maxillary expansion.
CONTRAINDICATIONS OF R.M.E.
Some cases where R.M.E. is contraindicated are :
1. Single toolh crossbites.
2. In patients who are u n-cooperative, R.M.E. is
contraindicated os the appliance requires frequent
activation and maintenance of good oral hygiene.
3. Rapid maxillary expansion is not carried out after
ossification of the mid - palatal suture unless it is
accompanied by adjunctive surgical procedures.
Skeletal asymmetry of maxilla and mandible and
adult cases with severe antero-posterior skeletal
discrepancies, f. Vertical growers with steep
mandibular plane
ongle are usually a contra-indication. 6. As the posterior
teeth are used as anchors to move the bones apart, the
procedure is not indicated in a periodontal^ weak
dentition.
a. Palatal osteotomy
b. Lateral maxi 11 cry osteotomy
c. Anterior m axil I cry osteotomy
CLINICAL TIPS FOR R.M.E.
1. Oral hygiene instructions should be given to the
patient and reinforced during the procedure.
2. Orthodontic movement of the anchor teeth should
be avoided prior to rapid maxillary expansion, as
mobile teeth do not offer odequate anchorage for
palatal split. Recently moved teeth tend to tip.
3. The potient should be trained to use the key. The
key should be tied to a string and the free end
should be secured around the oatient's wrist to
avoid accidental swallowing.
4. Moxillary occlusal radiographs should be

RETENTION FOLLOWING R.M.E.

Failure to retain the expansion results in relapse. Most

authors recommend a retention period of -ot less than 3
- 6 months. Isaacson recommends -e use of the R.M.E.
appliance itself for the purpose of retention. The screw
Fig 9 Jack screw immobilized with cold cure acrylic
should be immobilized using cold cure acrylic (fig 9}.
-Jternatively, either a removable or fixed retainer e.g.
TPA) can be used.

SURGERY AS AN ADJUNCT

-atients who exhibit unusual resistance to separation of

the palatine bones may require sjrgical intervention.
This usually occurs in female patients over 16 years of
age and male patients over 18 years of age in whom
the m id-pa lata I suture has ossified. Surgical
separation may also be required in patients exhibiting
increosed circum-maxillary rigidity as a result of aging.
Maxillary expansion can be brought about
by surgery alone or by Surgery along with a rapid
exponsion appliance. The surgical procedures usually
carried out ore :
OSS
 Feature
taken at regular intervals to monitor the expansion.
expansion, producing greater stability and relapse
5. The possible immediate effects of premature
potenTiol Than :n rapid exponsw procedures.
cppl'ance removal include dizziness, pressure at
the bridge of nose, pressure under eyes, APPLIANCES USED FOR SLOW EXPv SION
branching a? soft tissues under the eyes, etc.,.
These symptoms may occur on removal of the
Jack screws
apaliar.ee for repair or recementcnon. The
patients should therefore be kept seated ond The various jack screws incoraorated in appliances

asked not to stand immediateiy after appliance described for rapid expansion can 2 used for slow
rernovol. expansion (fig 10), bu" with a mc spread out
activation schedule. The screws us for slow
SLOW EXPANSION expansion have a smaller pitch than th used in
R.M.E.
According to the proponents of slow expansion, the
results a-e more stoble when the maxillary arch is Coffin spring
expanded slowly at a rate of 0.5-1 mm per week. The
Tnis copliance was designed by Walter Corf - around
forces generated by such procedures is much lower :.e.
the beginning of this century (fig 11 ). fc is a removable
2-4 pounds as against 10-20 pounds generated during
appliance capable of slow dentc- alveolar expansion.
rapid maxillary exponsion. Unlike in rapid maxillary
The appliance consists of an omega shaped wire of
expansion where the treatment is completed in 1 -2
1.25 mm thickness, placed in tne mid-palatal region.
weeks, slow expansion may take as much as 2-5
The free enc:- of the omega wire ore embedded in ocry
mon-ns.
ic covering the slopes of the palate. The spring is
Slow expansion has traditionally been termed
cctivated by pulling the two sides apart manually It con
denfo-alveolcr expansion, although some skeletal
also be activated by using three prong pliers. Coffin
chcnges can be observed. Tne slower expansion
spring is believed to bring about a
techniques have also been associated with a more
w and rapid expansion
physiologic adjustment to the maxillcry
Rapid expansion

Skolc-t

a
Slow expansion
Rapid

Wore irau malic

Type of expansion Rats of Moaily dental Slow
Greater forces
expansion . Type of :.issje Mora physiologic W ider force
More frequent
reaction Force used Less Frequent long
Short
Frequency of activation Eiiher iixed c 'enwable Any
Mostly iixec appiance Before tuson of
Duration of treatment sge
micpaalal s,1ure More c'ancG of
Type ot appliance Age lesser chance of relapse
relapse
Retention
Bg 10 (A| Removable moxillory slow cxcansion appliance. (B) Mandibular slow expansion appliance incorporating retferior bite plare.
cento-alveola r expansion. However use of this
appliance in younger patients is believed to bring
cbout some amount of skeletal expansion.
Quad helix
One of the appliances used to expand a narrow -yjxilla
is the quad helix (fig 12). It is said lo ~ave evolved from
the original Coffin loop. The quad helix incorporates
four helices that increase —e wire length. Therefore
the flexibility and range cf action of this appliance is
more. The oppliance s constructed using 0.038 inch
wire and is
soldered to bands on the first molars.
The quad helix consists of a pair of anterior
helices and a pair
posterior helices.
portion of wire between the
Fig 11 Co:fin spring
two anterior heliccs is called
the anterior bridge. The wire
between Ihe anterior and posterior helices is called the
palatal bridge. The free wire ends adjacent to the
posterior helices are called outer orms. They rest
against the lingual surface of the buccal teeth and are
soldered on to the lingual aspect of Ihe molar bands.
The quad helix can be used to expand a
narrow arch as well as to bring about rotation of molars.
It can be pre-aclivaled by stretching the two molar
bands apart prior to cementation or by using three
prong pliers after cementation (fig 13).
The quad helix brings about a slow
dento-alveolar expansion. But when it is used in
children during the deciduous and early mixed dentition
periods, o skeletol mid-palatal splitting can be
achieved.
Arch expansion using fixed appliances
Arch expansion can be achieved in a patient who is
undergoing fixed mechanotherapy. Mild expansion can
be brought about by using expanded arch wires. In
addition appliances such
of
The
 .194-199
2. Bjcrklir <, Ku<ol J . Ectaoic eruption of maxillc
References nerrnanent motors: rtiolcgic
"ac-o's. Am J 1983; 84 :
147-165
3. Carut J. 3uga C : Morphological analysis o'" wi'h
ectosic eruption of maxillary first perm mob's. Ejro J
Orthod 1983; S: 249-253.
4. Dr. James P Moss : Scpid Expansion of tne Arch. J
Clin Orhod 1968 ; 215-223
5. Feurnier A, Turcctt J. Bernard C : Orthod
considera'icns in the treatment o; max I cry inr
can.res. Am J O-tnod 1982, 51 : 236-239.
6. Fro n k and Engel : Effects of maxillar,- CLod- opp
iance expansion on cepholorne'ric meo mcnts. Am J
Orthod 1982; 378-389
7. Glcssmor, N'ahigian, Mecv/ey, find Aronow;*-
Conservctive surgical orhodontic adjlt rapid p- exparsion.
Am .1 Orthod- 1984; 207-2" 3
Fig 12 Qviac helix
S. Graber l\V : Congenita abscence o; reetn : R with
emphases on inheritance patterns. J Am Assoc i
978. 94:246-275
9. Hoos : JCO Interviews: Dr. Andrew J . J Clin Or 1973;
as the quad helix or the transpolatal ctrch con be used 227-245
"0. H e as : Paloto expansion: Just the beginning centofocial
along with fixed mechanotherapy.
crthccecics. Am J Orthod 19/0 ;21 255
1". Hass: Rapid exponsion of the m cxi lla ry dentn I arcs one
'he ncsal covity by opering the mid pcla'r suture. .Angle
Orthod 1961; 31 : 73-90
12. Hass : Long term post treatment evaluation o: rap>d
uala'al excansion. Angle orthod 1980; 50 : 189- 217.
13. iciss : Treotmen- of maxillary deficiency by coenrng he
miopolatl sutjre. Angle Orthod 1965; 66 : 20d 2" 7.
14. Jacobs : Control of rho -ransver.se dimension wit n
surgen,- ond orthodontics. Arn J Orthod 1980 ; 284-
306 s
15. Longford : Soot resorption extremes resulting from
clmical RME. Am J Orhod 1982 ; 371-377

B
Fig 13 (Aj Quad hel'x activotion for mol c r expansion using
three orcng pliers (B) Quad helix activation for oremolar ond
con'ne expansion using tnrec prong pliers
1. Adkins, Ncnda, and Currier: Arch perimeter on rap'd
pr.latal expansion . Am J Ortnod
 he philosophy of extraction in conjunction with of the orthodontic patients hod extractions of some
orlhodontic treatment is not new. Establishment of teeth, usually but not always first premolars.

Extractions

normal functional usion in balance with supporting

structures ional'.y requires the reduction of one or
more

Most extractions are pe-^ormed as part 3 general

plan of treatment which also involves use of an
appliance. The noture of -elusion and the age of the
patient may be rtant factors in deciding whether or not
to ft to extraction. Extractions in orthodontia ude serial
extraction carried out as an -eptive procedure during
the mixed dentition and therapeutic extractions
carried out as tment procedure for gaining space.
To extract or not to extract has always and will always
remain a controversy in Pontics. The great extraction
controversy of 's was based on two schools of thought
king the philosophy of two pioneers in
orthodontics namely, Edward Angle and his student
Calvin Case. "Hie former advocating non- extraction
while the latter recommened extraction.
Edward .Angle believed that an individual wo
s capoble of having 32 teeth in normal occlusion and
orthodontic treatment for every patient involved
expansion of arches.
Calvin Case argued that although arches
could always be expanded so that teeth could be
placed in alignment, neither esthetics nor stability
would be satisfactory in the long term for many
patients. He thus advocated extraction of teeth.
By the late 194Q's extraction was
reintroduced into orthodontics by Charles Tweed who
observed that the post-treatment occlusion wasfJ53
more stable in patients treated with extraction of
four first premolars. By the early 1960's more thon half
THE NEED FOR EXTRACTION also to discourage the forward development of the
upper arch.
There ore a number of circumstances that necessitate
In Angle's Class II cases, where there is
extraction of teeth as a part of routine orthodontic
lower arch crowding orthe molars aro not in full Class II
treatment. They are listed as follows :
occlusion, it may be necessary to extract in both the
Arch length - toot/) material discrepancy upper as well as the lower arches to achieve proper
Ideally the arch length and tooth material should be in inter-arch relation ond to correct the crowding.
harmony with each other. The size of the dentition and
orch length are usually genetically determined. The
presence of tooth material in excess of the arch length
can result in crowding of teeth or proclination of
anteriors (fig 1).
In many cases the tooth material- arch length

Fig I 'oo-h material in EXCESS of arch length CCUSBS crowding of lectn. (A) Severe crowding due to tooth materiel crch lengfci discrepancy
(B) ronning o: lower anteriors n an indication of crch leng-h deficicncy
disproportion cannot be treated by increasing the orch
length. Hence reduction of tooth material is the only
alternative. Extraction of one or more teeth is resorted
to in case of severe tooth material - arch length
discrepancy.

Correction of sagittal Inter-arch

relationship

Abnormal sagittal malrelationships such as Class II or

Class III malocclusion may require extraction of teeth to
achieve normal sagittal inter-arch relation. The
extraction of teeth in such cases in ec'oblishing normal
incisor and molar
relationship.
It is a known fact that extraction of teeri
impairs the forward development of the dentc! arches
and the alveolar process. Thus extraction of certain
teeth in Angle's Class II and Class II malocclusions
improves the sagittal relationship not only by tooth
movement but also by selective forward growth
impairment.

Angle's Class / : These patients are characterized by a

normal sagittal inter-arch relarion. Thus it is not
advisable to discourage the development of one dental
arch more than the other. Hence in Angle's Class I
cases, it is preferable to extract in both the arches.

Artg/e's Closs // : In most Class II cases, the upper

dental arch is forwordly ploced or the lower arch ploced
back. Thus by extracting only in the upper arch it is
possible to reduce the abnormal upper proclination and
Fig 2 (A) In Ang'c's C loss I. patten it is advisab'o to extract n bo-h -he arches so "hef 'he growth oa-e'n o; the jows is maintained (B) In Angle's Class II, upocr
arch extractions help in discouraging the forward growth of moxillo (Cj In Anglo's Clcss III, lower orch ex^actions help :n discouraging the -orword growh
of mandible
C
Severe skoletal malrelationship of the jaws may not be
satisfactorily treated using orthodontic appliances
Angle's Class III : It is beneficial to avoid extraction
alone. Surgical resective procedures along with
in the upper arch as it may affect the :cfward
development of the maxilla. Angle's Cass III cases are extraction maybe required in such cases.

preferably treated by extraction only in the lower arch

THE CHOICE OF TEETH FOR EXTRACTION
or by extraction in both crches.
The decision to extract teeth during orthodontic
Abnormal size and form of teeth
therapy should be based on a sound diagnostic
"eefh that are abnormal in size or form may exercise. Premolars are the most commonly extracted
-«ecessitate their extraction in order to achieve teeth as part of orthodontic treatment.
s^sfactory occlusion. Such anomalies include
-acrodontia, severely hypoplastic teeth, r cceration
and abnormal crown morphology.
Skeletal Jaw malreletlons
 The maxillary incisors are rcrely extracted as a port of Extraction of lower incisors should as far as possible
orthodontic therapy. However, there are certain be avoided. The extraction of a lower incisor to relieve
conditions when one or more of the upper incisors may lower anterior crowding is often followed by the
262 f Orthodontics - The Art and Science
have to be socrificed.The following are some of them : narrowing of lower

Fig 3 (A) Mucrodonlic incisor i.ndioaled for exlroctioil(B) rod ogroph cf Ine same patient |Q and ID) Scpplemental la-era incisor incicaled
for extraction
inter-canine width, retroclination of lower incisors,
EXTRACTION OF UPPER INCISORS deep bite and re-appearance of crowding. This leads
a. An unfavorably impacted upper incisor thor
to a collapse of the lower arch.
cannot be brought to normal alignment.
b. A buccally / lingually blocked cut lateral incisor
with good contact between the central incisor and
canine can be extracted.
c. If one of the lateral incisors is congenilally
missing, the opposite lateral may have to be
extracted in order to maintain arch symmetry.
d. A grossly carious incisor tnat cannot be restored
may have to be sacrificed.
e. Malformations of incisor crowns that conno* be
restored by prosthesis, may necessitate their
extraction (fig 3.a).
f. Trauma or irreparable damage to incisors by
fracture may indicate their removal.
g. An incisor with d i lacerated root cannot be
efficiently moved by orthodontic therapy. It is
hence preferable to extract them.

EXTRACTION OF LOWER INCISORS

 b. A lower incisor that was

Fig 4 (A) & (B)lowe' lateral

incisor impacted. The position
of the lower incisor is deep and
is unfavourable for surgical
oxoosu-e fol owed by
ortnocontic treatment. (Q
Radiograph o: the same pa'ient.

traumotized, or exhibiting severe

The reduction in lower intcr-canine width
often leads to a secondary reduction in upper
nter-canine width resulting in upper anterior crowding.
The extraction of a lowe" anterior may -hus have for
reaching consequences 'hat are best avoided.
There are however some conditions when
d.
caries, gingival recession or bone loss
may have a poor prognosis.
c. Presence of severe arch length
deficiency is often characterized by the presence
of fan - shaped flaring out of the lower incisor
crowns. In these cases it may not be possible to
flatten the lower anterior segment by extracting
teeth further distally in the arch. Thus one of the
incisors may have to be extracted so as to
improve the crowding ond axial inclinationof rest
of the incisors.
In mild Class III cases with lower incisor

. Fig 5 Lower la-eral 'reiser *ot'ly clocked linguaIIy will contact

between the cen'rcl incisor crd corinc. Sucn cterals -nay bo
extracted

a lower incisor moy have to be extracted.

a. If one of the incisors is completely out of the cch
with good inter-dental contact between the rest of
the teeth (fig 5).
 midi Tie. Such a ccnine may be ndiccted ror cxvaction !B| rodiograpn of Ine sane patien*.

crowding, one of the lower incisors nay be

extracted to achieve normal overjet, overbite and
to relieve crowding.

EXTRACTION OF CANINES

Canines are not frequently extracted as a part o* orthodontic treatment.

The extraction of canines is said to cause flattening of face, altered
facia! balonce and change in focial expression. In addition the contact
produced between the premolar and lateral incisor is rarely
satisfactory.
Some of the conditions under which canrnes may
have to be extracted are :
a. The canines develop faraway from their final locotion. In addition
they nave a long path of eruption from their site of development
to their final position in the oral cavity. Thus the canines arc highly
susceptible to ectopic eruption end impaction (fig 6 and '/).
Such unfavorably impacted canines or canines that have
erupted in unusual locations may hove to be removed.
b. A canine that is completely out of the arch with reasonably good
contoct between the lateral incisor and first premolar is an
indication for its extraction.

Fig 7 (A| A orfovojrob'y impeded jppc o:t carine ccn be c. Premature shedding of o deciduous canine
extracted as it is ci^icj.t to sirgicaily expose arc allign with
orthodontic TectTieiv. (B) Radiograph of the aa'ient
 Extractions

Fig 8 (A) Ext'cction of f:rst cremolars gives g'eater posterior

anchorcco -hcreforc more space is ova lable for anterior refraction. (B) extraction of secorc prernclor resu'ts in less onchorage pos'e'icly
end the'e:ore -he posteriors move forwards . Thus esser space is ova lab!c :or an-cic rotrodion

usually indicates the extraction of its fellow on the anchorage for the retraction of the six anterior
opposite side of the arch to restore symmetry. teeth.
d. In Class II coses if the lower deciduous canines The following a'e some of the indications
are shed early, the upper deciduous canines for first premolar extraction :
should also be removed so as to avoid worsening a. They are the teeth of choice for extraction to
of the post-normalcy (Class relieve moderate to severe onterior crowding of
II tendency). the upper or lower arch (fig 9.a).
e. In Class III cases if the upper deciduous canines b. The first premolars ore extracted for correction of
are shed early, it moy necessitate the extraction of moderate to severe anterior proclination as in a
the lower deciduous canines to avoid worsening Class II, division 1 malocclusion or a Class I
of the pre-normalcy (Closs bidentel protrusion {fig 9. b &c).
III tendency)
EXTRACTION OF SECOND PREMOLARS
Deciduous canines moy be extracted as a part of
serial extraction procedure.
The indication for extraction of second premolars
ar
EXTRACTION OF FIRST PREMOLARS
e
The first premolars are the most commonly extracted a.
teeth as part of orthodontic treatment. The reason for The extraction of second premolars instead of the
their extraction is as follows : first premolars results in the anchorage of the
a. Their location in the arch is such that the space anterior segment being strengthened {fig 8). Thus
gained by their extraction can be utilized for an environment is creoted that favors mesial
correction both in the anterior as well as the movement of the posterior teeth. The second
posterior region. premolars are usually extracted to treat mild
b. The contact that results between the canine and anterior crowding. The remaining space can be
second premolar is satisfactory. closed by controlled mesiol movement of the
c. The extraction of the first premolar leaves behind a molars.
posterior segment that offers adequate

%(>S
b. The second premolars ore usually extracted when
4-5 mm of anchorage loss is deliberately desired.
c. Whenever the second premolars are unfavorably
impacted, it is preferred to extract them rather than the
first premolars (fig 10. a & b ) .
d. If extractions are to be undertaken in open bite
cases, it is preferable to extract the sccond premolors as
their extraction encourages deepening of the bite.
e. In case of grossly carious or deeply filled second
premolars, it is wise to extract them and preserve the first
premolors.
f. Early loss of a deciduous molar may cause forward
movement of the first permanent molar leaving
inadequate space for the second premolar to erupt. In
such coses, the second bicuspid erupts completely out
of the arch. Such a tooth may be indicated for extraction
{fig lO.c&d).

Fig 9 Indications for firs- premolar cxtraction(A) Severe crowd

EXTRACTION OF FIRST MOLARS
ng is usually -rented by ermoion o: first premo'of (8) ond fC!
8imax llory protrusion ere also treated by extraction of first
The first molars are not commonly extracted in premolars
conjunction with orthodontic therapy. Extraction of the
first permanent molars is avoided for the following
b. The extraction of the first molar results in
reasons:
deepening of the bite.
a. The extraction of the first molar does not give
adequotc space in the incisor region. c. The
mild second
anteriorpremolar
crowdingond molar
or mild may tip into the
proclination.
extraction spacc.
d. Mastication may be affected.
The indications for first rnolor extraction are
os follows:
a. Minimal space'requirement for corrcction of
^ 10 Indicat ors h' second prerrola' extraction fAJ ond s entirely (ft! ectopic second n'enolar fC) end (D) Seconc premolar "hat loss o:
blocked ling-jally. This cfen occurs due -o ecrfy -clar drihinq decidjo'js second mo cr resulting n the ;irst permanent moy erupt
rnesia ly. The second premolar in such coses lingua ly dee to inadeqjacy ot soace

r. Grossly dccaycd molar or heavily filled teeth. : Open c. The removal of the first molars deprives the

bile coses can benefit from extraction of first molar as orthodontist of adequate anchorage for any

there is a tendency for the bile to deepen ofter orthodontic appliance.

extraction of first molars.

Wilkinson extraction
EXTRACTION OF SECOND
Wilkinson advocated extraction of all the four first
PERMANENT MOLARS
permanent molars between the age of 81/2 - ?T/2
years. The basis for such extractions is the *cct that the The extraction of second permanent molars although not
first permanent molars are highly r.sceptible to caries. common, is advocated fora number of reasons, as
The other benefits of exacting the first molars ot an follows:
early age are : Their extraction provides additional
spoce for eruption of the third molars. Thus impaction
of third molars can be avoided, ir. In general, crowding
of the arch is minimized. Thus the other teeth have a
lower risk of caries.
Wilkinson's extraction has a number of
drawbccks. The following ore some of them :
a. The extraction o* first molars offers limited space
to relieve crowding.
b. The second bicuspids and second molars rotate
and may tip into the extraction space.
 A. To prevent third molar impaction : The
removal of second molars has been advocated for the
prevention of lowerthird molar impaction. The cases
268 f Orthodontics - The Art and Science
that benefit from such extractions are those where tne
third molars are upright or not tipped mesially more
than 30g. Upper second molar extraction if carried out
prior to the eruption of the third molars, results in
satisfactory third molar position.
the extraction space car also move distally into the space.
Thus the midlines of the arch may shift to the side of the
extraction space. To avoid such unestheticshife of the
dental arch, balancing extractions are advocated.
Balancing extraction refers to removes of another tooth
on the opposite side of the same arch.
COMPENSATING EXTRACTIONS

8. To relieve impaction of second premolar:
The premature loss of second deciduous molars is
usually followed by forward drift of the first permanent
molars leaving inadequate space for the second
bicuspids to erupt. The extraction of second molars in
such coses may allow the distal movement of the first
permanent molars thereby offering sufficient spoce for
the second premolars to erupt.
Compensating extraction refers to extraction o*' teeth in
opposite jaws. Compensating extractions are carried out
to preserve the buccal occluso; relationship. In a Class I
relation it is usually advisoble to extract in both the arches
to preserve the buccal occlusal relationship.
EXTRACTIONS OF PERMANENT TEETH
WITHOUT APPLIANCE THERAPY

C. Lower mdsor crowdr'ng : Very mild crowding in Most therapeutic extractions are followed by active
the anterior part of the arch can be relieved by appliance therapy. However there may be instances
extraction of the second molars. Some authors when extraction of a permanent tooth not be followed by
suggest that extraction of second molars minimizes orthodontic therapy for varied reasons such as
anterior imbrication and crowding.
non-availability of specialist,
D. To enable distalization of first molars : In
cases where the first permanent molars are to be
distalized, the extraction of second molars can benefit
the procedure.

E. Open bite cases : The extraction of the second

molars deepens the bite. Thus they can be considered
in open bite cases.

EXTRACTION OF THIRD MOLARS

Extraction of third molars during orthodontic treatment

does not yield spaco that can be used for decrowding
or reduction of proclination. Third molars are extracted
for otner reasons as follows: a. Grossly impacted third
molars that are unable to erupt into ideal position are
usually
extracted.
b. The erupting third molars have b implicated to
be the cause for late I r anterior crowding.
Although this theory not been confirmed it
nevertheless may some role in lower anterior
crowding.
c. Malformed third molars that interfere wtii normal
occlusion.

BALANCING EXTRACTIONS

Removal of a tooth from one side of a dei arch results

in a tendency for the rest of thete to move towards the
extraction space. The tee*" distal to the extraction
space move into the spcce while the teeth mesial to
Maxillary A. Unfavourably impacted incisors B. Totally
space leading toExtractions ^289
blocked bucalty or lingualty
C. In case one lateral is congenitalty missing, the non-coincidence of the
midlines and asymmetry. Another factor is the buccal
occlusal relationship. iVicsial migration tendencies

Teeth Indications may often upset the buccal occlusol relationship of the
dentition. In order to preserve the relationship,

other maybe extracted to maintain symmetry

extractions may have to be done in both the orches
Grossly carious unless undue migration or tooth movement is required
Malformed incisors that cannot be restored with
prosthesis
in a particular arch.
Dilacerated indsor
References
Mandibular A. Totally blocked bucally or lingually incisors B. Severly
1. Beck and Harris : External apical 'oot resorption. Am
traumatized, gingival recession or bono toss C. Severe arch length J Orthod 1994 ; 350-361
deficiency with fanning of leaver anteriors 2. Berrstein : Edward H. Angle versus Calvin S. Cose:
Extraction versus nonextraction. Am J Orthcd 1992 ;
Canines A. Ectopically erupted or unfavourably impacted
B. Totaly blocfced bucally or lingually 464-470
C. Dedduous canine extracted as part of serial 3. Bisharo aid Andreasen : Third molars. Am J Orthod
extraction 1983,131-137
4. Bisharo and Burke/ : Second molar extractions. An J
First premolar To relieve moderate to severe crowding and prodlnation Ortnod 19S6 ;415-424
5. Bisharo, Cummins, ond Jokobsen : Morphologic basis for
Second A. To relieve mild crowding and premolar proclination where
extraction decision. Am J Orthod 1995 ; 129-135
anchorage loss is desirable
B. Unfavourably impacted
C. In open bites, they are preferred over first
6. Ch'pmcn : Second and third molars: Their role in
1-ic iheropy. Am J Orthod 1961 ,- 498-520
premolars as deepening of bite is encouraged. orthedon
D. If grossly decayed or has a targe filling vrfth
questionable prognosis, then they are extracted
Instead of first premolars.
9.63
First molar A. Minimal spsce requirement to
correct mild crowding or proclination
B. Grossly decayed or heavity fitted
C. In open bites as their extraction encourages
deepening of bite.

Second molar A. To prevent third molar impaction

B. To relieve impaction of second bicuspid
C. To enable distalization of first molar

Third molars Not extracted for orthodontic

purposes. May be extracted for other reasons such
as carles, malformed or impacted tooth.

patient unsuitable for fixed appliance thercpy etc.

Teeth have a natural tendency to drift into
extraction space. The extent of this tipping varies
from patient to patient and depends on various
factors such as the extent of crowding and age of
the potient. The long term effect following extraction
of permanent teeth is the mesial migration of the
posterior teeth, the mesial drift is usually rapid in
young age when the teeth are still in a state of
active eruption and the jaws are still growing.
Extractions of the lower first premolar is
often associated with spontaneous decrowding of
Ihe lower anteriors. Such spontaneous decrowding
by drifting of teeth, referred to as driftodonticsare
less frequent in the upper arch.
While considering such extractions it is
always advisable to extract in a balonced manner
so as to preserve the integrity of the arch. Extraction
of a permanent tooth on one side of the arch would
result in shifting of the teeth towards the extraction
 Orthodontics - The Art and Science
7 Dewel : Prerequisites in sere I extraction. Am J Orthod
196987-93
8. Dewel : Serial extraction orthodontics: Indicators,
objectives and treatment prccecures . Am J Orthod
195^ 906 -926
9. Dibbols ard van der Weele : Exlradion. orthodontic
treatment, and CM3. Am J Crthcd 1991; 210-2" 9
10. IHcte ; Gjidcnce Ot eruptions verses serial exlruc- ton. Air
J Orthod 1970; '-20
11. Klapper, Ncva-ro, Bov/nior, ond Pawlowski : E "tecs ot
extrnd'or ard ronex'radion trea'ment on growtn pafcrns.
Arr- J Orhoc 1992 ; 425-430
12. Little, Wallon, and R edel : Mandibular cnterior
alignment first premolar extraction cases trected by «
Bdgewise onhocort cs Am v Crthcd 1981 ;349-365
13. Profir WR: Contemporary Grtnorfonl cs, St Louis, CV
Mosby, 1986.
' 4. Rofcer E Moyers : Hand book ot Ofthcdonrics. Year
book mediccl publishes, inc. 1988 "5. Slodov, Benrents, and Dobrowski : Clinical experience with
ttiiro rno ur orthodontics. Am J Orhod 1989; 453-46" 16. Staggers : First premolar extraction. Am J
Ortnod 1994; 19-24
17- Vig, Weintraub, Brown, and Kowa ski : Djrat'on ot
orthodontic veawen- with and without extractions. Am J
Ortnod 1990 ; 45-51 18 Weintrctb, V'g, Brown, and Kowa so :
Orthodontists' extraction 'ctes. Am J OnhoO 1989 ; 462-466
 rthodontic elastics, screws, etc.,. These appliances can be

O treatment aims at
improving the
esthetics and
further classified as removable and fixed appliances.
Myofunctional applionces are loose fitting or
passive appliances that harness the natural forces of
function of the the oro-faciol musculature which are transmitted to the
orofacial region. teeth and alveolar bone through the medium of the
Most of these appliance. These appliances either transmit, eliminate
or guide the natural

odontic Appliances perioral

forces on
muscle
to the

eral Concepts dentition

mechanical
. Unlike

jnges are appliances the myofunctional appli-

brought about
using devices
which /e teeth or
modify the
growth of the jaws. These /ices are called orthodontic
appliances.
Orthodontic appliances ore devices by ins of
which mild pressure may be applied to ; 'ooth or
group of teeth and their supporting tures so as to
bring about necessary changes lin the bone which
will allow tooth movement.

ZLASSIFICATION OF ORTHODONTIC
>PUANCES

5-oadly the appliances can be classified info two

~oups : Mechanicol appliances
a. Removable appliance
b. Fixed appliance
2. Myofunctional appliances
a. Removable appliance
b. Fixed applianc

Mechanical appliances exert mild pressure

on a tooth or a group of teeth and their supporting
structures in a pre-determined direction with the help
of active components which are part of the appliance
itself. The active components may include springs,
282 f Orthodontics - The Art and Science
ADVANTAGES OF REMOVABLE APPLIANCES
t J The■ removable nature ot -he
appLance makes it possible for the
patient to maintain good orai- hygiene,curing .ortftcctonlic therapy. In -
acdtior) the applianoo can be Kept o'ean by fte patient.
21 Most nalocdivs'ons requiring lipping type of tooto movement can
vv^v^5,feadily;cctrtied out usitg removable:'appliances.
3j Many tooth movements like lipping, over bile reduction can be undertaken.
4} Removable appliances are fabricated in the laboratory utilizirg less chair side time
of the orthodontist,
51 As these.appliances lake less chair side time, the orthodontist cari handle, mote
number at patents. •
6) Removable appliances, bring 3bout lipping loo'h movement. Thus . Jesse?
lorces are used than those needed for bodily tooto movement.
As forces employed are less, the strain on the anchor teeth is lesser lhan in
fixed appliance therapy.
7) Removable appliances can be used by general dental practitioners who have
received adequate training. This makes is possible tor tl>e specialists: to
concentrate on more atftcu-t cases.
8) The fabrication ol removable appliances need less inventory.
9) They are relatively less expensive than, fixed appliances.
10} As removable appliances take less chair side time and are by far less expensive
than fixed appliances, tteycan bo 'used in community, based programs where
in a large number bt patients are treated,
Removable appliances, are less conspicuous than roultibanded. fixed,
appliances.
Damaged appliances thai apply undesirable forces can be removed by the
patient
ancesdo not usually contain active components.
Functional appliances are used for growth modification
procedures that are aimed at intercepting and treating
jaw discrepancies.
Both mechanical and the myofunctional
appliances can be classified as removable and fixed
appliances. Removable appliances as the name
suggests are appliances which can be inserted into
and removed from the oral cavity b, the patient.
Removable appliances offer a number of advantages
DISADVANTAGES OF REMOVABLE APPLIANCES
1) As the appliance can. be removed, partem
cooperation is vitally, important for the
success of the ireatmeni:^^:
2) . Removable appliances are capable ot
oniy tipping tooth movements. This is a
major limitation of removable appliances.
3} Whenever multiple tooth movements are to be
earned outfit should be dene one at a time.
Thuslfto treatment durafon is prolonged in
case of severe malocclusion.
4): Multiple rotations are difficult'to treat using
removable appliances.
6) In cases requiring extraction, it &Veiy
difficult to close residual space by forward
movement of posterior leeih.
7) ' As the appliances are removable, there
is a greats chance of patient misplacing or
damaging them.
8) Patients should exhibit enough skill to
remove and replace the appliance without
distorting them.
?j They cannot be used to treat severe cases of
Class II and Class 111
O malccdusions.wlh unfavorable growth pattern,
including the ability to maintain oral hygeine and the
need for less chair side time. The main drawback of
these appliances is the need for patient cooperation
and the inability lo perform complex tooth movements.
Refer to table 1 for advantages and disadvantages of
re-
i;f|

^g 1 Orthodontic opplicnces (AJ How-ley's appliance with Z springs - n removable mechanical applionce (3) A removable inechonica!
opplicnce incorporating a screw for arch expansion (C) & |D; Fixec mechonical appliances (E) Hyrex expander ; fixed mechonical
appliance used for skclcta exparsion (F) Quad helix • a fixed mechcnica appliance for expansion

movable appliances. Removable appliances are
jsually used for simple tooth movements that can be
brought about by tipping.
Fixed appliances are those that are fitted
onto the tooth surfoce and can only be removed only
by the operator. These appliances ere versalite and
offer a number of advantages overthe removable
appliances. These appliances offer better control ond
also to a lorge extent remove the need for patient
compliance. Table 2 gives the advantages and
disadvantages of fixed appliances. Fixed appliances
can bring obout various types of tooth movement
including tipping, bodily movement, rotations, intrusion
ond extrusion.

W
 ADVANTAGES QF FIXED APPLIANCES DISADVANTAGES OF FIXED APPLIANCES

1} Patent cooperation is dispensed with to a large removable appliances, they nevertheless have a number of disadvantages

extent in the use ot lixed appliances. The which are lisled as follows :

orthodontist does nol depend on ihe patieni 1 ) The most important disadvantage of a fixed appliance is oral hygisne maintenance

for timely wear ard management of Ihe which becomes more difficult. Plaque and food debris tend 1O accumulate around

appliance. the attachments and cleaning of teeth becomes more difficult tor the patieni due to

2) It is possible to bring about various types of their enirapmenl around the various attachments.
tooth movements, such as tipping, bcdjfy 2 ) . Fixed appliances are more lime consuming to fix and adjust. Thus tney take

movement, rotation, intrusion and extrusion. up more chair skla time unlike removable apples which can be fabricated at the

3) Multiple tooth movements are possible laboratory.

simultaneously. As many tooth movements 3} Fixed appliances are more conspicuous man removable appliances. Unless modern

are undertaken at the same time, the tooth colored appliances are used, Ihey may not be pleasing esthetically.

trealment duration is considerably reduced. 4) Fixed orthodomic appliances require special training of the operator and ar8

4) More precise tooth movements and detailing invariably handled by specialized orthodontists.

ot occlusion is possible using fixed appliances. 5) Damaged appliances, that apply mis-directed forces cannot be removed by the

5) Fixed appliances can be used to treat mosi patient.

malocclusions including very complicated 6) The patient has to visit Ihe orthodontist at regular interval.

ones. 7) Fixed appliances are by lar more expensive than removable appliances.

6) Fixed appliances offer better control over 8) Unless the treatment is done by a skilled operator who has been irained to use fixed

anchorage. appliances, there is a greater possibility ot producing adverse

Although t«ed appliances have a number of . tooth movements.

advantages as compared to

Passive and active appliances

Orthodontic opplionces con also be classified as active and
passive appliances. Active appliances exert a force on Ihe
teeth or Ihe supporting structures to bring about the
necessary tooth movement. Passive applionces are mostly
used to retain teeth which have been moved to ideal
location. Active and passive appliances can also be
classified as removable and fixed appliances

IDEAL REQUIREMENTS OF AN ORTHODONTIC

APPLIANCE

Appliances which are used for orthodontic purposes should

fulfill certain requirements. These requirements can be
discussed under the following four headings:
Fig 2 Ortiodontic appliances (A) Bonded retairer • a fixed passive oppliance (B) Bandec relciner • a :ixec pessive appliance (C) Hav/leys
reta'nsr - a re-iovable passive oppl'cncs (Dj Herusl appliance - a fixed r-.ycfj-ic'ional appliance T) Activator • a removable myo'vrctknal
appliance (F) Jasp-cr jumper • a fixed myofunctional cppl'cnce.

1. Biologic requirements d. It should not interfere with normal function.

2. Mechonicol requirements e. The appliance should not bring about sudden
3. Esthetic requirements changes.
4. Hygienic requirements

B/o/og/c requirement
o. The appliance should bring about Ihe desired tooth
movements.
b. The orthodontic appliance should not produce
pathologic changes such as root resorption, periodontal
damage or non vitality of the teeth.
c. The appliance should not interfere with normal growth.
 f. It should not bring about unwanted tooth movement.
g. The material used in its fabrication should be
biocompatible-and
276 Orthodontics Theshould
Art not
andproduce toxic effects.
Scicnce
h. The appliance should not disintegrate in oral fluids.

Mechanical requirement
a. The appliance should be simple ro fabricate.
b. It should not be bulky. The patient should be
comfortable using them.
c. The applionce should be strong enough to withstand
masticator/forces.
d. The appliance should be able to deliver controlled
force. It should apply a force of desired intensity,
direction and duration.
e. The appliance should be universally applicable i.e. it
must be able to handle various malocclusions.

Hygienic requirement
The orthodontic appliance should ideally be self- cleansing.
If not it should be eosy 1o clean them. The appliance should
not interfere with oral hygiene maintenance.

Esthetic requirement
The orthodontic appliance should be esthetically
acceptable. It is desirable to have an appliance that is os
inconspicuous as possible.

References

1. Adams : Removoble appliances yesterday and today. Am v

Orthod 1969 ; 202-213
2. Adams CP: Tne design and corstrjclion of removable
Orthodontic appliances, 5th edition,Wright, Bristol. 1984.
3. Foster TD : A textbook of Orthodontics, Bluckv/eil Scientific.
Oxford, 1 982.
't. Goullschin and Zilberman : G rgivel response ro removaale
orthodontic appliarces. Am J Orthod
1982 ; \4 7-149
GrabBr Tfvl, Neumann B : Removable Orth Appl-'onces, WB
Saunders, Philadelphia, 1984.
Protitt WR: Contemporary Ortncdonrics, 5t CV Mosby,l 986.
Robert E Moyers : Hanc hook of Orlhodon'ics, book medical
publishers, inc,1988.
Sclzman JA : Proclice of Orthodontics, J3 Lippi company, 1966
Tang end Wei : Treatmeni effectiveness of orth tic appliances.
Am J Orlhod 1990 ; 550-556

I
R
emovable orthodontic applionces, as the term
suggests, are devices that con be in serted into
and removed from the oral cavity by the patient at
will. Removable appliances were used routinely in the 19th
century. However they were crude and were made of
precious metol wires which lacked the mechanical
advantage of ♦he modern wires. The development of the
modi- ;ied arrow head clasp by Adorns in 1950 brought
about a see chonge in the way the removoble appliances
were looked at. The modern day appliances are fabricated
using stainless steel and acrylic ond ore more efficient than
their predecessors.
Although removable appliances can be
effectively used to treat a number of minor mal-
Appliances
occlusions, they are often ignored and the more complex
fixed appliances used instead. However removable
appliances continue to be the appliance of choice in treating
certain conditions. Removable appliances can olso be used
in conjunction with fixed appliances and for retention ofter
treatment with fixed oppliances.
In America, the term removable appliances
generally means functional appliances that use the orofacial
musculature. In the European countries, removable
appliances are considered to be of two kinds. The first
catagory includes appliances which ore clasped to the teeth
and are referred to os fixed plates. The other cofagory
includes removable appliances, which lie loosely in the
mouth and produce their effect by modifying the pattern of
activity of the orofacial musculature and hence the
pressures produced on the teeth by these activities. In this
chapter we limit our discussion to the clasped mechanical
appliances that are used to bring about various tooth
movement. The appliances that make use of
muscle forces ore discussed separately os myofunctional
appliances.
Removable orthodontic appliances offer a
number of advantages including tne ability to maintain oral
nygiene and the need for less chair side time. The main
disadvantags of removable appliances is the need for
patient cooperation. Failure to adhere to prescribed
removable cppliance wear schedules will result in either
slow trectment response or no response ct all. Table 1
summarizes the advantages and the disadvantages of the
removable appliances.
ACT/OW OF REMOVABLE APPLIANCES
Appliances that are loosely fitting end do no: have
adequcte intraorc i anchorage cannot bring about the
necessar. -ooth movements. Adequate retention of a
removable appliance is ochieved by incorporating
certain wire components that engoge undercuts on the
reeth. These wire components that aid in retention of a
removable appliance cro called clasps.
Mode of action of clasps
Closps act by engaging certoin constricted areas of the
teeth that arc colled undercuts. When clasps are
fabricared, rhe wire is mode to engage these
undercuts so thot their displacement is prevented.

Removable appliances work by applying a single force on There are two types of undercuts that are found in

to the crown of the teeth. Thus removoble applionces act by natural dentition.

tipping -he tooth around its centre of resistance. Tipping a) Buccal and lingual cervical undercuts (fig l.a).

can be brought about in the mesio-distal or bucco-lingual b) Mesial and distal proximal undercuts (fig

direction. Tne key point ro be considered is 'he posi tion of l.b&c}.

rhe root apex before the begining of trectment. Tee"h thct Buccol / lingual cervical undercuts : The buccal
have their apex or the correct position are ideally suired for and lingual surfaces of molars have a distinct undercut
treatment with removable cppliances. In such patients the at the cervical margin. These can be seen from the
irregularis/ is usually due to rhe crown being tipped from its mesial aspect of a molar.
correct position and therefore respond well to tipping tooth
movements possible using a removable orthodontic
appliance.
Removable appliances are generally considered
ineffective in bringing about bodily translation, derotation
and uprighling of teeth due to the single point of contact of
these appliances. Intrusions and extrusions using
removable applionces are often mediated using the forces
of eruption and occlusion. In addition the acrylic base plate
of the oppliances also can be designed by incorporating
biteplanes that can aid in selective extrusion or intrusion of
the tooth. The bite planes include the anterior ond the
posterior bite planes.
COMPONENTS OF REMOVABLE
APPLIANCES

Removable appliances are made up of three bc- sic

components.
a. Rerentive components
b. Active components
c. Base plate

RETENTIVE COMPONENTS

They are components rhat help in koeping the opplicnce in

place and resist displacement of the appliance. The
success of a removable appliance is to c large extent
dependent upon gooc retention of rhe applicnce.
w
2) It should permit usage in both fully erupted as
Removable Appliances • jj^J

well as partially erupted teeth.

3) It should offer adequate retention even in the
presence of shallow undercuts.
4} They should not by themselves apply any active
force that would bring about undesirable tooth
movements of the anchorage teeth.
5) It should be easy to fabricate.
6) It should not impinge on the soft tissues.
7) It should not interfere with normal occlusion.

Circumferential clasp

Fig 1 (A) Cervical undercut (B) & [C) Mes ol and dis'ol oroximal
The circumferential clasp is also known by the terms
unde'cut three-quorter clasp or 'C clasp. They are simple clasps
thot are designed to engage the bucco-cervical
Examples of clasps that engage these buccal and
undercut (fig 2). Wire is engaged from one proximal
lingual cervical undercuts are the circumferencial
undercut along the cervicol margin then carried over
clasp and Jackson's clasp. These undercuts are
the occlusal embrasure to end os o single retentive
available for clasp fabrication only in those teeth that
arm on Ihe linguol aspect thot gets embedded in the
are fully erupted.
acrylic base plote.
Mesia) and distal proximal undercuts : The molars Advantage of this clasp is its simplicity of
are widest mesio-dislally at the contoct point and design and fabrication. Disadvantage of this
gradually taper towards the cervical margin. These
surfaces slopping from the mesial and distol contact
areas towards the neck of the teeth are called the
mesial and distal proximal undercuts. They can be
seen when the mo- 'or is viewed from the buccal
aspect. These proximal undercuts aro more
pronounced than the cervical undercuts and therefore
offer more retention. Examples of clasps that engage
these
undercuts are the Adams clasp and Crozat clasp.

Requirements of an Ideal clasp

1) II should offer adequate retention.
 The Adams clasp offers a
Fig - Adams clasp (A) Buccal view (BJ Occlusal view

number of ad vantages which are listed

clcsp is that it cannot be used in partially erupted teeth below:
wherein the cervical undercut is not available for clasp 1) It is rigid and offers excellent retention.
fabrication. 2) It can be fabricated on deciduous as
well a: permanent teeth.
Jackson's ctasp 3) T hey can be used on partially or fully
erupted teeth.
This clasp was introduced by Jackson in the year 1906. It is
4} It can be used on molars, premolars
also called full clasp or 'U' clasp. This clasp engages the
and incisors.
bucco-cervical undercut and also Ihe mesial as well as
5) No specialized instrument is needed to
distal proximal undercuts (fig 3). Wire is adapted along the
fabricate the clasp. Young's universal
bucco- cen/ical margin and both the proximal undercuts,
pliers that is used routinely for most wire
then corried over both the occlusal embro- sures to end as
bending can be used.
retentive arms on both sides of the molar. The advantage of
6} It is small and occupies minimum space. 7)
this clasp is that it is simple to construct and offers adequate
The clasp can be modified in a number of
retention. The disadvantage of Jackson's clasp is that it
ways.(fig 8)
The Adams clasp con be modified in
offers inadequate retention in partially erupted teeth. a number of ways. These modifications permit ad-
ditional uses or enhanced retention. The following are
Adams clasp
some of the modifications of Adams clasps:
The Adams clasp was first described by Professor Phillip
Adorns. It is also known as Liverpool clasp, universal clasp
and modified arrowhead clasp. When properly constructed
this clasp offers maximum retention. The closp is
constructed using 0.7mm hard round stainless steel wire.
The Adams clasp is made of the following parts :
a) Two arrowheads
b) Bridge
c) Two retentive arms The two
arrowheads engage the n
and the distal proximal undercuts (fig 4}. arrowheads are
connected to each other by bridge which is at 45° to the
long axis
Fig 5(A) Tho lergth of -he bridge is determined by mo iking 'he proximol crdercuts (B) & (Cj Two right onglc cerris
are mode to :0'm the bridge (D)&(E) "no f rst orrov/hocc is formed (FJ The arrowhead is scueezed slighty'o hove the
correct width of arrowhead [G) The second arrowhead is comple'ed (H) Thefi'starrowhead s bent fo a oryle of 45
degrees tothebricce
292 f Orthodontics - The Art and Science

Fig 6 Ma<ing of Adams clasp continued (A) The second arrownead is also hep.M5derjreesto the bridge to sent the
arrowheads over tne proximal undercuts. (6) I ho outer aim of the arrowhead is bent 90 dcgices at a level that is holf
Ihe height of the bridge. The wire snould pass over tne embrasure when the closp is placed in normal position |Q
,(D)&(E) The cross over wire is bent to pass over the occlusal embrasure (FJ The cross over wire tt stepped down
jus* beyond the proximo contact [G) A small step is made in ihe retentive arms to go over the pelalai marginal
gingiva (H) The retentive tags a.'e bent a: the end of the retentive arms.

^g 7 Completed Adams closp (A) Occlusal view - bridge -zvay
from the teelh and parallel to the buccal surface. |B) rrdge 45C 'o
long axis of toolh. (c)9uccal view - bridge dose to middle third
ond parallel to occlusol sur'ace
Adams wiffi srng/e arrowhead : The Adams dasp
can be modified to have a single arrowed. This type of
clasp is indicated in a partially erupted tooth which
usually is the last erupted •-olar. The single arrowhead
is made to engage -e mesio • proximal undercut of the
Removable Appliances
last erupted molar. The bridge is modified to encircle
the tooth distally and ends on the polafal ospect as a
retentive arm (fig 8. a).
Adams with J hook : A J hook can be soldered on to
the bridge of the Adams clasp. These hooks are useful
in engaging elastics (fig 8. b).
Adams with incorporated helix : A helix can be
incorporated into the bridge of the Adams clasp. This
also helps in engaging elastics (fig 8. c).
Adams with additional arrowhead : Adams
clasp can be constructed with an additional ar-
rowhead. The additional arrowhead engages the
proximal undercut of the adjacent tooth and is
soldered on to the bridge of the Adams. This type of
clasp offers additional retention (fig 8.d).
Adams wrfb soldered buccal tube : A buccal tube
can be soldered on to the bridge of the Adams clasp.
This modification permits use of extra-oral anchorage
using face bow - head gear assembly (fig 8.e).
Adams with distal extension : The Adams clasp can
be modified so that the distal arrowhead hos a small
extension incorporated distally. This distal extension
helps in engaging elastics P9 8.f|.
Adams on incisors and premolars : Adams clasp
can be fabricated on the incisors and premolars when
retention in those areas are required. They can be
constructed to span a single tooth or two teeth (fig
8.g).
Southend clasp
The Southend clasp is used when retention is required
in the anterior region. The wire is adapted along the
cervical margin of both the.central in-
284 Orthodontics - The Art and Science

G
Fig 8 Modifications of Adorns closp (A} Single orrowheod Adams clasp IB) Adams with J hook }C) Adams with helix (D.i Adorns with
additional arrowhead \C> Adorns with soldered buccal tube {F| Adams with distol extension (G) Adams on incisors.
 E

cisors. The distal ends are carried over the occlusal

additional retention is needed (fig 9 c). Ball
embrasures to end as retentive arms on •he palatal side (fig
9.e).
- end clasp

Triangular clasp This closp is fabricated using stainless steel wires

having a knob or a ball like structure on one end (fig 9
They are smoll triangular shaped clasps that are used
B). The ball can be made at the end of the wire using
between two adjacent posterior teeth. Thus ♦hey engage the
silver solder. Pre-formed wires having a ball at one end
proximal undercuts of two adjacent teeth. Triangular clasps
are also available.
are indicated when
The ball engages the proximal undercut
 between two odjacent posterior teeth as in a triangular
clasp. The distal end of the wire is carried over rhe
occlusal embrasure to end on the palatal aspect as a
286 f Orthodontics - The Art and Science
retentive arm. The ball-end clasp is indicated wnen
additional retention is required.
Schwarz clasp
The Schwarz closp or the arrownead clasp can be said to
be the predecessor of the Adam's clasp. The clasp is
designed in such a way that a number of arrowheads
engoge the inter-proximal undercuts between the molars
and between premolars and molars (fig 9 a). This clasp is
not ; used routinely due to a number of drawbacks :
1) Needs special arrowhead forming pliers to fobricate.
2) Occupies a large amount of space in the buccal
vestibule.
3) The arrowheads can injure the interdental soft
tissues.
4) It is difficult and time consuming to fabricate.
This type of labial bow is constructed using 0.7m."
hard round stainless steel wire. The short labio bow
consists of a bow that makes contact wi~ the most
prominent labial teeth and two U loops that end as
retentive arms distal to the canines (fig 10). This type
of labial bow is very stiff ore exhibits low flexibility.
Thus they are indicated on!, in cases of minor overjet
reduction and anlerio- space closure. The short labial
bow can also be used for purpose of retention at the
termination of fixed orthodontic therapy.
The short labial bow is activated by com-
pressing the U loops. The activation should be such
that the labial bow is displaced palotally by 1mm.

Crozat clasp Fig 10 Shorr Icbicl bow

This clasp resembles a full clasp but has an additional
piece of wire soldered which engoges into the mesial and
distal proximal undercuts. Thus it offers better retention
than the full clasp(fig 9 d).

ACTIVE COMPONENTS OF REMOVABLE

ORTHODONTIC APPLIANCES

They are components of the appliance which exert forces

to bring about the necessary tooth movement. The active
components include :
1) Bows
2) Springs
3) Screws
4) Elastics
Bows

Bows are active components that are mostly ui=3 for incisor
retraction. There are various types bows routinely used by
the orthodontist. The lowing is a list of some of the
commonly u labial bows.
1. Shon labial bow
2. Long labial bow
3. Split labial bow
4. Reverse labial bow
5. Robert's retractor
6. Mills retractor
7. High labial bow with apron springs
8. Fitted labial bow

Sftort labial bow

 Removable Appliances 287

Fig 12 Reverse Icbicl bow is

activated by opening the
loop. This resul'8 in
lowering of 'he bow rrorc
incisally. (B! Compensatory
bend given to r-antain
proper level of bow
Fig 1 1 Long labial bow
vation of this labial bow is done in two steps. First the U
Long labial bow loop is opened. This results in lowering of the labial
This labial bow is similar to the short labial bow ; except that bow in Ihe incisor region. A compensatory bend is then
it extends from one first premolar to —e opposite first given or the base of the U loop to maintain proper level
premolar. The distal arms of the > I loops are adapted over of the bow (fig 12).
the occlusal embrasure between the two premolars to get
embedded n the acrylic plate(fig 11).
Robert's retractor
The indications of long labial bow are : Minor This is a lobiol bow mode of thin gauge stainless steel
anterior space closure Minor overjet reduction Closure wire having a coil of 3 mm internal diameter mesial to
of space distal to canine Guidance of canine during the canine. The use of thin 0.5 mm diameter wire along
canine retraction using palatal retractor As a retaining with increased wire length due to the incorporation of a
device at the end of fixed orthodontic treatment coil makes the
The activation is similar to that described •b'short
labial bow. A modified form of the long cbial bow can be

n. made by soldering Ihe distal crm of the U loops on to the

bridge of the Adams e'esp.

Split labial bow

This is a labial bow that is split in the middle. This results in
two separate buccal arms having a L loop each (fig 13.a).
This type of labial bow exhibits increased flexibility as
compared to the conventional short labial bows.
The split labiol bow is used for anterior —•'action.
A modified form ofsplit labial bow can be used for closure of
midline diastema (fig 13.b). In this form, the free end of the
buccal arms are made to hook on to the distal surface of the
opposite central incisor.
The split labial bow is activated by compressing
the U loop 1 -2mm at a time.

Reverse labial bow

This is also colled reverse loop labial bow. Here the U loops
are placed distal to the conine and the free ends of the U
loops are adapted occlusally between the first premolar and
canine {fig 13.c). As a longer span of wire is incorporated,
the bow exhibits increased flexibility. Indications for use are
similar to that of short labial bow. The acti-

A
 E
Fig 13 (A) Split laoial bow for retraction of onleriors (B) Sp it labial bow for closure of midline diastema (C) Reverse lobtci bow (D)
Roberts retractor (E) Mills retractor (F) High labial bow with apron spring
labial bow highly flexible (fig 13.d).
As very thin wire is used for its fabrication, the bow
is highly flexible and lacks adequate stability in the vertical
plane. Thus the distal part of the retractor is supported in a
stainless steel tubing of 0.5 mm internal diameter.
The Robert's retractor is indicated in patients
having severe anterior proclination with over jet of over 4
mm. As Ihe bow is highly flexible it generates lighter forces.
Thus they can be used in adult patients in whom lighter
forces are desirable.

Milts retractor
This is a labial bow having extensive looping (fig 13.e) of the
wire so as to increase the flexibility
 zr.d range of action (ability to remain active over tended Springs that are designed to bring about various tooth
periods of time). movements should possess certain ideal requisites.
Mills retractor or extended labial bow as * is
Removable AppliancesThey are listed below:
sometimes called is indicated in patients with c large a. The spring should
overjet. The disadvantages of the Mills -"'roctor include be simple to fabricate.
difficulty in construction and roor patient acceptance due to b. It should be eosily adjustable.
the complex de- of the bow. c. It should fit into the available space without

Jlgh
discomfort to the patient.
labia t bow with apron springs

E consists of a heavy wire bow of 0.9 or mm

ickness that extends into the buccal vestibule Sg
13.f). Apron spring made of 0'4 mm wire is reached to the
d.
e.

f.
It should be easy to clean.
It should apply force of required magnitude and
direction.
It should not slip or dislodge when ploced over a
high labial bow. The apron spring be designed for
sloping tooth surface.
retraction of one or more •=efh. This type of labial bow is
g. It should be robust.
highly flexible ond s "hus used in cases of large overjet. As
h. It should remain active over a long period of time.
very ght forces are generated by them they can be I ised in
adult patients. Factors to be considered In designing a spring
The apron spring is the active compo- Irent that Diameter of Wire : The flexibility of the spring to o
is activated by bending it towards the =eth. As it is highly large extent depends upon the diameter of wire used.
flexible, activation of upfo 3 I rn at a time can be done. The Thus the force generated is
disadvantages ■indude difficulty in construction and risk of
F
soft | *ssue injuries.
L3 ../'where,
F = Force
fitted labial bow
D = Dia met re of wire L = Length of wire
I lb this type of labial bow the wire is adapted to I femfirm to
the contours of the labial surface (fig The U loop is usually
small. The fitted la- 1 foci bow cannot be used to bring
about active 'oath movement. They are used as retainers
at ^completion of fixed orthodontic therapy.

Springs
Icings are active components of removoble orthodontic
appliances that are used to effect various

I -ec* movements.
There are a number of ways by which —rngs
can be classified. Table 1 gives the vari-

ous classification of springs.

Ideal requisites of a spring

 Finger spring
The finger spring is also called single cantileve- spring
Based on the presence or absence of helix they can be claasllted as one end is fixed in acrylic and the other end is free. It
290 f Orthodontics - The Art and Science
as; is constructed using 0.5 mm or 0.6 mm hard round
a. Simple - wthput helix
stainless steel wire.
b. Compound : • with hetix
The finger spring is used for mesio-dis- tal
movement of teeth. It can be used only or. those teeth
Based on the presence of loops or helix they can be classified as :
that are located correctly in the bucco- lingual direction
a. Helical Springs - have a helix
i.e., the teeth should be within the line of the arch.
b. Looped Springs • have a kx>p
The finger spring consists of an active arm of
12 - 15 mm length which is towords the tissue, a helix of
ggiased on Ihe nature ot stability ol the spring they
3 mm internal diameter and o retentive arm of 4-5 mm
length which is kept away from the tissue and ends in a
a. Salt • supported springs - They are usually made:;'0t - ' thicker
small retentive tag (fig 15.a).
gauge wire. Thus they can support lhemsoives,.
The finger spring should be constructed in
b. Supported springs • They are made of thinner gauge • wire and
such a way that the coil should lie along the long axis of
thus lack adequate stability. Hence a section ol
the tooth to be moved, perpendicular to the direction of
the spring is encased in:a. metallic tubing to give it .. .^adequate
movement {fig 15 .b). The
support.

Thicker wires when used, decrease the flexibility of the

spring and apply a greater force on the tooth. By
doubling the diameter, the force increases by almost
16 times. Thus by decreasing the dia meter the force
applied is lesser and therefore the spring remains more
flexible and active over a longer period of time.

(.engfh of wire : Force can be decreased by

increasing the length of the wire. Thus springs that are
longer are more flexible and remain active for a long
duration of time. Helices ond loops can be incorporated
into springs to make them more active. By doubling the
length the force con be reduced by 8 times.

.Force to be applied : The force that should J* 'be generated

by the spring is calculated based on the number of teeth to be
moved, root surface
orea and patient comfort. On an average, f of about 20
gm/cm2 of root area is recomme for most tooth
movement.

Patient comfort : The spring should not any patient

discomfort by way of its design, or the force it generates. The
patient should 41 able to insert the appliance with the spring
in proper position so as to bring about the desi tooth
movement.

Director? of tooth movement : The direi tion of tooth

movement is an important consi otion in designing a spring.
The direction of t movement is determined by the point of
cont between the spring and the tooth. Palatally placec
springs are used for labial and mesio-distal ti movement.
Buccally placed springs are used whs~\ the tooth is to be
moved palatally and in a mi distal direction.
15 (A^l Finger spring |B) Activation of finger sp'ing Cranked single cantilever spring
This spring constructed with 0.5 mm hard stainless
steel wire is used to move teeth labially (fig 16.a). The
spring consists of a coil, close to its emergence from
the base plate. The coil helps in increasing the
flexibility of the spring by increasing the length of the
wire. Ths spring is cranked to keep it clear of the other
teeth. The coil is so designed that the spring is
activated by unwinding the coil.

Z spring
The 'Z' spring is also called double cantilever spring.
tion of the coil is opposite
The Z spring is used for labial movement of incisors.
to that of intended
They can also be used for bringing about minor rotation
movement. Prior to
of incisors.
acrylization, the helix the active arm are boxed in
The Z spring is made of 0.5 mm hard round
wax so that the ig lies in an recess between the
stainless steel wire. The spring can be made for
mucosa and i base plate.
movement of a single incisor or two incisors (fig 16.b).
The finger spring is activated by moving i
The spring consists of two coils of very small internal
active arm towards the teeth intended to be
diameter. The spring should be perpendicular to the
moved. This is done os close to the coil as pos-
palatal surface of the tooth. It has o retentive arm of
sible. Activation of upto 3 mm is considered ideal
when 0.5 mm wire is used for its fabrication. When 10-12 mm length that

ever 0.6 mm wire has been used the activation

should be half of that.

Fig 16 (A) Cranked single caniilcvcr spring |B) Z spring

302 f Orthodontics - The Art and Science

Fig 1 7 T spring

gels embedded in acrylic. Z spring should be boxed in Fig 1 8 Coffin spring

wax prior to acrylization.

Tne Z spring is activated by opening both the
helices by about 2-3 mm ot a time. Incase of minor
rotation correction, one of the helices is opened.
T spring
Buccal movement of premolars and sometimes
canines can be brought about using a T spring. It is
made of 0.5mm hard round stoinless steel wire. The
spring consists of a T shaped arm whose ends are
embedded in ocrylic {fig 1 7). Loops can be
incorporated in both the orms of the T so that as the
tooth moves bucolly the head of the T can be made to
remain in contact with the crown by slightly opening the
loops.
The spring is activated by pulling the free
end of the T towards the intended direction of tooth
movement.
Coffin spring
first molors and the first premolars or deciduous
molars.
The Coffin spring con be activated
manually by holding both the ends at Ihe regies of the
clasps and pulling the sides gently cpc~; Activation of
1 -2 mm at a time is considered appropriate.
Canine retractors
Canine retractors are springs that are used to mo.=
canines in o distal direction. The canine retractors can
be classified by a number of ways (Tabic
-3).
U loop canine retractor
It is made of 0.6 mm or 0.7 mm wire. It consists of a U
loop, an active arm and a retentive arm which is distal.
The base of the U loop should be 2-3 mm below the
cen/ical margin (fig 19). The mesial arm of the U loop
is bent at right angles and adapted around the conine

This is a removable type of arch expansion spring that below its mesic' contact point. Mechanically it is least

was introduced by Wolter Coffin (fig 18}. It is used to effective and

bring about slow dento-alveolar arch expansion in

patients where the upper arch is constricted or there is
a unilateral crossbite.
The Coffin spring is made of 1.2 r-.n^l hard
round stainless steel wire. It consists of c J or omega
shaped wire placed in the mid - pcl;- tal region with the
retentive arms incorporc'ei into base plates. The
appliance gains retention from Adams clasps on the
 immsmm'f&Mf,
Based on I heir localion I hey can bB class'rfrad

a. Buccal - bucally placed"

b. Palatal • palatal!/ p'aced

mm
Based on the presence ol helix or loop they

can be clwsllled as :

a. Canine retractor with helix

b. Can'f-e retractor wth leep

Based on their mod» of action Ihey can be classified as :

a. Push type

b. Pull type

is used when minimal retraction of 1 -2 mm is required.

It is activated by closing the loops by 1 - 2 mm or
cutting the free end of the octive ami by 2 mm and
readapting it. Advantages of this redactor are ease in
fabrication and less bulk.
Fig 20 Heliccl ccnine rciractor

tal arm is active and is bent at right angles to engage

the canine below the height of contour. The coil is
ploced 3-4 mm below the gingival margin (fig 20). The
height of the coil can.be adjusted based on the
vestibular height.
It is activated by opening the helix by 1 Palatal can/ne retractor

It is made up of 0.6 mm stainless steel wire. It consists

of a coil of 3 mm diameter, an active arm and a guide
arm (fig 21). The active arm is placed mesial to canine.
The helix is placed along the long axis of the canine. It
is indicated in re-

mm or by cutting 1
Fig 19 U loooconine 'ctracor
mm of the free end

Helical canine retractor and re- adapting it around the

h is also called reverse loop canine retractor and :s

made of 0.6 mm wire. It consists of a coil of 3 mm
diameter, an active arm (towards the tissue) and a
retentive arm. The mesial arm (retentive arm) is
adapted between the premolars. Thedis-
Fig 21 Palotal canine retractor
canine. It is indicated in patients with shallow sulcus,
and specially in the mandibular orch.
It is indicoted in case of bucally placed canines and Removable applionces having screws

Fig 22 3ucca coninc rc-rcc-cr jAiSjaported corine retractor hoving a stainless steel sloeve to give support (B) Seit succored canine
retracor made of thicker gcuge w re to support itso.f
usually consist of a split acrylic plate and Adams
fraction of canines that are palatally placed. Activation clasps on the posterior teeth. The screw is placed
is done by opening the helix 2 mm at a time. connecting the split acrylic plate. These appliances
can bring about various types of tooth movements
based on the location of acrylic split, the location of
Buccal canine retractor the screw and the number of screws used in Ihe
appliance.
canincs placed high in Ihe veslibule.They are used to
Broadly the removable applionces that
move rhe canine in a distal as well as palatal direction.
make use of screws can bring about three types of
It consists of a coil of 3 mm diameter, an active arm
tooth movements.
(away from the tissue) and a retentive arm. The coil is
a. Expansion of arch {fig 23.a).
placed distal to the long axis of canine. The buccal
b. Movement of one or a group of teeth in a buccal or
canine retractor can be of two types- supported ond
labial direction (fig 23.b).
self supported. The self supported canine retractors
c. Movement of one or more teeth in a distal or
are made of thicker gauge wire (0.7mm) so that Ihe
mesial direction (fig 23.c).
spring can support itself, (fig 22.b)The supported
canine retractors are made of thinner gouge wire
(0.5mm). Thus they are more flexible and therefore
mechanically efficient. The supported canine
retractors lack the stability and are therefore enclosed
in a stainless steel tubing os shown in thefigure(fig
22.o). The self supported canine retractors are
activated by closing the helix 1 mm at a time, while the
supported canine retractors can be activated upto 2
mm at a time.
Screws
Screws are active components that can be incor-
porated in a removable appliance. Screws con be used
to bring about many types of tooth movements. The
screws are activated by the patient c? regular intervals
using a key that is supplied for this purpose. Thus
appliances incorporating screws are a valucble aid in
patients who cannot visit the dentist frequently for
reactivation of the appliance.
 Removable Appliances £95

F'g 24 Elastics used c s act ve com pone nt

Elastics
Elastics as active components are seldom used along with
removable appliances. They are mostly used in conjunction with
fixed appliances. Removable appliances using elastics for anterior
retraction generally make use of a labial bow with hooks placed
distal to tne canines. Latex elastics are stretched between them
and lie over the incisors (fig 24). The disadvantages of such an
appliance includes the risk of tne elastic slipping gingivally ond
causing gingival trauma and the risk of the arch form getting
flattened.

BASE PLATE

base plate also help in retention of appliance and for

anchorage.
The following are the uses of base plotes in
removable appliances.
a. The base plate unites all the compo-nents of the
appliance into one unit.
b. Helps in anchoring the appliance in place.
c. It provides support for the wire components
C d. Helps in distributing the forces over a larger
Fig 23 Removable applionces incorpo'ating screws [A)
Anoyance for nrch expansion (Bj Appliance fo' bucca
movement of o group of reeih (C) Appliance for d'sia
movement of teeth
The bulk of Ihe removable appliance is made of the
acrylic base plate. The prime function of the base plate
is to incorporate ell the components (active and
retentive} together into a single functional unit. The
 i

Fig 26 Ortnodontic clasps (A| Crcjnfe'eitial clasc (B) Jackson's clasp [C) Schwarz clasp JDJ Triangular clasp (E) Adams Cftsp (rj
Adorns claso wih J hook JO) Adar-w c csp with helix (H) Adams with njcca- tube \IJ Adomswith distal extension |J) Single anowhesc
Adams |<) Adans with add'tional arrowhead |LJ Adams on incisors
G H

Removable Appliances 297

J K L
Fig 26 Springs and Bows (A) Finger spring (B) Z spring \Q T soring (D) Shor lab-cl bow (El Long labiol bow (F) Split labia' bow |G)
Robe-fs retractor {HJ Mills retracto' (I) High cbial bow (J) Fitted lebial bow IK) Reverse labial bow (LJ Labial bow soldered to
Adomsclaso
298 Orthodontics - The Art and Science

for this ir should be made thicker to increase the

strength. The base plate should; - snugly around the
necks of teeth that are not being moved. This helps in
avoiding food accumulating under the base plate.
Tho bose plate is made of cold cure- acrylic
or heat cure acn/lic. Cold cure acrylic is more
frequently used as it is less time consuming and
simpler to use. The disadvantages of co:c cure acrylic
are that there is more chance of porosity and it is not
as stable as heat cure acrylic During construction of
the appliance care should

F:g 27 Anterior bite p one

area.
e. Bite planes can be incorporated into the plate to treat
specific orthodontic problems.
Tne bose plate should be of minimum
thickness to help in patient acceptance. Thick plates
are not tolerated by patients. Base plates of 1.5 - 2 mm
thickness offer adequate strength and at the same time
are tolerated well by patients.
The maxillary bese plate usually covers the
entire palate till the distal of the first molar.
This full coverage helps in gaining odequcss strength.
Narrow maxillary bose plales rese- bling a horse shoe
are less stable and are like-, lo gel dislodged during

Fig 28 Posterior bite plane

movements of Ihe tongue

The mandibular base plate is usuc.'. shallow
to avoid irritation to the linguol sulcui To compensate
be 'aken to block ou- undercuts so that insertion and
removal of the appliance will not be o problem. This is
more so in case of mandibular appliances. o
Bite planes can be incorporated into the v
a
base plates. These bite planes help in disengaging the
b
occlusion. The cnterio-- bite planes are fabricated by
l
thickening the base platebehindthe maxillary anteriors e
(*ig 27}. Anterior bite planes are useful in trea'ment of
deep over bites by selective eruptuion of the posterior a
p
teeth relative to the onteriors. Posterior bite plane are
p
formed by extending the base pla+e cover the occlusal l
surace of the teerh (fig 28). They are generally used in i
the trea'ment of crossbites as they help in removing the a
n
interference o; opposing *eeth.
c
e
CLINICAL MANAGEMENT OF REMOVABLE
s
APPLIANCES
y
e
Delivery of the appliance
s
There ore a number of factors that should be looked t

into at the time of appliance delivery. e

r
1. The tissue surface of the appliance should not
d
have ony sharp creas or nodules. Run your fingers a
over Ahe tissue surface of the appliance to feel for y
ony sho'p areas tha- may injure the tissues. They
a
should be trimmed to avoid tissues irritction.
r
2. The base plcle may need some trimming to help in c
easy insertion and removal of the appliance. This
is mostly so in case of undercuts being present. r
o
3. The clcsps should be examined for adequate
d
retention. If not they should be cdjusted *o engage
a
the undercut, so as to increase retention. y
4. The active components should rest at the desired .

location. They should no* impinge on

A
the gingiva, sulcus or-he trenum.
m
5. The patiert should be educated on how to insert
ard remove tne copliance. It is a good idea to J
4
show the appliance o the patient and
O
demonstrate to them xhe ac'ion o 8 the various
r
l
h
8 o
d
A
d 1
o 9
r 6
n 9
s ;

: 2
0
R 2
e -
m 2
 components of the appliance. They should be
irstruced not to distort the various active
components of the appliance.
6. The octive components con be activated after c
few days once the oatien- gets used to the
appliance.

/nstract/ons to the patient

The patient is given instructions be'ore he 'eaves the
dental ofice on the use ond core of *he appliance. Sim
ale verbal instructions often serve the purpose.
However printed instruction shee^orfu- ture reference
car be given to 'he patient. The following are some of
the instructions given.
1. Patient should be instructed on the number of
hours of wear. Most apoliances are to be worn
both dcy and nignt i.e. 24 hours.lt is
recommended that they be worn during the meal
time as well. r~
2. The apoliance ard the teeth should be cleaned
after every meal. They should oIso be cleoned
before retiring to sleep.
3. The parent is asked *o clean the appliance using
detergen-solution and c brush. While cleaning the
cppliance, ca'e should be taken not to bend or
dislodge ony of the components of the appliance.
4. In case of removable appliance that incorporate
screws, the patient and parents should be given
clear instructions on now to activate Ihe
appliance.
5. The patients are instructed to report immediately
to the clinic in case of appliance damage or any
other oroblem while wearing them.

1
8
 6. The potient should be instructed not to leave the
appliance out of rhe mouth for a long poriod of
time as it increases the risk of loss ond damage.
300 f Orthodontics
Prob/eros - The Art
encountered /n and Science
removable
appliance therapy
Ora/ hygiene mainJenonce : Patient who fail to clean
the appliance and teeth pose the risk of gingival
inflammation and hyperplasia.

Soft tissue irritation : Removable plates that are not

trimmed and polished properly can leod to tissue
irritation and ulceration. Caro should be taken to avoid
shorp nodules and irregularities in the appliance. In
addition wire components that extend deep into the
vestibule offer risk of vestibular irritation and injury.

Cones ; Improper oral hygiene can result in caries. The

appliance should be designed in such a way that areas
of food stagnation do not occur.

Pain ; Excessive forces applied by the active

components can cause tenderness or even pain of the
teeth being moved.

Tootf) mobility : Presence of traumatic occlusion

orthe use of excessive force during therapy can cause
abnormal mobility of the teerh.

References
6. Pro' tt WR: Co-Temporary Orrhodortics. St Low^ CV
Mosby, 1986.
7. Robe't E Moycrs : riend bc-ok of Orthodon-ics, Yeo--
boo;< medicol publishers, inc. 1988.
8. Sa.'zmcn JA : Practice of Orthodontics, J3 Liopincc.-
compony, 1966
9. Tang and Wei : Trea'ment effectiveness of orhodor- <ic
appliances. Am J Orlhod 1990 ; S5C-S56
A
n important aspect of treatment planning is
choosing an appropriate appliance for a
particular patient. Various types of appliances
are available from which the orthodontist has to select
the one that is most
suited forthe patient.
Most malocclusions
require some form of
^Uu^a Ja

Appliances
fixed therapy for their
correction, -ppliances
that are fixed or fitted
onto the teeth by the
operator and cannot
be removed by the
catient at will are
called fixed appliances.Patient cooperation is
dispensed with to a large extent in ~e use of fixed
appliances. The orthodontist does -iot depend on the
patient for timely weor and management of the
appliance. Unlike removable appliances that arc
capable of only tipping type of tooth movements^ fixed
appliances can bring about various other types of tooth
movements including bodily movement, rotation,
lipping, intrusion, extrusion and even root movements.
r
ixed appliances ore therefore very versatile and can
be used to treat most malocclusions.
The most important disadvantage of a fixed
appliance is oral hygiene maintenance which becomes
more difficult. Plaque and food debris tend to
accumulate around the attachments which mokes
cleaning of teeth difficult for the patient. In addition, the
fixed appliances are more time consuming to fix and
cdjust and require specialized services of an
orthodontist. Refer to chapter 24 for more details on
the advantages and disadvantages of fixed and
removable appliances.

TOOTH MOVEMENTS POSSIBLE USING

FIXED APPLIANCES

A greot advantage of fixed appliances is their ability to

bring about more than one type of tooth movement at
the same time unlike removable appliances that can
only perform simple tooth movements. The various
tooth movements possible using fixed applionces are :
Tipping
Tipping is the simplest type of tooth movement,
produced by the application of a single force on the
tooth crown. As a result, the crown moves in the
direction of the force around a fulcrum in the apical
region of the root. The root apex experiences a
counter-reaction and moves in the opposite direction.
Tipping type of toorh movement can be used to treat
only certain malocclusions. Most fixed appliances are
capable of producing tipping. However, s'ery rarely can
a malocclusion be treated entirely by tipping
movements.

D E F
Ffg 1 To o'h movements possible using 'ixed opplionccs. (A) Tipp'ng of c'owns |B) Bodily movement (C) Torqying (D)
Irtrvs.on (E) Ext'tsion (Fi Mes'o-distol uprighthg

Bodily movement
Bodily tooth movement implies an equal movement of
both the crown as well as the root in the same
direction. Certain fixed appliances

are capable of bodily movement.

Torqulng
Torquing implies root movements in the labial or
lingual direction. It is possible to move the roots in a
labial or lingual direction using fixed applionces.

Uprlghtlng
Uprighting refers to mesio-distal movement of the
roots. Finer detailing of roots by moving them
mesio-distally con be brought about by fixed
appliances.

Rotations
Teeth that are rotated around their long axes can be
derotated using fixed appliances. The degree
of rotational control possible with fixed applicnces ■s 4) Although it is possible to bond attachments on teeth
not possible using removable appliances. that have porcelain or gold restorations or crowns,
banding is preferred in these cases.
Extrusion and Intrusion 5) It is preferable to band teeth that show recurrent
Extrusion and intrusion refer to vertical movements of breakage of the bonded attachments due to bond
teeth along their long axis. Ex'rusion and to a lesser failure.
4
extent intrusion of eeth or groups of teeth is possible 6} If is preferable to use banded attachments whenever
using fixed appliances. they are likely to contact the opposing dentition when
the jaws are closed.
METHODS OF FIXING ATTACHMENTS ON TO
THE TEETH Steps In banding
a. Seporation of teeth
The various attachments that ore used in fixed
b. Selection of band material
appliance therapy such as brockets and molar tubes
c. Pinching of the band
can be fixed directly onto the teeth with composite
d. Fixing the attachments
adhesives or can be ottached to metallic bands thot
e. Cementotion of the band
are cemented onto the teeth. The method of fixing the
attachments directly to the teeth is colled bonding. Separation of teeth : Due to the presence of tight
When ever the attachments are fixed to bonds which inter-dentol contact between the teeth, it moy not be
are cemented around the teeth, the technique is possible to force the band past the contact area. It is not
referred to os banding. advisable to force the bond through a tight inter-dental
contact as it is uncomfortable for the patient and also
BANDING difficult for the operotor. Tight contacts should hence be
broken using tooth separators prior to band pinching. The
Bonding involves the use of thin stainless steel strips
various types of separators are discussed later in the
called bands that are pinched tightly around the teeth
chapter.
and then cemented to the teeth. The stainless steel
Most separators have to be left in the
tape is available in different widths and thicknesses to
suit different teeth. While the molor band material is
wider and stiffer, the anterior band material is relatively
thinner ond narrower in width. Tho outer surface of the
band materiol is smooth and glossy while the inner
surface is comparitively rough and dull, so os to aid in
retention of the cement.

Indications for banding

The following are some of the situations where
banding is advontogeous.
1) Banding is preferred over bonding in case of
posterior teeth. The banded attachments are
better capable of resisting occlusal forces than
bonded attachments. In addition, bonding needs
thorough moisture control which is difficult in the
posterior teeth.
2) It is preferable to band a tooth that requires buccal
as well as lingual attachments.
3) Bands are better likely to resist heavy forces, as in
the cose of extraorol devices such as head gears.
 M
i
Orthodontics - The Art and Science
•X'XsSSwH

.NV.vSScSBB

XOXNSSKSB
''•'I'MwSS
VlVVviS
D^MS

Fig 2 Separates (A) and (B| Placemert of ring separator (C) and (Dj Kcslngs scperotor.

mouth for 24 hours or more to bring about sufficient
separation of the irrer-dental contact.
Selection of band material : Bosed on which tooth is
being banded, the band material of appropria*e
Fixing the attachments : Once the band pinching is
completed, rhe appropriate artachmerits are fixed
onto the bond. The attachments include brackcrs for
the anterior teeth and buccal or molar tubes for the

thickness and width is selected. posterior teeth. These attachments are fixed to :he
band by spot welding or by soldering.
Pinching of the bond : Bard material of adequate
length is taken and the two ends are welded together. Cemen/afion of fhe band : The final step involves

The bend is now passed through Ihe separated cementation of the band around the tooth. The inner

inter-dental contact around the tooth to be banded. surface of the band is rough in order to aid in retention.

Using band pinching pliers, the band is tightly drawn
around the tooth to form a ring. The neck of the band is
spot welded to retain the tight fit. The excess band
material is then cut off and the ends are adapted close
to the band. The beru portion is spot welded and the
gingival margins of the band are trimmed to conform to
the contour of the gingival margin. The weld spots
A well pinched band is one that has adequate retention
even without the use of cement. Nevertheless,
cementation is required to eliminate the space
between the band and tooth into which coriogenic
material may seep

and rough margins are then smootnened and

polished.
 n and stagnate.
During cementation, cdequate moisture
:ontrol is necessan/ by means of so live ejectors

end cotton rolls. Cements that can be used include zinc

E poly-carboxylcte, zinc phosphate,
glass ionomer cement etc.,.
=
g 3 S'eps in bonding (A) Sirip of bend molericl fenred nto welder used lo n rinq (B; Ba-td is placed around lie tooth and pinched (Q cut off (Ej The
form we c spots (D) Excess bend motercl i urs of the banc (F) Bond rema nhg band rrclerial is edeptsd along the
cemented in placc

Preformed seamless bands are now available in

various sizes. They hove eliminc'-ed the need lo pinch
custom made bands.
Fig 4 Electron microscope images of no'nal enamel and acid etched enamel (A) Norma c-ia -iel rrccritkxrior v. 500 |B) Normal enamel magrif cntion
x 1 500 (C| Acid etched enomel magnification x 50C iD'l Acid etchec enoTic-l -nagrif cction xSOO
BONDING 2. Enhances the surace area ond poros/fy: the etching
of the enamel increases the surface area and porosity
^ne method of fixing attachments directly overthe
of the enamel thus increasing the bond strength. The
enamel using adhesive resins is called bonding, "he
enamel is etched to a depth of 20-25 microns.
elimination of bands greatly enhances esthetics and
oral hygiene maintenance and has red to its popularity
Advantages of bonding
over banding. This procedure cfdireaattachment on
Bonding offers numerous advantages over banding
the *oolh surface requires crefreatment of enamel.
which can be listed as :
Enamel can be pretreated by various methods. The
1) It is est'netically superior.
most accepted method is the prctreatment by acid
2) It is faster to bond than to pinch bands around the
etching technique. This ^hnique was introduced in
teeth.
1955 by Buonocore. The pretreatmen4, of enamel by
3) It enables maintenance of better oral hygiene.
acid etch technique ~elps in the following ways: 1.
4) It is possible to bond on teeth that have aberrant
Enhances the surface energy : The etching of the
shapes or forms. It might be impossible to band
enamel helps in removing surface deposits and
such teeth.
organic materials that are found on -ne surface of the
5} It is easier to bond than band in case of
teeth. It also increases the surface energy thereby
partially erupted and fractured teeth. 6) The risk of
enhansing the wettability of the enamel.
caries under loose bands is eliminated.

Pa 5 Bonding procedure ■ see next page for legend

Fig 5 BoicJing procedure (AJTee-h cleaned using
ojrrice (8) & (C) 30-50% phosphoric u c id esed to
etch enamel (D) Etcnant is washed o^ with water
(E) Teeth are d'ied using oir (F) Sealant is cpplied
(Gj & {HJ Sealont & adhesive applied on under
surface of bracket nicsh |IJ Brac<e» olaced o-i teetn
(JJ Excess' :lo'e ol adhesive 'emoved (K) Bonding
completed on a I teeth
7) Interproximal areos are accessible for restoration
ond proximal stripoing.

Disadvantages of bonding 5. Lock phs

1) Bonded attachments are weaker than banded 6. Ligstjre w re

attachmen-s and hence are more prone to bond

failure.
2) Bonding involves etching of the enamel with an
acid which may lead to enomel loss and an
increased risk of demineralization.
3) Enamel fracture can occur during debording.
Steps in bonding
Bonding is done in the following steps (fig 4}:
1) The crowns of the *eelh to be bonded are cleaned
using pumice and bristle brush so as to remove
olaque and other organic debris present on the
enamel surface.
2) After thorough cleaning, the teeth arc washed and
dried. During the bonding procedure, adequate
moisture control should be maintained by the use
of saliva ejectors and cotton rolls. It is advisable to
use o cheek retractor to keep the lips and cheeks
6] The bond is allowed to strengthen for some time
before placing the arch wires.
BAWDS
Bands are passive components that help in fixing the
various attachments onto the teeth. They are
availoble in various sizes to suit different teeth. They
are made of soft stainless steel. The attachments like
molar tubes and brackets are soldered or wolded over
these bands which are cemented in position around
the teeth. The use of preformed bonds or seamless
bonds is becoming popular. These bands are
available in
Band Thickness Band Width

away from the teeth to be bonded. (Inches) (inches)

:
3) 30-50% phosphoric acid in gel or liquid orm is Inciscr 0.003 0.125 '

used to etch enamel. This etching is usually done Canine 0.003 0.150
for 45-60 seconds, after which the etchant is
Premolar 0.004 0.150
washed off with water. The teeth are then dried
and once ogain isolated using fresh cotton rolls.
Molar 0.005 0.180
The aopecrcnce of etched enomel is described as 0.006 0.180

matte, dull whitish and lightly frosted.

4) Sealant is opplied onto the etched enamel surface.
5) Adequate quantity of bonding adhesive is placed
on the base of the brackets. The bracket is placed
on the tooth and is firmly pressed into position.
Excessive adhesive that appears
v as flash is removed using a scaler.
Active components

1. Arch wires

2. Springs

3. Elastics

4. Separators

Passive components

1. Bands

2. Brackets

3. Buccal tubes

4. Ung&l attachments

Fig 6 Preformed bands availab e in various sizes
various sizes. The orthodontist chooses the best fitting
band and cements them directly on the tooth. The use
of these bands thus reduces the chairside time by
eliminating the tedious task of pinching the bands.
They are also more comfortable for the patient (Fig 6).
BRACKETS
Brackets act as handles to transmit the force from the
active components to the teeth. Brackets have one or
more slots that accept the arch wire. There are a
number of bracket designs available. Brackets con be
classified in a number of ways.
Edgewise type of bracket
Brackets used in Ihe Edgewise and Straight Wire
technique hove a horizontal slot facing labially (fig 7.a).
These brackets with rectangular slots
Fig 7 (A) Edgewise lype of bracket IB) Ribbon ore n type of bracket
are so called because they accept wires rectangulor
cross-section with Ihe larg* dimension being
horizontal. These bracl provide greater control over
tooth movement < do not permit tipping of teeth.
Ribbon arch brackets
They are brackets which possess a vertical facing the
occlusal or gingival direction (fig 7.J The slot is also
narrow mesio-distally. This kinc bracket is used with
round wires to bring aboj» tipping of teeth in
lobio-linguol as well as mesio- distal direction. Ribbon
arch brackets are used - the Begg fixed applionce.
Weldable and bondable brackets
As mentioned in the earlier section of this chapter, the
brackets can be either bonded directly onto the teeth
using bonding adhesives or they ccr be welded onto
bands which in turn are cementec
Fig 8 Mesh work on tne under s jrfoce of
bondoble brocket*
around the teeth. Brackets that are bonded directly
over the enamel ore called bondable brackets, while
those thot are welded or soldered over bonds are
called weldable brackets. The under surface of
bondable brackets has a mesh work or grooves to help
in interlocking with the adhesive (fig 8). Weldable
brockets have o metal flange that can be welded to the
bond.
 Fig 9 (A) Metalic brac<els (Bj Ceromic brackets

Meta///c brackets c. They exhibit greater friction at the wire-bracket

I Most brackets in current use are of the metallic : interface than metallic brackets.
«ariety. Of these, steel brackets are most commonly I
used. The advantages of metal brackets include : I a. Plastic brackets
They can be recycled, f b. They can be sterilized. B c.
iViost of Ihe plastic brackets are made of
They resist deformation and fracture.
polycarbonate or a modified form of polycarbonate.
d. They exhibit Ihe least friction at the wire-brocket
These plastic brackets were introduced to improve the
interfcce.
esthetic value of the appliance. Plastic brackets are
e. They are not very expensive.
available in tooth colored or transparent forms.
The disadvantages of metal brackets are:
The disadvantages of plastic brockets
a. They are esthetically not pleasing. The patient
are:
tends to have o metallic smile.
They tend to discolor particularly in patients who
b. They can corrode ond cause staining of teelh.
smoke or drink coffee.
Ceramic brackets They offer poor dimensional stability.

Ceramic brockets were introduced to orthodontics n the Thoir slot tends to distort.

late 1980's. They are made of aluminum oxide or The friction between plastic brackets and metal

zirconium oxide. The advantages of ceramic brockets orch wire is very high.

are :
BUCCAL TUBES
a. They are dimensionally stable and do not distort in
the oral cavity. Brackets are usually fixed on the anterior teeth and
b. They are durable and resist stoining in the oral premolars. The attachment that is generally used on
environment. molars is the buccal tube or the molar tube (fig 10). The
The disadvantages of ceramic brackets buccal tube can be weldable i.e. welded to bands
include : which are cemented around
o. They ore very brittle and therefore fracture or crack
when undue forces are applied.
b. To compensate for their brittleness, their size is
increased which tends to increase their bulk.
 Fig 10 3JCCQ Ijbcs (A) Sirgle (H| Dojble {C! Triple

tne teeth or they can be bondable i.e. att cirectly to

teeth by using bonding acnesives Buccal tubes
car. be rounc rectangular in cross section. The
buccal rube i sometimes hove double or triple
tubes, additional tubes are for additional arch
wires for face bow insertion.

UNGUAL ATTACHMENTS

Bracxets and buccal lubes are attached on : labial or

buccal aspect of the teeth. Sometimes may oe
necessary to heve ottaenmcnts on the lingual side as
well. There are vcriou: attachments available I naf can
be fixed on the lingual aspect and are called lingual
attaenmems They ore usually required for engaging
elastics
Examples of lingual attachments include
lingucl buttons (fig 11 .b), lingual cleats (fig 1 1 .c.
eyelets (fig 1 1 .d) end oall end hook (fig 11 .c).

LIGATURE WIRES

They are sof* slain less s*eel wires of 0.009 to 0.0 r

inches diameter and are used to secure the arcr. wire
to the orackels (fig 12). This process cf securing the
arcn wire to tne brackets is called ligation. Ligation is
usually necessan/ in edgewise type ot brackets that
have c lobiolly facing slot. The ligoture wires are
available in long lengths or ore preformed into small
ligatures. The arch wires can also be secured to ihe

ig 1 1 Lnyuol cllachmems |AJ lirgual clea- (6; lircuol ojtton (C) Ball
= brocket using
end hook iyclol
 Fig 12 Ligature wire used to secu'e arch wire to bracket

elastic ligature rings. These rings ore available in
various colors for the pctienr to choose from.
LOCK PINS
movements through the medium of brackets and buccal
tubes which act as handles on the teeth.
In early doys (prior to 1940), pure gold arch
wires were used. Their high cost and mechanical

They are small pins that arc used to secure the arch inefficiency led to the use of stainless steel archwires. In

wire to brockets with vertical slots such as ribbon arch the 70's and 80's a number of titanium based arch wires

brackets {fig 13}. The lock pins are usually mode of were introduced into orthodontics. These arch wires

brass. exhibit superior elastic properties. A number of

multi-stranded arch wires are also being used
effectively.

Fig 13 Lock o n used to secure wire in

*iobcn arch 'yoa of brac<et
ARCH WIRES

Arch wires are one of the active components of fixed

appliances. They can bring obout various tooth
 324 Orthodontics - The Art ancj Science
Ctassificalicn of arch wires
the working range cff the appliance.
Based on material used

1} Gold a.od goto alloys Stainless s:eel Nicket Itanium alloys Beta
fiiocompatabilify ond environmental stability :
titanium 5;- Coba t chromium nickel alloys 61' pplltlexarch wiras Orthodontic arch wires should exhib* resistonce to
tarnish and corrosion and shoub be non-toxic. The
Base- on cross section (lig 14} ||g§:.Round Z) Square
material should maintain its desirable properties for
3) Ractanguar
extended periods of time after manufacture.
4) Multislranded BSSSSSBW^^

Ideal requirements of Joinobility : The wire should be amenable to soldering

2
) orthodontic arch wires and welding.

3 Spring back : It is the measure of how far a Friction : Many tooth movements are accompanied by
} wire can be deflected without causing sliding of the arch wire over the bracket slots.
4 Presence of excessive friction at the wire-brackel
permanent deformation. It is also called
}
elastic detlecrion. The arch wire should interface results in undue strain on the anchorage and
ideally possess high spring back which results in an limitation of tooth movement. The wire should
increase in its range of action. therefore provide least friction ar the wire-bracket

a interface. ■

Gold and gold alloys

Stiffness: The presence of a low sTiffness proviae; the
ability to apply lower forces and a mo»= •, constant
force overtime.
Formability: The orthodontic arch wire moter r. should
exhibit high formobility so as to bend tr* arch wire into
desired configuration such as coas, • loops, etc.,
without fracturing the wire.
Prior to 1 940, gold was extensively used in the
manufacture of orthodontic arch wires. The high cost
involved led to the invention of gold alloys in which
other metals like copper, silver and pallodium were
added and the percentage of gold reduced- Gold and
gold alloy arch wires exhibit excellent formabilily,
environmental stability and b i oco m potability. The
drawbacks of these arch wires include low spring
back and high cost.

Resi/rence : Resilience is the amount of force the wire

can withstand before perrnaner* deformation. Arch
wires should exhibit hig- resilience so as to increase

Fig 14 Crcss-s&dio-i of archwires (A) Rotund \3) Square {C)

Kecrcngle (D)Twisted (E) Coaxial
Stainless steef
Austenitic stainless steel which is sometimes referred
to as 18/8 stainless steel is used to make orthodontic
arch wires. Stainless steel arch wires exhibit adequate
strength, resilience, formabili7 and adequate spring
back. In addition they are biocompatible and
economical.
Nickel titanium alloys
Nickel titanium alloy also called Nitinol (Nickel Titanium
Naval Ordinance Laboratory] was invented by William
R. Buchler at the Naval Ordinance loborctory. This alloy
exhibits super- elosticity and shape memory. They
were introduced to the orhodontic community by
Anderson in 1971. Nitinol arch wires exhibit high spring
back, high working range and low stiffness. Thus these
arch wires on cctivation produce lower ard more
constant force on the teeth. The disadvantages of
Nitinol are that it is resistant to taking a bend, helices or
loops cannot be made on ^hem ard they cannot be
soldered or welded.
form (fig 1 4). The odvantaae of these multistranoed
wires is thct they exhibit increased flexibility.
ELASTICS AND E LAS TOMERICS
Elas'ics are routinely used as active components o:
fixed orthodontic appliances. The elastic procucts used
in orthodontics include simple elastics, elastic chairs,
elastic thread and elastic modules.
Elastics
They are elastics that resemble a rubber band. They
are mace of latex rubber and are available in various
diameters. The force applied by *hese elastics depends
uoon their diameter. They are color coded tor easy
identification.
Elastics ore used in orthodontics for a
number of purposes such as closure of space, to
correct open bites, treatment of cross bite, ond to
correcrinter-arch relationship. The following are some
of the applications of elastics :
C/ass j elastics : They are intra-arch elastics stretched

Beta titanium between the molars and anteriors (fig 15.a). They are
generally used for closure of space and rctraction of
Beta titanium wos introduced by Jon Goldberg and C.J.
teeth.
Burstone. It is available by the tradename of T.iVi.A.
wires. These wires exhibit a high range of action and
spring back. They also permit making of loops and
helices due to their high formability. An added feature of
these wires is that they can be welded.

Co bait chromium nickel alloys

Cobalt chromium nickel alloys drawn into wires can be
used successfully in orthodontic appliances. These
olloys are available commercially as Elgiloy. These
arch wires exhibit adequate spring bock, formability and
are biocompatible.
Opt/ f lex arch wires
It is a new type of arch wire developed by M.F. Talass in
1992. These arch wires are made of cleorop'ical fiber
and ore therefore highly esthcic. In addition, they
exhibit high resilience. The drawback of t-iis wire is that
it cannot accept a shcrp bend.

Multlstranded arch wires

These arch wires are made up of a number of thinner
wires. These wires can be either twisted or coaxial in
316 Orthodontics - The Art and Science

D.

Fig 15 Elastic applications (A) C oss i elastics |B| C ess II elastics

{C; Class II classics (D) Box elastics (E) Crassbiie elastics

Goss l'/ e/asties ; They ore intermaxillary olcstics

stretchcd between the lower molars and the upper
anteriors (fig 15.b). Tney are used in the treatment of
Class II malocclusion. They bring about reduction of
upper anterior proclination and mesial movement ot
the lower molars.

Class III elastics : They are intermaxillory elas*ics

that ore stretched between the upper molars and Ihe
lower anteriors (fig 15.c). They are used in treatmenr
of Class III malocclusion to bring o bout mesial
movement of upper buccal teeth and retraction of
lower anteriors.

Crossbite elastics : They are tnrough-thc-bite

 mter-moxillary elastics used to trea" molar crossoites between two teeth or two groups of leeth to close
(fig 12.e). They extend between the oala'al surlcce ot spcce. They can also be used to d e rotate a tooth. (Fig
the upper molar and the buccal surfoce of lower molar 1 7)
or vice versa.
Elastic modules
3ox e.'asrVcs : This form of elastic is used to correct
They are mace ot two elastic rings separated by a
anterior open bites. An elastic is stretched between the
variable distance. Elastic modules are available in
upper and lower anteriors like a box (fig 12.d). The
vorious sizes based on the inter-ring distance. They
open bite gets corrected by forced eruption of the
are general y used to close space and for derctationof
upper ard lower anteriors.
teeth.
Elastic chain (E-Chain)
Llgating rings
They are elastics tha-are avoilable as long chcins of
Arch wires can be secured to the brackets using smoll
inter-connected rings. They are usually made of
elas*orneric rings called ligating rings. They are
synthetic polyeurythene material and are available in
available in various colors. An alternate way 'o secure
different forms based or the distance between the
the archwire to _he bracket is the use of ligature wires
rings (fig 16). E-chain is used in the ; closure o: space
that was described earlier in the chap-er.
between teeth by sketching the [_ rings between them.
available in a spool. It is cut to desired lergth and lied

Fig 16 E cjsric chains

F £ 13 I igot'rrj rings tc secure orehv/ re to brackets

Elastic thread
Eloslic thread is made of o core of latex rubber,
surrounded by a sleeve of woven silk and is
SPRINGS
Springs are the other active components that can be
used to bring abou* various tooth-movements. The
following springs arc used in orthodontics:

Uprlghting springs
They are springs which move the root in c mesiol or
distal direction (fig 19).

F g "7 Elastic Thread

 Fig 19 Up'ightrg sp'ings for mes o-d s'ol uprghting of lech

Fig 20 Close coil so'ing i^sed to close spoces

Fig 21 Open coil spring used to cp-en spoce

TorquIng springs
They are springs which move the root in a lingual or palatal direclion.

Open coll springs

They are springs that are compressed between two teeth to open up
space between them (fig 21 and 22).

Closed coil spring

They are stretched between teeth to close space (fig 20 and 22).

Fig 22 (A) c ose coil Spring (B) Open coil so-ing

 D
Fig 23 Seporotors (A) Psing sepcra'or (BJ Dumfcel! separator (C| B'oss wire separator {D) Kesling's spring separator

SEPARATORS together. The end is cut short and is tucked between

the teeth {fig 23.c)
In many patients the presence of a tight interdental
contact results in difficulties during banding. While Ring separators
attempting to pass a band through the interdental
They are small elastic rings that are passed through the
contact, the band tends to get distorted. In addition, the
contact using special pliers (applicator). The stretched
oatient may experience some amount of discomfort.
elastic ring encircles the interdental contact and as it
The teeth should therefore be separated to break the
contracts, the teeth are separated (fig 23.a).
tight inter-dental contact. This is usually achieved using
various types of separators available. Dumbell separators

Brass wire separators It is a dumbell shaped piece of elostic that is stretched

and passed through the interdental contact (fig 23.b).
Soft brass wire of 0.5 or 0.6 mm diameter is passed
The stretched separator tries
around the contact and the ends are twisted tightly
 facing occlusally. Angle used golc arcn wires end lock
pins with this technique. The ribaon arch techr:que
enaaled rotation contro as well as bucco-lingual and
inciso-gingival rootn movement. However mesio-riistal
tipping movements were considered difficult with this
technique.
Over the years o number of fixed appliance
teenniques have evolved. It is not within the scope of
this book to discuss in derail the various technicues as
numerous philosopnies anc mechoniccl principles are
involved.Thus the discussion !s limited to few of the
more poaular techniques that have been widely used
by the practitioners.

Fig ?5 P r ond -i.be cpp:icrce

to regain its origincl length and in doirg so orings about

separation of 'eetn.

nesting's spring seperator

This is a spring separator-mat effectively seoarces the
contact. The spring consists of a coil and two arms.
The shorter arm of Ihe spring is passed below the
contact while the longer cnm rests above the contact. Fig 26 Rio bon a'cn a c pi ia nee

When the spring is olaced in position the coil opens up

thus activating the spring. As the two arms try to come
back to position they break the contact (fig 23.dj.

Fixed appliance techniques

Pierre Fauchcrd in 1728 devised the first orthodontic

appliance to expand tne dental arch. The concept of
fixing orthodontic cttcchmentsto teeth took a definite
shape in the late nineteenth century. Edward H. Angle
introduced Ihe E Arch or the expansion crch in the late
1800's (fig 24 The appliance used bands on the
molars'with cr exoonsion arcn threaded totho buccal
aspect o' 'he molar bands.
In 1912, Edward H. Angle introducec ■ne pin
and tube appliance (fig 25). The appliance cons sted of
bands with a verticci tube placed or all teeth. Tne crch
wire carried soldered pins the nserted into the vertical
tubes. Tooth movemerr was cchieved by altering the
placement of these pins.
In 1925, Edward H. Angle introducec the
-ibbon arch appliance (fig 26). This was the first
appliance to use a true bracket having c vertical slot
£D6£W/S£ APPLIANCE B

Angles last contribution to orthodontics was the Fixed Appliances 321

introduction of Ihe edgewise technique in 1928. He
deviced c metal bracket hoving a rectangular slot of
0.022' x 0.028" dimension facing labially. The slot
received a rectangular arch wire of
0. 022. x 0.028" dimension. The wire is
inserted info the bracket with the narrow dimension
ploced occluso-gingivclly. This mode of insertion of the Fig 27 (A; First order oend (B) Second order bend (C)Third order
bend
wire is called edgewise and therefore the technique
was called edgewise technique. The unque feature of
having a rectangular arch wire in a rectangular slot
enab'ed control of tooth movement in all the three
planes of spcce. For this purpose Angle described the
use of an ideal arch wire that incorporated certain
bends called the first, second and third order bends.
The first order bends or in-out bends ce
placed to com oen sate for differences in the bucco-
lingual prominence of the teeth. They comprise of the
lateral inset, the caninc offset and the molar offset. The
second o'der bends are placed to acheive correct
mesio-distal axial inclination of teeth. They comprise of
the lipback bends ploced in the posterior segments.
The third order bends or torque are placed to get
correct bucco-linguol position by moving the roots.
They are o laced by twisting the arch wire.
The advantages of the edgewise technique
include :
1. Ability to move teeth in all the three plones of
space
2. Good control over tooth movement.
3. Bodily tooth movement is possible.
4. Precise finishing is possible.
The disadvantages of Ihe edgewise tech-
nique include :
1. The need to apply heavy forces.
2. The need for complex wire bending.
3. Increased friction between the archwire and -n
the bracket.
4. The need for exlraora' forces for anchorage.
5. Difficulty to ooen deep bites.
Charles H. Tweed modified this technique
and advocated extraction o: teeth in selected cases for
better stability. He also introduced the concept of
anchorage preparation wherein the terminal molars
were init'ally tipped distally to better resist the traction
forces that were used in the later stages.
Overtheyearsa number of modifications have been
proposed in this lechnicue.
 Orthodontics - The Art and Science

siwm ■

Fig 28 -A) ond <B) Begg appliance \C) arc (D) Preodjtsred edgewise appliance
BEGG APPLIANCE include :
1. The use of light forces which are within the
Raymond Begg received his training in orthodontics
physiologic limits.
from the Angle School during tne early 1900s. He later
2. Relatively continuous forcc application
relumed to Australia in 1925 and practiced the
3. Minimal friction between the wire and the
edgewise technique. In the mean time Begg modified
brackets.
Ihe Angle's ribbon arch technique and introduced the
4. Rapid alignment and over bile correction.
Begg light wire differential force technique {fig 28.a and
5. The appliance docs not strain the anchorage.
b). This appliance used the concept of differential force
6. Extraoral forces were not required to conserve
ond tipping of leeth rather than bodily movement.The
anchorage.
Begg appliance used high strength stainless steel
wires along with a number of auxiliaries and springs to
achieve I he desired tooth movement.
The treatment using Begg appliance is
carried out in three different stages. Stage one is
concerned with clignment, correction of crowding,
rotation correction, closure of anterior spaces and
achieving on edge to edge anterior bite. In stage two,
the remaining extraction spaces are closec while
maintaining the previous corrections thct have been
achieved. In the final stage uprighting and torquing is
carried out to achieve normal axial inclination of the
teeth.
The advantages of the Begg appliance
STRAIGHT WIRE APPLIANCE

The straight wire technique is a recent modification of

the edgewise appliance introduced by Lawrence F.
Andrews in the 1970's based on his six keys to normal
occlusion. The basic concept Aras to programme tne
bracket to have the first, second and third order
components so that the •vire need not have any
complex bending as 'ecuired in edgewise appliance.
D
Hence it is called reodjusted edgewise appliance.
This technique mode it possible to substantially reduce
the wire bending required and clso enabled good
finishing of cases (fig 28.c and d).

LINGUAL TECHNIQUE

The lingual orthodontic fechniaue was introduced 1976

by Craven Kurz. In this technique the brackets are
placed on the palatal and lingual aspects of the teeth.
Both the edgewise and the Begg principles can be
employed in treatment. Ungual appliances are highly
esthetic but have the disadvantages of poor access
and difficulty in speech and maintaining oral hygiene.
STAGES IN TREATMENT
B
Fig 29 Levelling and alignment (A) Prio' to alignment
|B) Afte' ol'grrnent
nickel titanium or braided stainless steel archwire as
they apply gentle forces. Progressively larger diameter
wires ore ploced to acheive the objectives of levelling
and alignment.

Levelling and alignment Over bite reduction

Levelling and alignment signifies bracketalignment in
both vertical and horizontal planes of space (fig 29}. In
addition during this phase of treatment all rotations are
corrected. Levelling and alignment are the major
treatment objectives during the early stage of
treatment. Achievement of objectives during this stage
would help in future tooth movements and
adjustments.
The initial levelling and alignment is
achieved by use of light round archwires such as
Correction of deep over bite should be undertaken
soon after Ihe alignment phase. Overbite reduction
334 Orthodontics - The Art ancj Science
should precede overjet reduction inorder to have a
smooth movement of teeth in the horizontal plane.
I. FricUon or sliding mechanics : Once the brocket
slots hove aliigned it allowes the archwire to slide
through the posterior bracket slots. Thick rectangualar
stainless steel wires such as .018" x .025" or .019' x

Fig 30 (A} and (Bj Ovcrb'te 'eduction (Q end (D) levelling of the excessive curve of Spee

Deep over bite are corrected by intrusion of the .025" are used for the purpose of anterior
anteriors or by extrusion of the posterior teeth, the retraction.Hooks are soldered
choice should be based on a number of factors
including the skeletal and dental growth pottern of the
individual, lip configuration and the inter-occlusal
clearance (for more details see the chapter on
management of deep bite). Incisors can be intruded by
using intrusion utility arches and arch wires with onti
curve of Spee in the mandibular and exagerated curve
of Spee in the maxillary arch. Posterior extrusion can
be acnieved by use of bite planes and vertical elastics.

Overjet reduction and space closure

Fig 31 SI'ding mechcnics :or redaction of anterior teeth
One of Ihe major objectives of treatment with fixed
appliances is to obtain a normal overjet relationship
between the upper and lower arches and to obtain a
Class I canine relationship. Added to this we have an
additional objective of closing ony residual space
specially in cases where some teeth have been
extracted for orthodontic purposes.
There are two types of mechanics used for
anterior retraction. They are the friction and the
frictionless mechanics.
Fig 32 Diffcc-If fixed appliances (A; & (B) Readjusted edgewise appliance • cerarn'c braces (C) & (D) Preadjusted edgewise
appliance - meta ic braces {El & (FJ Begg appliance (G| & |H| Tipcdge appliance
Fig 33 Components o' f'*cd cppliorcos (A) Brackets (BJ Bands (Cj Torcuinc auxiliary {DJ Lingo c I button (E) U prig h ti rig
spring (F)Ligatjro wire |G) Intra-oral e C sties (H) BLCCHI tuoes JiJ Lock Pns |J) Open coil saring (K) Ligat ng r ngs (L) Elastic
chain
 loop mechonics con be done by two ways
1. Enmass retraction : Here the entire antcrio' segmented is
retracted .This kind of retraction is more taxing on the anchorage.
2. Canine retraction followed by incisor retraction: The canines are
first retracted followed by the retraction of the incisors.This enhanses
the posterior anchorage control during space closure.

Final tooth positioning

This phase involves treatment aimed at finishing ard
occlusal detailing. This is thus a fine tuning of the tooth
posit'on in terms of the axial inclinations and
angulations and to optimize the

Fig 34 Loops used for anterior ro'rodion (A) arci w rc wi'h tear drop loco |B] <ey ho'e loop (C! T oop {D|
omega ! ooo

on to the archwirc either mcsicl or distal to the canine and elastics or niticoil springs
are aoplied from this post to tho hooks present on the molar bands (fig 31}. This
results in retraction of Ihe anterior teeth by the archwire sliding through tne
slots of the posterior brackets. Care should be taken to adeouately reinforce the
posterior onchoroge.
2. rricf/on/ess or /oop mechanics : this type of mechanics relies on spring and
loop designs aimed ot producing a controlled force system thot can be modulated for
anterior retraction or posterior protraction depending upon the anchorage
need of the patient, various designs of loops are available such as T loop, omega
'oop, key hole loop and tear drop loop (fig 34).

Anterior retraction cither by friction or the

Fig 35 F'rishirc ond detci ing nay rcqu<rc minor tooth movements in
first second or third order. Note how -ho occlusion in tho premolar
a'ea is improved by miror bends in -hft arch wire
328 Orthodontics - The Art ancj Science

occlusion. During this phase of treatment srnoller

diameter wires such as .016 inches stainless steel or
rectangular beta titanium are used as they are more
flexible and allow precise finishing. Minor arch wire
bends in first, second or third order may be required for
detailing of tooth position. Vertical settling elastics are
also used in this phase for settling of the occlusion.

Reference s

1. Begg. PR, Kesling PC : Begg Orthodontic Theory ond

Technique, Third edi'ion. Philocelphic, VVB Saunders Co,
1977.
2. Fastlichl.J : Tne universal Orthodomic clinic, Philadelphia, WB
Sounders Co, 1972.
3. Lindquist JT : The Edgewise appliance, in Grober TM, Swain
BF, Orthodontics : Current principles and Techniques, St
Louis, CV Mosby, 1995, 565-639
4. Proiilt WR: Conremporary Orthodontics, Si Louis, CV MosbyJ
986.
5. Robert E Moyers : Hand book of Orthodoxies, Year book
medical publishers, inc,19B8.
6. Thompson WJ: Modern Beyg : A combination of straight wire
oppliance and techn.ques in G-'aber TM, Swcin BF.
Ortlicdoivics : Current principles ard Techniques, St Louis, CV
Mosby, 1985, 717-789
7. Thurow RC : Edgewise Orthodontics, St louis. CV Mosby,
1982
8 Tweed CH : Clinical Orthodontics 2 Volumes. Si Louis, CV
Mosby. 1966
F //
ffGfifTfzax
unctional
or
appliances
myo-functional

appliances as they ore

sometimes referred to
improvement of the occlusion, and an altered relation
of the jaws. It also includes changes in the amount and
direction of growth of the jaws and differences in the
facial size and proportions.

are appliances that

depend upon the
>M
oro-facial musculature
,

ofunctional
iances
for their action. In
contrast •o active removable appliances that make use
of active components like springs, elastics and screws,
the force component of functional cppliances are
derived from the oro-facial musculature. These
appliances either transmit, eliminate or guide the
notural forces of the musculature.
Functional applionces ore used for growth
modification procedures that are aimed ot intercepting
and treoting jaw discrepancies. They can bring about
the following changes :
1. An i ncreasc o r dcc rca so i n j a v/ si ze
2. A change in spatial relationship of the jaws
3. Change in direction of growth of the jaws
4. Acceleration of desirable growth
Functional applionces are defined as •oose
fitting or passive appliances which harness
natural forces of the oro-fccial musculature that
ore transmitted to the teeth and alveolar bone
through the medium of Ihe appliance.
The theoretical basis of functional
treatment in general is the principle that o 'new
pattern of function' dictated by the appliance,
leads to the development ol a corresponding
'new morphologic pattern. The new pattern of
function can refer to different functional
components of the orofacial system, for example,
the tongue, the lips, the facial ond masticatory
muscles, the ligaments, ond the periosteum.
Depending on the type of appliance, its
proponent puts more emphasis on one of these
different functional components. The 'new
morphologic pattern' includes a different
arrangement of the teeth within the jaws, an

i-.,
CLASSIFICATION OF FUNCTIONAL to the teeth for the purpose of correction of re
APPLIANCES malocclusion. Examples include oral screen crc inclined
340 Orthodontics - The Art ancj Science
planes.
Functional applionces can be classified in a number of
ways (table 1):
Table 1 Classification of myofunctional
TooJ/i borne passive app/Ionces : They are tooth
appliances
borne appliances mat have no intrinsic force gencra'irg
components such as springs or screws. They depend
Group II appliances : These appliance.- reposition the
on the soft tissue stretch and muscular activity to
mandible and the resultont force s transmitted lo the teeth
produce the desired treatment results. Examples of
and other structures Examples include activator and
tooth borne passive appliances includes activator,
bionator.
bionatorand Herbst appliance.
Group Hi appliances : These appliances alsc i reposition
Tooth borne active appliances : They include
the mandible but their area ol operatior is the vestibule,
modifications of activator and bionator that include
outside the dental arch. Examples include Frankel
expansion screws or other active components like
appliance and vestibular screen
springs to provide intrinsic force tor transverse or
antero-posterior changes.
TREATMENT PRINCIPLES
T.:ssue borne passive appliances : Tissue borne
Functional appliances work on two brocc principles:
appliances are mostly loeated in the vestibule and
1. Force application
have little or no contact with the dentition. Example of
2. Force elimination
such an appliance includes the Functional Regulator of
Fronkel. Myotonic appJ/onces : They are functional
Force application
appliances that depend on the muscle mass for their
action. Compressive stress and strain act on the structures
involved ond result in a primary alteration in form with a
Myodynamic appliances : They are functional
secondary adaptation in function. Most o:
aapliances that depend on the muscle activity for their
function.

.Removable funcf/o/ia/ app/iances r They are

myofunctional appliances that can be removed and
inserted into the mouth by the patient. Examples
include activator and bionator.

Fixed functional appliances : They are functional

appliances that are fitted on Ihe teeth by the operator
and cannot be removed by the patieni al will.

Group f appliances : They consist of appliances

thattransmitthe muscle force directly

I. Tcoth borne active appliances •Tooth borne passive

appliances Tissue borne passive appliances . li. Myotonic

appliances

Myodynamic appliances

III. Removabie functional appilances Fixed

functional appliances

IV. Group I appliances

Group II appliances

Graip III appliances

the fixed ond removable functional appliances work on
this principle.
Force elimination
This principle involves the elimination of abnormal and
restrictive environmental influences on the dentition
thereby allowing optimal development. Thus function is
rehabilitated with a secondary change in form.
All functional appliances are assemblies of a
few simple components. Each component has a
desired function and is generally incorporated for a
specific purpose. The currently used appliances are
made of combinations from three basicfundionol
components. They are bile planes, shields or screens
and construction or working bite. These components
produce skeletal and den- toalveolar changes by acting
on the following :
5. Unimpeded posteriortooth eruption may also result in a
downward and backward mandibular rotation that
tends to increase anterior vertical lower facial height
and reduces the prognathism of the mandible
Inclined planes may be designed to provide guide
planes for the labiolingual mechanical eruptive displacement
of incisors or the buccolingual deflection of erupting posterior
teeth.
It should be remembered that as upper posterior
teeth erupt, they migrate not only in a vertical but also in an
anterior direction. Therefore, impeding or slectively arresting
the eruption of maxillary molars not only permits the relative
increase of mandibular dentoalveolar height, but also results
in a relatively greater mesial or anterior movement of the
lower buccal segments, both through eruption and also by
their forward translation, which is produced by normal
mandibular growth. With the diminished or arrested eruption

1. Eruption (bite ploncs) of the maxillary molars, this combination of effects can be

2. Linguofacial muscle balance (shields or screens) expected to result in the improvement of a Closs II molar

3. Mandibular repositioning (construction or working relationship. Conversely, if the lower posterior leeth are

bite) restrained from erupting while the uppers do so unimpeded,

The details of these components vary the expected result would be an improvement in a Class III

qualitatively and quantitatively as does Ihe con- molar relationship.

figuration of the connecting elements and hence the

overall appearance (and name) of the appliance.

Bite planes
Bite planes may be flat or inclined, and anterior or
posterior, which contoct single or multiple teeth.
Although they are usually thought of as blocks of acrylic
resin, they may in fact be made of wire or any other
suitable material. Recent research indicates that
relatively low forces, if applied either continuously or
intermittently, are capable of impeding Ihe eruption of
teeth. Apically directed forces may therefore be
expected to impede or arrest eruption, other forces
may produce tipping or eruptive deflection from the
starting axiol inclination.
A flat anterior bite plane of sufficient di-
mensions to disocclude the posterior teeth may be
expected to have several effects. These effects may
comprise some or all ofthefcltaw-'ng:
1. Differential eruption of posterior teeth
2. Noneruption, relative or absolute intrusion of
incisors
3. Incisor overbite reduction
4. Disocclusion with removal of intercuspction may
well be responsible for any additionc! increments
of mandibular growth
 Table 2 Advantages and limitations of functional
All of the functional appliances are constructed to a
appliances
'construction or 'working bile registration. Such registrations
Advantages
332 Orthodontics - The Art ancj Science
of maxillomandibularrclation- ships are based on the
t. II enables elimination ot abnormal muscle lunction thereby aiding in
assumption thai by displacing the mandible from its rest
normal deveiopment.
position, and thus stretching Ihe muscles attached to it, reflex
2. Treatment can be initiated at an ear,y age. It is mc«t
activity tends to restore the mandible to a postural position
otten started in the mixed dentition period.
thai was originally determined by the unstretched muscles.
3. As the treatment is started at an early age,
Hence, most construction bites are taken at a vertical
psychological disturbances associated with
dimension that is beyond the freeway spacc or interocclusal
malocclusion can be avoided.
clearance. In addition lo this increase in the verticci
A. These appliances are mostly fabricated al the dental
dimension, the construction bite may also displace Ihe
laboratory. Thus less chair side time is spenl which
mandible in the sagittal and transverse planes.
enables more patients to be treated.

5. The frequency ot the patient's visit to the orthodontist ACTION OF FUNCTIONAL APPLIANCES
is less than In case of fixed or removable appliances.
Functional appliances are capable of producing the following
6. They do not interfere with oral hygiene maintenance.
changes:
7. West functional appliances are worn during ihe n>ght.
1. Orthopaedic changes
Thus patient acceptance is gocd.
2. Dento-alveolar changes
Limitations
3. Muscular changes
They cannot be used in aduit patients In whom growth

has ceased.
Orthopaedic changes
They cannol be used to bring about individual tocth
1. Myofunctional appliances are capable of accelerating the
movement.
growth in the condylar
Most functional appliances are dependent on the patient

for timely 'wear. Thus patient cooperation is essential

for the success of the treatment

They, may require pre-tunctional orthodontic tooth

movement for correction of minor local irregularities

that may interfere with the functional therapy.

Fixed appliance therapy may be required at the

termination of treatment for final detailing of the

occlusion.

Shields or screens
There is little doubt that the growing dentoalveo- lar
structures are plastic and responsive to linguofacial
muscle pressures. The so-called equilibrium theory of
tooth position predicts that over time tooth movement
occurs in response to any perturbation of the
homeostatic relationship between the radially
directed forces of the tongue and the opposing forces
exerted by the circumo— muscles of the lips and
cheeks. Vestibular shie'ei or oral screens and lip pads
have been used :: sheild the muscles away thereby
allowing unrestricted growth of the jaws and
dentoalveolar structures. They are also used to
transmit muscle forces on to the dentoalveolar
structures.

Construction or working bite

 region. considerations : An ideal case for functional appliance
2. They can bring about remodeling of the glenoid therapy is one that is devoid of gross local irregularities like
fossa. rotations and crowding. Only in uncrowded cases is it likely
3. They can be designed to have a restrictive that a malocclusion can be treated satisfactorily by functional
influence on the growth of the jaws. appliance alone. The local irregularitiesaretreoted prior to or
4. They can change the direction of growth of the after functional therapy with fixed appliances. S^e/eta/
jaws. considerations ; Moderate to severe skeletal Class II
malocclusions are ideally suited for functionol applionce
Dento-alveotar changes
treatment. Class II, division 1 malocclusion exhibiting a Class
They can bring about dento-alveolar changes in the II skeletal tendency duetoashortor retrognathic mandible can
sagittal, transverse and the vertical directions. Most be considered for functional therapy.
functional applionces allow the upper onteriors to tip Low angle cases (i.e.horizontal growers) respond
palatally ond lower anteriors to tip labially. In the well as most functional opplionces encourage vertical
transverse direction, they can bring obout exponsion of development of posterior teeth. High angle (vertical growers)
the dental arches by incorporating screws in them or by Class II cases are usually of two categories: those with
shielding the buccal muscles away from the dental increased overbite and those with some degree of open bite.
arch. In the vertical plane, they can be designed to The deep over bite type of high angle cases are successfully
allow selective eruption of teeth. treated using functionol appliances while the open bite type
of cases pose a special problem. Most functional appliances
Muscular changes
allow vertical development of the posterior dentoalveolar
Functional appliances can improve the tonocity of the structures which may induce unwanted backward rotation of
oro-facial musculature.
the mandible.
Class II, division 2 type of malocclusions may be
CASE SELECTION
treated with functionol appliances after
The traditional view that functional appliances are only
suited to treot Class II, division 1 malocclusion with
uncrowded lower arches is largely discarded iri recent
years. A wider range of coses is being treated in recent
years using functional appliances as most of the coses
may require some form of finishing with fixed
appliances. Age : The growth modification therapy
using functional appliances is possible only in o
growing patient. The optimum time for myofunctional
therapy according to most authors in between 10 years
of age and pubertal growth phase. Socio/
considerations : As stated by Andresen, functional
appliances achieve their results with minimum
supervision and unlike fixed appliances can be worn
safely for long periods without supervision.
Unfortunotely all cases cannot be treated with
functional appliances alone. Patients who live far away
from the clinic or those attending boarding school may
benefit from these appliances, provided they fulfil all
other criterias for case selection. However such
patients should exhibit high degree of motivation if the
functional therapy is to be successful. Denta/
 Fig 2 Visuol "reafment objective 'o visualize the lil profile at llio termination 0> myofunctional therapy

Fig ' (A) Ft net ion Regjlntor ll (B' Activator (Cj Herbst cppl.arce (DJ Jasper J.jrrpo' ISIVesMbuior screen |FJ Bionctor

correcting the axial inclinations of the maxillary anteriors.

 Mild Class III malocclusions, which present with
a reverse overjet and an average overbite can be
regarded as potentially treatable with functional
oppliances. There is as yet no strong clinical evidence of
beneficial skeletal effect in the use of Class III functional
appliances and most reported cases have demonstrated
only dento-alveolar change.

VISUAL TREATMENT OBJECTIVE

This is an important diagnostic test undertaken before
making a decision to use a functional appliance. This test
enables us to visualize how the patient's profile would be
after functional appliance therapy. It is performed by
asking the patient to bring the mandible forward. An im-
provement in profile is considered a positive indication
forthe use of a functional appliance. In case the profile
worsens, then other treatment modalities nave to be
considered. Photographs of the potient taker with forward
mandibular posture are a valuable aid in motivating the
patient and parents (fig 2).

VESTIBULAR SCREEN
The vestibular screen is a simple functional appliance Ihal
takes the form of a curved shield of acrylic placed in the
labial vestibule (fig 3). This myofunctional appliance was
first introduced by Newell in the year 1912.

Principle
The vestibular screen can be used either to apply the
forces of the circumoral musculature to certain teeth or to
relieve those forces from the teeth thereby allowing them
to move due to forces exerted by the tongue. Thus the
vestibular screen works on the principles of both force
application
as well as force elimination.
5. The models are covered with 2-3 mm of wax over
the

?
ig 3 Ves-ibUor screen Fig 4 Addtiona! screen is placed on the I'rguol csper
Indications of -he teetn

labial surface of the teeth anc the alveolar

The following are tne indications for the use of
process. In cose of proclined teeth which need to
vestibular screen :
be retracted the wax relief is removed to expose
1. These appliances have been used mostly to
the incisal one-third of the teeth.
intercept mouth breathing habit. They can also be
6. The appliance is fabricated using either self cure
used for interception of habits such as thumb
or heat cure acrylic resin.
sucking, tongue thrusting, lip biting and cheek
7. The appliance is smoothened using sand paper
biting.
and polished.
2. Mild disto-occlusions can be trected using the
vestibular screen. Management of the appliance
3. They con be used to perform muscic exercises to
The patient should be asked to wear the appliance at
help in correction of hypotonic lip ond cheek
night and 2-3 hours during the day time. The patient is
muscles.
instructed to maintain lip seal. During
4. The vestibular screen can be used to correct mild
anterior proclination.

Fabrication
1. Upper and lower impressions are made and the
working models poured. The casts should
reproduce the depths of the vestibular sulcus.
2. The upper and lower casts are occluded in normal
intercuspationand the models sealed together using
plaster. In case the appliance is being used for
correction of disto- occlusion, a construction bite
should be taken to advance the mandible.
3. The vestibular screen should extend into the sulcus
to Ihe point where the mucosal tissue reflects
outwards. Care should be taken nor to impinge on
the frenum and the muscle attachments.
4. Posteriorly the appliance should extend upto tne
distal margin of the last erupted molar.
 Myofunctional Appliances 337
the first few days the oatienf may show certain areas of
irritation in the sulcular and the frenal areas. Such
areas of the appliance should be carefully trimmed to
avoid tissue irritation.
Modifications ot the vestibular screen
A number of modifications of the vestibular screen are
possible. The following are some of them :
a. Hotz modification : The oral screen can be
fabricated with a metal ring projecting between
the upper and the lower lips. This ring can be
used to cam/ out various muscle exercises.
b. In patients who have tongue thrust habit an
additional screen is plcced on the lingual aspect
of the teeth. This additional screen is attached to
the vestibular screen by means of a thick wire
that runs through the bite in
I the lateral incisor region (fig 4).
c.In case of mouth breathers the vestibular screen
should be fabricated with a number of holes that
are gradually closed ir a phased manner.
LIP BUMPER
The lip bumper or lip plumber as it is sometimes called
is a combined removable - fixed appliance. The lip
bumper can be called a modified vestibular screen that
is used for muscular force application or force
elimination. The appliance can be used in both the
maxillo and the mandible to sheild the lips away from
the teeth.
Uses of tip bumper
1. They are used in patients exhibiting lower lip
habits such as lip sucking. The lip bumper shields
the lower lip away.
2. They are also used in patients exhibiting
hyperactive menlalis activity that causes
flattening or crowding o;the lower anteriors. Thus
lip bumpers are mostly used in the mandibular
arch end rarely in the maxillary orch. By removing
the soft tissue forces from the labial aspect of tne
lower anteriors it may produce toward tilting of
These teeth under the influence cf fhe tongue
pressure. Thus they increase the arch length,,
'educe crowding end decrease the excessive
overjet.
3. Lip bumpers can be used to augment anchorage.
The muscular force transmitted on to the molars in
a distal direction would discourage the forward
movement of the molars.
4. Distalization of tne first molars can be achieved by
use of iip bumpers. The degree of distal movement
can be very limited, especially where the second
molars are erupted.
5. The lip bumpers can be used as space regainers if
the lower rriolars have drifted mesially due to early
loss of dcciduous molcrs.
Appliance design
The appliance is mode of thick stainless steel wire
extending from one molar lo Ihe opposite molar. The
wire is made to lie a wo y from the anterior teeth so that
the lips are kept away from the teeth. The lip bumper is
inserted into round molar lubes of 0.93mm diameter
soldered to bands on the
 6. Children with lack of vertical development in lower facial

heighl
338 Orthodontics - The Art ancj Science
Contraindications

1. Tne aoplarce is not used in correction of Class I

problems of crowded teeth caused by disharmony

betwsen tcotfi size and jaw size.

2. The appliance is ooniraindicated in children with

excess lower facial height and extreme vertical

mandibular growth.

3. The appliance is not used in children whose lower

incisors ate severely procumbent.

F g 6 Activator
4. The appliance cannot be used In chttiren vdth nasal

first molars. The anterior portion of the wire from canine stenosis caused by structural problems within the

to canine can be reinforced with acrylic nose or ctironic untreated ailergy.

1 5. Tbe appliance has limited application in non-

ffig 5}.
Although lip bumpers are mostly used in the growing individuals.

mandibular arches, they can also be used in the forward it reduced the risk of airway obstruction.
maxillary arch. Sucn an appliance is similar in design Viggo Andresen in 1908 in Denmark
and is called Denholtz appliance. developed a loose fitting appliance which he firs?
The lip bumper con be custom made using used on his daughter. He made a modified Howley
0.9mm hard round stainless steel wire or are readily type of retainer on the maxillary arch to which he
available in various sizes. added a lower lingual horse shoe-shaped flange
which helped in positioning the mandible forward {fig
ACTIVATOR
6). He made this appliance on his daughter who was
Kingsley in 1879 devised a vulcanite palatal plate to be going on a 3 month vacation. On her return 3 months
used in patients having retruded mondible. Tnis later, he found a marked sagittal correction and
vulcanite plate consisted ot an anterior incline that improvement of the facial profile.
guided the mandible to o forward position when the
patient closed on it.
Hotz devised a 'Vorbissplatte' which was a
modified form ol Kingsley's plale. This was used to treat
retrognathism associated with deep bite. It was also
used to treat retrognathism associated with lingually
inclined lower incisors.
Pierre Robin devised an appliance called
Monobloc made up of a single block of vulcanite. He
used it to position the mandible forward in patients with
glossoptosis and severe mandibular retrognathism. By
positioning the mondible
Table3 Indications and contraindications of activator

Indications
1. Class Jl, division 1 malocclusion

2. Class II. division 2 malocclusion

3. Class III malocclusion

4. Class I open bite tnatooclusicn

5. Class I deep bite malocclusion

6. As a preliminary treatment before major fixed

appliance ttorapy to. improve skeletal jaw- relations

7. For post-treatment retention


And resen colled itbiomechanical working retainer. Later
And resen moved over to Norway and teamed up with
Karl Haupl end brought about lot of changes in his
device. They called it Functionol JawOrthopoedics.
As Andresen and Hcupl were in Norway while
developing the appliance, it become known as
Norwegian apoliance. They later called it the activator
due to its ability to activate m use'e forces.
Indications of activator
It is primarily used in actively growing individuals with
favorable growth pattern. The maxillary and mandibular
teeth should be well aligned. The mandibular incisors
should be upright over the basal bone. Refer to table 3 for
the indications and contraindications of activator.
Advantages of activator therapy
1. It uses existing growth of the jaws.
2. During treatment the patient experiences minimal
orol hygiene problems.
3. The intervals between appointments is long.
4. The appointments are usually short due to need for
A
In addition o t n is myotactic reflex, a
condylar adaptation by backward and upward growth
occurs.
Athird facor is the force generated while
swallowing and during sleeping. According to Harvo;d,
Woodside and Herren passive tension coused by
stretching of muscles, soft tissue, tendinous tissue,
etc., are responsible for the action. They called it the
viscoelastic property'.
Construction bite
The construction bite is an intermaxillary wax record
used to relo'e the mandible lo Ihe maxilla in the three
dimensions of space. They are used to reposition the
mandible in order to improve the skeletal inter-jaw
relationship. The bite registration involves
repositioning the mandible in a forward direction as
well as opening the bite vertically (fig 7). In most cases,
the mandible is advanced by 4-5 mm and the bite
opened to the extent of 2-3 mm beyond the freeway
space. The general considerations for construction bite
are: 1. In case the overjet is too large, the forward

minimal adjustments.
5. Due to the above reasons they are more
economicol.

£>/sadvantages of activator therapy

1. Requires very good patient co-operation.
2. The activator cannot produce a precise detailing
and finishing of the occlusion. Thus post-treatment
fixed a ppl iance therapy maybe needed for
detailing of Ihe occlusion.
3. It may produce moderate mandibular rotation
(anteriorly downwards}. Thus activators are not
used in cases of excessive lower face height.
Mode of action of activator
According to Andersen ond Haupl, the octivotor induces
musculoskeletal adaptation by introducing a new pattern
of mandibular closure. The appliance loosely fits into tne
mouth. The patient has to move the mandible fon/zards
to engage the appliance. This results in stretching of the
elevator muscles of mastication which starts contract'ng
thereby setting up a myotactic reflex. This generates
kinetic energy which causes :
a. Prevention of further forward growth of the
maxillary dento-alveolar process.
b. Movement of the maxillory dento-alveolar process
distally.
c. A reciprocal f o ward force on the mandible.
 positioning is'donestep wise in 2-3 phases.
In case of forward positioning of the mandible by 7-8
350 Orthodontics - The Art ancj Science
mm, the vertical opening should be slight to
moderate i.e. 2-4 mm.
If the forward positioning is not more than
Construction bite with opening and posterior
positioning of the mandibh : In Class III
malocclusion, the bite is taken after retruding the
mandible to a more posterior position. In addition, the
bite is opened sufficiently

Fig 71,A) Mo crs ir Class I relation (B) Wax

3- 5 mm, then the vertical opening can be

4- 6 mm.

Low construction b if e with marked mandibular

forward posrt/on/ng ; This kind of construction bite is
characterized by marked forward positioning of the
mandible but minimal vertical opening. As a rule of thumb
the anterior advancement should not exceed more than 3
mm posteriorto the most protrusive position. Vertically the
opening is minimal ond is within the limits of ihe
inter-occlusal clearance. This kind of activator
constructed with marked sagittal advancement but
minimal vertical opening is called an 'H activator1. The H
activator is indicated in a patient with Class II, division 1
malocclusion having a horizontal growth pattern.
H/gh' construction bite with slight manc/rbu/ar forward
positioning : The mandible is positioned anteriorly by 3-5
mm only and the bite is opened vertically by 4-6 mm or a
maximum of 4 mm beyond the resting position. This kind
of activator constructed with minima! sagittal
advancement but marked vertical opening is called a 'V
activator1. The V type of activator is indicated in a Class II,
division I malocclusion having a vertical growth pattern.

Construction biYe without mandibular forward

posrtJonr'ng : Sometimes a construction bite without
forward positioning of the mandible is made in cases such
cs deep bite and open bite.
to clear ihe bite. In general o vertical opening of 5 mm with 2 vertical loops. The ends of the vertical loops
and a posterior positioning of about 2 mm is required. enter the acrylic body between the canine and
deciduous first molar for first premolar). The labial bow
Fabrication of activator
con be active or passive.
Impressions : Impressions of the upper and lower
Fabrication of the acrylic portion : The appliance
arches are made to construct 2 pairs of models:
consists of 3 parts.
1. Study models
a. Moxillary part
2. Working models
b. Mcndibullar oarf
c. Inter-occlusal part
Bite regis,Va f ion :
Tne aopliance can be fabricated by using

1. The amount of sagittal and vertical advancement either heat cure resin or cold cure resin. In case of heat

of the mondible is planned. cure resin the models are first waxed and then they are

2. A horse-shoe shaped wax block is prepared t for flasked.

insertion between the upper and lower teeth. It Management of the appliance :
should be 2-3 mm thicker than the planned 1. The patient should be sufficiently convinced obout
vertical opening. the benefits he is going to derive by using the
3. The patient is made to sit in an upright relaxed activator. In this respect a good patient-doctor
and non-strained position. relation is essential. The dentist can make use of
4. The mandib'e is guided to the desired sagittal video tapes, booklets etc., to motivate the patient.
position. The operator should merely guide the 2. The patient is also taught how to use, ploce and
mondible using the thumb and forefinger. He remove the appliance by himself.
should not use pressure or force.
5. The patient is asked to practice placement of
mandible at the desired sagittal position a few
times before registration of the bite.
6. The horse-shoe shaped wax block is placed over
the occlusal surface of the lower cast and is
gently pressed so as to form the indentations of
the lower buccal teeth.
7. The wax block is placed on the lower jaw and the
patient is asked to bite at the desired sagittal
position.
8. It is then removed and placed on the models and
checked.
9. If found all right, it is chilled and once again tried
on the cast. The excess wax is trimmed off.
10. The hardened wax block is ogain tried in the patient's
mouth.

Articulation of the mode) : The wax bite registration is

placed on the occlusal surface between the upper and
lower models. The models are then oriiculated in a
reverse direction so that the anterior *eeth face the
hinges. This kind of articulation ensures sufficient access
to the palatal surface of the upper and linguo surface of
lower models during the fabrication of the appliance.

Preparation of the wire e/ements : The usual design

requires an upper labial bow. The labial bow is made with
0.8 or 0.9 mm wire and consists of o horizontal section
3. Usually the patient is asked to wear the appliance
for 2-3 hours a day during the day time for the first
342 Orthodontics - The Art ancj Science
week. During the second week the patient is asked
to wear it for 3 hours during the day as well as while
sleeping. In case tne patient has difficulty in using it
the whole night, more daytime use is prescribed
until the patient can use it for the entire night. 4. A
trimming plan should be developed based on the
individual needs of the patient. Some orthodontists
prefer the appliance to be worn for a week withour
any grinding so that the potient can get used to it.
Trimming of the activator for sagittol control
Selective trimming of the activator can be done to
protrude or relrude ihe anterior teeth and also to
improve the molar relation of the buccal teeth.
Protrusion of incisors : In case the incisors should be
protruded, lingual surface of the teeth is loaded with
acrylic and a passive labial bow is given that is kept
away from teeth to prevent periorcl soft tissues
contacting the teeth (fig 8.e). This acrylic loading of the
lingual surface can be of two types.
a. Entire lingual surface is loaded. Since the area of

Trimming of fhe activator ; After fabrication of the contact is more the force for proclination is also

activator it's usually found to fit tightly as acrylic is low.

interposed between the upper and lower occlusol b. Only the incisal portion of the lingual sur- foce is

surfaces. Planned trimming of the appliance in tooth loaded. As acrylic contact is small greater degree
of force is generated to tip the incisors labially.
contcct area is carried out to bring abourdento-alveolar
Retrusion of incisors: The acrylic is trimmed away from
changes so as to guide the teeth into good relation in oil
Ihe lingual surfacc and an active labial bow
the 3 planes of space.
Selective trimming of acrylic is done in the
direction of tooth movement. The acrylic surfaces that
transmit the desired force by contact with the teeth are
called guiding planes. The areas of acrylic that contact
the teeth become polished.
Approximate trimming can bo done on the
plaster casts. However, final trimming should be done at
the chair side.

Trimming of activator
Trimming of activator for vertical control Selective
trimming of the activator can be done to intrude or extrude
the teeth. Intrusion o I 1eeth : Intrusion of the incisors
are achieved by loading the incisal edge of these teeth
with acrylic. In case labial bows are used, they should be
placed below the area of greatest convexity i.e. incisally,
to aid in Ihe intrusion (fig S.oJ.
In case intrusion of posteriors is neecei then
only the cusp tips are loaded with aay.c The fossae ond
fissures are free of acrylic (fig 8.z This applies a vertical
intrusive force on the rr<z- lars.
Extrusion of teeth: In case of extrusion of rra incisors, the
lingual surface is loaded above rr« area of greatest
convexity in the maxilla and bfr- low the area of greatest
convexity in the mc> dible. The extrusive movement can
be enhances by olocing a labial bow above the area of
grecr- est convexity i.e. in the gingival 1/3 of the lab'o
surface (fig 8.c).
In case of molars, extrusion is brougrr about by
loading the lingual surface above the area of greatest
convexity in maxilla and belo* the area of greatest
convexity in mandible (fi-c 8.d).
ng 8 Trimming of activator (A) For incisor intrusion (B) For molar intrusion {Q For incisor
extrusion (D) For molar extrusion T) For incisor prcclinafion (FJ For incisor retrod inction -|G) For transversa expansion of the orch (HI For
transverse contraction cf the arc'i. Note The b'ock do> 01 the labial sorface of ihe incisor indicates labial bow
 Fig 9 lr Class il malocclusion, the maxillory
mo ors are allowed to move distclly while the
mandioular molars ore allowec ro move
mesially by loadinc me maxillary mos
o-lincual surface and mandi bi. la r
d's:o-lingua I surfucc

Movement of teeth in transverse plane It is possible to

trim the activator to stimulate expansion of the buccal
segment. This is done by ollowing the contact of the
acrylic on the lingual surfaces of Ihe teeth to be moved
transversely (fig 8.g). But better expansion is possible
by placing a jack screw in the activator.

Modifications of activator
Over the yeors a number of modifications of the
classical activator have been described.

The bow activator of AM. Sc/nvorz : The

is used to bring about retrusion of the incisors (fig 8.f).

Movement of posterior teeth in sagittal plane : The
teeth in the buccal segment con be moved mesially
and distally to help in treating Class II and Class III
malocclusion. In Class II malocclusion, the maxillary
molars are allowed to move distally while the
mandibular molors are allowec to move mesially by
loading the maxillary mesio- lingual surface and
mandibular disto-linguc! surface.(fig 9)
 Fig 10 Bow activator of A.M. Schworz

Fig 11 Wunde'ers modification

bow activator is a horizontally split activator having a
maxillary portion and a mandibular portion connected components and consists of acrylic that covers the
together by an elastic bow (fig 10). This kind of maxillary buccal portion like an oral screen. This acrylic
modification allows step wise sagittal advancement of
the mandible by adjustment of the bow. In addition this portion extends into the inter-occlusal area and also as
design allows certain amount of transverse mobility of
the mandible. a lingual flange fhat helps position the mandible
The independent maxillary and the man- forward.
dibular portions can have a screw incorporated to
Cutout or palate free activator : This is a modification
allow arch expansions.
proposed by Metzelder to combine the advantages of
bionator and the Andresen's activator. The mandibular
WundereHs mod/fication : This is an activator
portion of the appliance resembles an activator while
modification that is mostly used in treatment of Class III
the maxillary portion has acrylic covering only the
malocclusion. This type of activator is characterized by
palotal aspect of the buccal teeth and a small part of
maxillary and mandibular por- ~ons connected by an
the adjoining gingiva. The palate thus remains free of
onterior screw. By opening ^he screw the maxillary
acrylic thereby making the appliance more con-
portion is moved anteriorly, with a reciprocal backward
thrust on the mandibular portion (fig 11)

The reduced activator or cybemator of Schmufh :

This modification of the activator is oro posed by
Professor G.RF. 5chmuth. This op- cliance resembles
a bionator with the acrylic por- •on of the activator
reduced from the maxillary anterior area leaving a
small flange of acrylic on the palatal slopes. The two
halves may be connected by an omega shaped palatal
wire similar to bionator.

The propu/sor : This is an activator modification

conceived by Muhlemann and refined by Hotz. This
appliance can be soid to be a hybrid appliance that
combines the features of both the monobloc ond the
oral screen. The propulsor is devoid of any wire
346 f Orthodontics - The Art and Science

_________________________________________ C ------------------------------------------------------------------------------
Fig 12 Pre end post treatment records of a patent treotec with activator. (A} Pre ireatment photographs (B) Photographs of appliance in tne
mouth {Q Post treatment photographs.
venient for patients to we o r the applicnce for longer hoiJrs. Due
to the greater amount of wearing time, success should be greater
with the palate free activator. According to Dr Klaws Metzelder
the appliance is excellent in mandibular positioning in TMJ
dysfunction cases.

The 'Karwetzky modification : This consists of maxillary and

mandibular plates joined by o 'U' bow in the region of the first
permanent molar. The maxillary and mandibular plates not only
cover the lingual tissues and lingual aspect of teeth, it also
extends over the occlusal ospect of all teeth.
This type of activator allows stepwise advancement of the
mandible by adjustment of the U loop.
The U loop has a larger and a shorter arm. Based on their
placement pattern we can have three types of Karwetzky
activators. Type I: This is used in the treatment of Class II,
division 1. In this modification, the larger lower leg is placed
posteriorly. Thus when the two arms of the U bow ore squeezed
the lower plate moves sagitolly forwards.(fig 13.a) Type I f : This
is used for the treatment of Class III malocclusion. Iri this
appliance the larger lower leg is ploced anteriorly. Thus when the
U bow is squeezed the mandibular plote moves distally (fig 13.b).
Type III: They are used in bringing o bout asymmetric
advancements of the mandible. The U bow is attached anteriorly
on one side ond posteriorly on the other side to allow asymmetric
sagital movement of the mandible.(fig 13.c & d)
This activotor allows mobility of the mandible ond therefore
makes the activator more comfortable to wear. The appliance
ollows gradual and sequential forward positioning of the lowor
[aw.
Herren's modification of the activator:

Fig 13 Karwetzky modification [A} for Class I! r>clocc'usion (B) for

Class III rrulocc usion (C) & (D) for assy metric saottol movement
11 e tren modified the octivator in two ways : Frankel has based his appliance on tne following
1. By over-compensating the ventral position of tne principles :
mandible in the construction wax bite. VesribuJor arena of operotion : According to Fronkcl,
2. By sealing the appliance firmly ogoinst the
the dentition is influenced by periora muscle function.
maxillary dental arch by means of clasps (ar-
Abnormal perioral muscle function creates a barrier for
rowhead, triangular or Jackson's}.
the optimal growth of the denlo-clveolar complex. Thus
The construction bile is taken in a strong
the Frankei appliance is designed to hold oway the
mandibular protrusion. Herren recommends maximum
muscles (buccal and labial) from the dentition, so that
forward positioning of the mandible reaching
the dento-alvcloor structures ore free to develop. In
sometimes the feasible maximum. This advanced
addition, Ihe Frankel appliance ads as an exercise
position of the mondible causes the retractor muscles
device or an oral gymnastic devico that aids in
to try to bring the mandible back to original position.
correction of the abnormal perioral muscle function.
This causes a bockwardly directed force on the upper
teeth and a mesial directed force on the lower teeth. Sogiffa/ correc/iori via foofh borne moxilfary anchorage

According to Herren, with every 1 mm increase of : The Frankel appliance is anchored firmly in the
forward position of the mandible, ihe sagirtol force on maxillary arch by means of grooves in the molar and

the jaws will increase by 100 gm. The amount of for- canine regions. The mandible is positioned anteriorly
ward positioning of the mandible is 3-4 mm beyond the by means of an acrylic pad that contacts the alveolar
neutral occlusion i.e. in case of Class II molar relation bone behind the lower anterior segment. This lower
the mandible is brought forward to Class I molar plus lingual pad ads more asa proprioceptive trigger for
an additional 3-4 mm forward. A vertical opening of 2-4 postural maintenance of the mandible.
mm is recommended.
Triangular or Jockson's closps are used to
firmly scat the appliance to the maxillary dentition.
Expansion screws can be used for expansion.Mobility
of the mandible is restricted by extending the lingual
flange of the activator as far os possible towards the
floor of the mouth.

FUNCTION REGULATOR

The Function Corrector or Function Regulator is a

myofunctional appliancedeveloped by Professor Rolf
Frankel of Germony. This oppliancc is also called
Frankel appliance, vestibular appliance and oral
gymnastic appliance.
The Frankel appliance has two main
treatment effects. First ir serves as a template against
which the cranio-facial muscles functio-- Tne
framework of the appliance provides c~ arrificial
balancing of the environment therec* promoting more
normal pattern of muscle adivir* Secondly, the
appliance removes the muscle forces in the labial and
buccal areas that restrict skele'a growth thereby
providing an environment which enables skeletal
growth.

The Frankel philosophy

Differential eruption guidance : The Frankel appliance
is free of the mandibular teeth. This allows seledive
eruption of the lower posterior teeth which aids in
correction of the discrepancy in the vertical dimension
and also helps in sagittal correction of Class II
malocclusion by allowing upwarcl and
movement of only the mandibular teeth.
Minima) maxillary basa.' effect : It has been noted that
in most Class II malocclusions, the maxillary position is
close to normal while the mandible is retruded. The
Frankel appliance has relatively little retrusive sagittal
effect on the maxilla in contrast to the marked
protrusive change in mandible.
Periosteof pull by buccaf shields and lip pads : The
buccal shields and lip pads are extended to bring about
outward periosteal pull. This aids in bone formation at
the apical base.
Mode of action of Frankel appliance
The following are the effects of the Frankel appliance
on the dento-alveolar structures.
Increase in transverse and scgittol intraoral1
The buccol shields and lip pads play an important role
in eliminating the abnormal forces octing on Ihe
dento-alveolar structures from the perioral region and
at the same time favour forces acting from within the
oral cavity (i.e. tongue). In addition, the buccal shields
ond lip pads exert a constant outward pull on the
connective tissue and muscles which is transmitted to
the underlying bone by means of fibres inserted into
the periostium of the bone. This tissue pull on the
periostium causes bone formation ond also aids in
lateral movement of the dento-alveolar shell.
fnc/ease in vertical spoce : An increase in vertical
intra-oral space is possible as the Frankel appliance is
kept free from the posterior teeth. The posterior teeth
are free to erupt.
Mandibu/ar protraction ; The lingual pad guides the
mondible to o more mesial position.
Thus the position of the mandible is changed in due
course of time by gradually training
protractor/retractor muscles and by condylar
adoptation. Whenever the mandible is brought back,
the linguai oads apply pressure on the lingual alveolar
process. This immediately causes the protractor
muscles lo position the mondible mesially.
Muscle function adaptation : The Frankel appliance
helos in overcoming the abnormal perioral muscle
forward activity and rehabilitates the muscles that are causing
the problem. The lip pads and shields cause periosteal
muscle pull leading to bone formation. The pads and
shields massage the soft tissues and improve blood
circulation. The shields loosen up the tight muscles
and improve muscle tone. Tho lip pads prevent
hyperactivity of the mentalis muscles, eliminate lip trap
ond help in establishing proper lip seal.
Frankel has recommended certain oral
exercise called oral gymnasts. Some of the exercises
recommended are:
a. To keep the lips closed ot all times. This can be
aided by osking the patient to. keep a piece of
paper between the lips.
b. Swallowing, speaking etc., become more or less
an exercise when the oppliance is used.
space :
Types of functional regulators
F R J : They are used tor treatment of Class I and Class
II, division 1 malocclusion. The FR1 is divided into the
following three types: FRla - used for Class I
malocclusion where there is minor to moderate
crowding. It is also used for Class I deep bite cases.
FR1 b - used for Class II, division 1 malocclusion where
overjet does not exceed 5 mm. FR1 c - used for Class
II, division 1 malocclusion in which the overjet is more
than 7 mm.
the
FK2 ; They ore used for treatment ot Class II, dento-alveolardevelop In addition they also cause
358division
division 1 and Orthodontics
2. - The Art ancj Science
periosteal deposition.
FR3 : They are used for treatment of Class III. Palatal bow : The palatal bow has its conv facing
FR4 ; They are used for treatment of open bite distally. The palatal bow should stand eleer' of the
and bimaxilliary protrusion. palatcl tissue. The lateral extension of -.r,t bow crosses
FK5 ; They are functional regulators that
the occlusal surface in the embrosu» mesial to the first
incorporate headgear. They are indicated in long
permanent molar and enters the acrylic buccal shield.
face patients having a high mandibular plane The recurved ends o' the palatal bow terminote cs
angle and vertical maxillary excess. occlusal rests on rr^ occlusal surface of the first
The FR 2 of Frankel is the most commonly permanent molars between the mesio-buccal and
used appliance and would therefore be discussed in distobuccal cusps. These occlusal rests prevent the
detail.
appliance frorr being dislodged superiorly and also
preverr supraeruprion of TIIC first permanent molars.
Functional regulator 2 of Frankel
Canine /oops : The canine loops act cs extensions of
They are used for treatment of Class II, division 1 and
the vestibular shields and are kep' 2-3 mm way from
division 2 malocclusion. The FR 2 consists of acrylic
the buccal surface of the canines. They are also called
ond wire components (fig 14). The acrylic components
canine guards. They help in elimination of the
include :
restrictive muscle function thereby helping in
a. Buccal shields
transverse development in the conine region.
b. Lip pods
c. Lower iingual pod Lobioi bow : The upper labial bow originates from the
vestibular shields. The wire runs in the middle 3rd of
The wire components include :
the labial surface of the maxillary incisors. It turns
a. Palatol bow
gingivally at right angles at Ihe distal margin of the
b. Labial bow laterol incisors. The labial bow should be bent in an

c. Canine extensions ideal.contour and not in the contour of malpositioned

teeth. This bow is passive in nature. In case of FR ill
d. Upper lingual wire
the labiol bow is adapted ori the labial surface of the
e. Lingual crossover wi r e lower anteriors.

f. Support wire for lip pads

9 Lower lingual springs

Up pads : The lower lip pads are also called Pellots.

The lip pads help in elimination of abnormal perioral
muscle activity i.e. hyperactive mentolis muscle
activity. It helps in eliminating lower lip trap which
causes or accentuates the proclination of upper
incisors. In addition, the lip pads cause periosteal pull
which results in bone growth. In case of FR ill, the lip
pads ere placed in Ihe maxillary vestibular region.

Buccal shields : The buccal shields are called the

vestibular shields. The buccol sir ore made to
extend as deeply into the vesti as possible within
the confines of patient co and tissue attachment.
These shields stand a from the dentition and
basal alveolar bone, helps in unrestricted
 mucosa 3-4 mm below the linguol gingival morgin of

Pig H Components of Frankel II appliance : fAJ Labial bow, |8) Carine loop, {C} Upoer lingual wire, (DJ Lingua! crossover •mre, (E) Support wire
for lip pen's, Buccol slde'd», |G) Lio pods, (H) Polatal bov/. (I) Lower lingual pad, (J) Lower linguol soring s.

Ungual stabilizing bow : This wire is also called the lower incisors. It is placed 1 -2 mm away from the
upper lingual wire or protrusion bow. It originates from mucosa. This wire crosses the occlusal surface
the vestibular shields ond passes between the upper between the deciduous molars and gets embedded in
canines and first deciduous molars ond curves along Ihe buccal shields.
the linguol surface of •he upper incisors ot the evel of
the cingulum. This wire prevents the linguol tipping of
the incisors during treatment.

Lower /inguo/ springs r These wire components rest

against the lingual surface of the lower anteriors. The
main uses of the lingual springs ore as follows:
a. To prevent supra-eruption of the lower incisors.
b. To screen the tongue oressure from lower
incisors.
c. To procline the lower incisors actively. This is
done when they are retroclined.
The springs get embodied in the linguol
pad.

Lingua/ crossover wire r This is made of 1.25 mm

stainless sfeel wire. It follows the contour of the linguol
Labia/ support wires : This is made of 0.9 mm wire.
They offer support for the lip pods. This wire should be appliance should be used during deciduous, mixed
at least 7 mm below the gingival margin. The central
362 VOrthodontics
wire is inverted - The Art
shaped to accommodate theancj
lower Science
and early permanent dentition.
labial frenum. Another wire emerges from the lip pad FR 3 has two upper lip pads. The lip pads
and gets embedded in the buccal shields.
are lorger and more extended than the lower pods of
Functional regulator 1 of Frankel FR 2. The pads appear teardrop shaped in sagittal
The FR 1 of Frankel has 3 modifications. section. They should lie in the depth of the vestibular
a. FR1 a sulcus parallel to the alveolus. The purpose of the lip
b. FR1 b pads are:
c. FR1 c 1. To eliminate the restrictive pressure of the upper
F.R 7 a : FRla is used in Class I malocclusions with lip on the underdeveloped maxilla
mild to moderate crowding. It is also used for Class I 2. To exert tension on the tissues and periosteal
deep bite cases. All aspects of FR 1 are similar to FR 2 attachments in the depth of the maxillary sulcus to
except that it lacks the lingual shield, lingual springs, stimulote bone growth.
lingual crossover wire, and the upper lingual bow seen 3. To transmit the upper lip force to the mandible
in FR 2. The applionce consists of acrylic parts and through the lower labial arch for a retrusive
wire components. The acrylic parts include: stimulus. Some of the forces are also transmitted
a. 2 vestibular shields via the vestibular shields.
b. 2 lip pads The buccal shields stand away from the
The wire components include: moxillary posterior dentoalveolar structures by about
a. Palatal bow 3mm. The buccal shields are in contact with the
b. Labial bow mandibular apical bone. They serve to eliminate the
c. Labial support wire buccinator muscle force and also cause a periosteal
d. Lingual Bow pull leading to bone growth.
e. Canine Loops Labial support wires connect the lip pads
Unlike in FR 2 and 1 b, the lingual acrylic together and to the buccal shields. The labial bow
pad is absent. A lingual bow is present that helps in
forword positioning of Ihe mondible.
The FR 1 has a canine loop that passes
through the embrasure mesial to the first deciduous
molar. This helps to guide the erupting canine.
FR? b r The FR1 b is used to treat Class II, div 1
malocclusion where the overjet does not exceed 5mm.
It differs from FR 1 a in that it has the lingual acrylic
pad. Among the wire components the lower lingual
springs are odded.
FRlc ; The FRlc is used in Class II, div 1 malocclusion
where the overjet in more than 7mm. In FRlc the
buccal shields are split horizontal and vertically into 2
parts. The anteroinferior portion contains the wires for
the lingual aery;-: pad and lip pads. This permits the
fonworc movement of the anterior section of the
appliance. The space created is filled with self cure
acrylic Thus FRlc is used when multiple stage
advancement is needed. \
Functional regulator 3 of Frankel
The FR 3-(fig 16} is indicated in Class II!
malocclusions characterized by maxillary skeletc!
retrusiori and not mandibular prognathisfh. The
 A

Fig IS Pre end pest- trectrrent

photographs of a patient with
mandibular retrogna:hisTi <reoted
with r R II applicnce (A)
Pre-trea-rrent photographs (B| &
(C) Post- treatment photographs.

C
 Fig 16 FR 3 of Frcnkel
is placed in Ihe lower arch. Protrusion bow is seen
behind the upper incisors to stimulate forward
movement of these teeth. The palatal bow lies slightly
away from the mucosa to prevent irritation. It crosses
the palate behind the last erupted molar
Functional regulator 4 of Frankel
The FR 4 is used for correction of open bites and to a
lesser extent bimaxillary protrusion. Its use is almost
exclusively confined to the mixed dentition. The FR 4
has the same vestibular configuration as FR 1 and 2. It
locks canine loops and protrusion bows. It consists of 4
occlusal rests on the maxillary first molars and first
deciduous molars lo prevent tipping of the appliance.
The palalol bow is like in FR 3 placed distal to last
molar.
Functional regulator 5 of Frankel
They are functional regulators that incorporate heod
gear. They are indicated in patients with long face
syndrome having a high mandibular plane angle and
vertical maxillary excess.
The appliance consists of posterior acrylic
bite blocks that prevent molar eruption due to the
action of elevator muscles of mandible. Head gear
tubes are incorporated that are used forextrooral
traction.
Construction bite
For minor sagittal problems, the construction bite is
taken in on edge to edge incisal relationship making
sure there is no obvious strain of the facial muscles.
Frankel has recommended that the construction bite
should not move the mondible forward further than 2.5
to 3 mm. He recommends a small vertical opening that
is only large enough to permit the crossover wires to
pass through the inter-occlusal area. In practice there
must be at least 2.5 mm to 3.5 mm clearance in the
buccal segments to allow the crossover wires to pass
through.
For;FR 3 the bite registralion is taken with
the patients mandible in the most comfortable refruded
position. In general the vertical opening is kept to a
minimum to allow lip closure wilh minimal strain.
Separation and seating grooves
the appliance in the vestibule.
Before making the impressions, separators (heavy
elastic separators) ore placed in the maxillary
BIONATOR
canine-first deciduous molar embrasure and in the
The bionator was developed by Baiters during the early
deciduous 2nd molar-first permanent molar embrasure.
1950's. It had much in common with the octivator. However
This procedure is carried out to provide sufficient room in
it differed from the conventional activator in that it was less
the embrasure for the seating of the crossover wires. If
bulky and more elastic. There are three types of bionator:
the separation does not create enough space it is
a. Standard appliance
necessary to slice the distal contact of the upper second
b. Class III appliance
deciduous molar os well as the deciduous canine and
c. The open bite appliance
first deciduous molar.

Standard appliance
Wear time
This is used for the treatment of Class II, division 1 and
1 st few weeks : 2-4 hours/day (day time) After
Class I malocclusions having narrow dental arches. The
3 weeks : 4-6 hours/doy (daytime) After 3rd visit
standard appliance consists of a relatively slender acrylic
(2 months}: Full time wear.
The patient is asked to perform oral body fitted to the lingual aspects of the mandibular arch and
gymnastics i.e. talking, reading, tightly grasping part of the maxillary arch (fig 1 7). The acrylic extends upto
356 Orthodontics - The Art and Science
A
mandibular canine where it is bent to reach the upper

Fig 18 Biona'or (A) Class 111
the distal of the first permanent molars. The maxillary
plate covers only the molars and the premolars with
the anterior region remaining uncovered. The acrylic
extends 2 mm below the gingival margin. The
interocclusal space of some of ihe buccal teeth is filled
with acrylic extending over half of the occlusal surface
of the teeth to stabilize the appliance.
canines. It forms a mirror image on the opposite side.
The vestibular wire is kept away from the surface of
incisors by the thickness of a sheet of paper. The
lateral portions of the wire are sufficiently awoy from
the teeth to allow expansion of the arch.
Class HI appliance
This is used in mandibular prognathism. The acrylic

The wire components of the bionator are the parts are similar to the standard appliance. The palatal

palatal arch and the vestibular wire. The palatal orch is arch is placed in the opposite direction so that the

made of 1.2 mm diameter wire. It emerges opposite rounded arch is placed anteriorly. The vestibular wire

the middle of the firs! premolars and follows the runs over the lower incisors insteod of terminating at

contour of the palate forming a curve that reaches the the lower conines (fig 18.a).

distal surface of first permanent molars. The palatal

The open bite appliance
arch is kept 1 mm away from the mucosa. The
This is used in open bite cases. The palatal arch and
vestibular wire is mode up of 0.9 mm stainless steel
the vestibular wires are same as the standard
wire. It emerges from the acrylic below the contact
appliance. The maxillary acrylic portion is modified so
point between the upper canines ond premolars. It
that even the anterior area is covered (fig 18.b}. Its
rises vertically and is bent at right angles to go distolly
purpose is to prevent the tongue from thrusting
along the middle of the upper premolar crowns. Mesial
between the teeth as the tongue is responsible in
to the molar, a rounded bend is made so that ihe wire
runs at the level of the lower papilla upto the
bionalor (Bj Open bite b.onotor
most cases for the open bite. Bfte
Myofunctional Appliances a
registration
Bi'e registration is done in the same way as for the
activator. In most cases an edge to edge bite is
desiroble. If the overjet is too much o stepwise
advancement is preferred.

Indications of bionator
1. In a Class II, div. 1 malocclusion having following
features:
a. Well aligned dentol arches •
b. Retruded mandible
c. Not very severe skeletal discrepancy
d. Lobiol tipping of upper incisors. Fig 19 Twin block appliance

2. 'Class III malocclusion where reverse bionator premolar. The lower molars are kept free to help in their
(Class III bionator) con be used. eruption if needed. The upper and lower bite blocks
3. Open bite cases where open bite bionator con be interlock at a 45° ongle.
used.
Bite registration
TWIN BLOCK APPLIANCE
The twin block appliance is constructed after a bite

The twin block technique effectively combines inclined registration procedure as described for octivator. The
planes with intermaxillary and extraoral traction. The mandible is sagitally advonced by 5-7 mm. Vertically the
appliance consists of an upper and a lower plate having bite is opened by 3-5mm in the premolar region.
occlusally inclined bite planes thot induce fovourably
Orthopaetf/c traction
directed occlusal forces by causing a functional
In coses with severe skeletol discrepancy extra oral traction
mandibular displacement
is used. The Iwin block appliance uses a Concorde face
(fig 19).
The upper plate is retained by modified arrow bow that combines the extraoral traction with intermaxillary
head closps. The clasp can incorporate a tube for traction. The face bow is unique as it has a curved labial
attachment of a face bow. The upper plote con also hook. The face bow is attached to the maxillary molar. Inter-
have a jack screw in cose maxillary arch expansion is maxillary elastics can be used from the curved labial hook
required. The upper appliance consists of a bite block of Ihe face bow to the mandible. Extrooral traction of 200
that covers the lingual cusps of the upper posterior grams each side for 8-10 hours o day is prescribed.
teeth, extending onteriorly till the mesial ridge of the Intermaxillary force
upper second premolar. The lower plate is retoined by
interdental ball clasps. The lower bite block extends
distally upto the distal morginol ridge of the second
 B
D
Fig 20 Herbst applioncu : (A) Side view (B) Plunger and tube (Q Maxillory occlusal view (D) Mandibular occlusal view

of 150 gms is applied from lower appliance to the labial c. Significant changes in patient's appearance is seen in
hook of the Concord face bow. 2-3 months.

Fixed twin blocks HERBST APPLIANCE

The twin block appliance may be designed for direct
Herbst is a fixed functional appliance that was developed by
fixation to the teeth by bonding. It resembles a Herbst
Emil Herbst in the early 1900's. It was introduced to the
appliance, substituting occlusal inclined planes for
dental profession at the International Dental Congress in
telescopic tubes, to guide the mandible into a protrusive
Berlin in 1905. This appliance was soon forgotten and it
position.
was reintroduced in 1979 by Hans Pancherz who

Patient acceptance popularized ils use.

This appliance has.very good patient acceptance due to

the following reasons, o. The bite planes offer greater
freedom of movement in anterior and lateral excursion
than other functional appliances.
b. They offer less interference with normal function.
Indications for use of Herbst appliance
1. The Herbst appliance is indicated in correction ot
Class II malocclusions due to retrognathic the mandibular premolar region.
mandible.
2. They can be used as an anterior repositioning
splint in patients having temporomandibular joint The following effects arc seen when the Herbst applionce is
disorders. -
The following are the specific indications of 1.
the Herbst applicnce : Post adolescent pafrenfs:
Treatment with Herbst moybe completed within 6-8 2.
months. Thus it is possible to use the residual growth left 3.
in these potients.
Mouth breathers: Herbst appliance can be used in 4.
mouth breathers unlike other removable functional
appliances.
l/nco-operaf/Ve parents: It is a fixed appliance and is
worn 24 hours a day. Thus it can be used in 6.
unco-operative patients.
Descr/pt/on of the appliance
The appliance can be compared to an artificial joint
working between Ihe maxilla and mandible. A bilateral
telescopic mechanism keeps the mandible mechanically
in continuous anterior position. The device consists of a
tube into which the plunger (that resembles a rod) fits.
The tube is fixed to the distal end of the maxillary molars
while the rod is fixed to the lower first premolars (fig 20).
area while the shaft
Myofunctional Appliances
is fixed to pivots in
Treatment effects
used for the treatment of a Class II malocclusion :
Class I molar relation or over-corrected Class I molar
relation.
An increase in mandibular growth.
A certain amount of distal driving of the maxillary
molars that helps in the correction of molar relation.
Overjet reduction by increase in mandibular length
and proclination of mandibular incisors.
5. It has an inhibitory influence or. the sagiMal maxillary
growth.
Weislander suggests double contour of the glenoid
fossa indicating anterior transformation of the glenoid
fossa.
8. Increase in SNB angle and decrease in SNA angle.
Advantages
The following are the advantages of the Herbst appliance:
1. As it is a fixed functional applionce that is not removed by
the patient, the action it

Types of Herbst appliance

Broadly the Herbst appliance can be classified into two
types :
a. Banded Herbst
b. Bonded Herbst

Banded Herbst : Upper and lower first premolars and

first molars are banded. The tubes are fixed to pivots
soldered to the disto-buccal aspect of the upper first
molar bands. The shafts or rods ere fixed to pivots
soldered to Ihe lower first premolar bands.

Bonded Herbst : The bonded type of Herbst appliance is

a wire reinforced acrylic splint that covers the occlusal
and pari of the buccal and lingual surfaces of all tee'h
except the anteriors. The pivots are fixed to the wire
framework at the distobuccal aspect of the upper first
molars and the mesial aspectof the lower first premolars.
The tube is fitted onto the pivots in the maxillary molar
 ----------------- c -------------------------
fig 21 Pre and po$t--reatmer.t photographsof o pctient with mandibda' retro-gnathism 1-ea-cd using Herbs- appliance (A) Prctrcotmcnl phctog'cphs {B) Photographs of appliance in 'he mojlh (Q Pbst-treatment o
 • -v. 'i•••• • v-^- 'i; ... V
Myofunctional Appliances 361

produces is continuous. flexible. The Jasper jumper is construded of stainless

2. The treatment duration is short due to the steel coil that is ottached at both the ends to stainless
continuous nature of action. steel end caps. The module in given an opaque
3. Less patient co-operation is needed as it is a polyurethane covering for purpose of hygiene and
fixed appliance. comfort. The Jasper modules are ovailable in seven
4. It can be used successfully in patients who are at sizes ranging from 26mm to 38mm in length.
the end of their growth. The end caps are attached to the fixed
5. Herbst appliance can be used in patients who appliance at the maxillary posterior and mandibular
have mouth breathing habit due to nasal a i n^/oy anterior region. The force module is attached
obstruction. posteriorly to the maxillary arch by a ball pin that
passes through the face bow tube of the maxillary first
Disadvantages
molar. Anteriorly the module is anchored to the lower
1. Like ony other functional appliance it requires arch wire distal to the mandibular canine by a small
patientco-operation, as initial discomfort is bayonet bend and a lexan bead.
usually present. Since the force module is attached to
2. It can cause minor functional disturbances in the previously placed fixed appliances, care should to
masticatory system which are temporary and taken to have adequately thick arch wires.
gradually disappear.
3. There is a n i ncreosed risk for ihe development Indications for Jasper Jumper
of a dual bite, with dysfunction symptoms of the They are basically indicated in skeletal Class II
TMJ as a possible consequence. malocclusion with maxillary excess and mandibular
4. Repoated breakage and loosening of the deficiency.
appliance occurs, especially in the lower
premolar area. Mechanism of action
5. Plaque accumulation and enamel decalcification The force module is selected by measuring the
occur, especially in the splint type of appliance. distance between the mesial aspect of the upper face
6. Tendency for posterior open bite at the bow tube and the distol asped of the lexan boll distal to
termination of therapy. the mandibular canine. To this length, 12 mm is added
to get the required length of the force module.
JASPER JUMPER
Thus when the teeth come into occlusion,
The Jasper Jumper is a relatively new type of flexible, the force module being longer tends to curve thereby
fixed, tooth home functional appliance that was producing o mesial force on the mandibular arch and a
introduced by JJ. Jasper in the year 1980. Its adi ons a distal force on the maxillary arch.
re si m i la r to Herbstoppliancc, but lacks the rigidity.

Appliance design
The appliance uses a modulor system commonly
known os Jasper Jumper, which can be attached to
fixed appliances that are placed on the upper and
lower arches. This Jasper module is analogous to the
tube and plunger of Herbst appliance but is more
 of mandible 20% - Condylar
stimulation and 20% - Downward
and forward remodeling of
glenoid fossa.

Advantages of Jasper Jumper

1) Produces continuous forces.
2) Does not require patient

Fig 22 The Josper jumper

compliance by way of timely

wear.
3) Allows greater degree of
mandibular freedom than Herbst
appliance.
4} Oral hygiene is easier to maintain.

Effects of Jasper Jumper

According to Rankin, Parker ond Blackwood the
Jasper jumper brings about both skeletal ond
dento-alveolar changers in the rotio of 40:60 The
skeletal ctfecrs include :
1) Holds ond displaces the moxilla distally.
2) A small shift of point A distally. 3}
Clockwise rotation of mandible. 4}
Condyle moves forwards.
The dental changes of Jasper jumper are :
1) Posterior tipping and intrusion of upper molars.
2) Backward tipping of maxillary incisors.
3) Anterior translation ond tipping of mandibular
teeth.
4) Intrusion of mandibular incisors.
Jasper stoies that Class II correction with
ihis appliance is brought about by : 20% -
Maxillary skeletal restraining 20% - Backword
dento-alveolor movement of maxilla
20% - Forward dento- alveolar movement
 D
Fig 23 Pre ond post-treatment records of a patient treated with Jasper jumper. (A) Pre--rectment extroorol photographs (B) ?re-lreatment
intraoral photographs |C) Phologrophs of appliance in the mouth (D) PosMreatmcnt ex-raoral and intraoral photogrcphs.
References 28. Pancherz and Anchus-Pancherz : Heodgeor effect -s the
Herbst applionce. An-, J Onhod 1993; 510-52:
29. Raymond R Howe, James A. Mcnamara : Clinic-
1. Albert H. Owen : Clinical Management of the Frankel FR II
Management of the BonOed Herbst Applionce. . Clm Orhod
Appliance. J Clin Orthod 1983; 60S-618
1983; 456-463
2. Corels and van der Linden : Functional appliances mode uf
30. Remrner, Marnanoros, Hunter, and Wo y Cepholometric
odion. Am J Ortnod 1987; 162-168
changes associuted with ocivokx Frdnkei applionce, and
3. Carels and von Stcenberghe: Changes in neuromuscular
fixed appliance. Am J Orlbc»: 1985; 363-372
reflexes in masseter muscles during functional jaw
31. Robenson : Treatment changes in children treats; with
orthopedic treatment. Am J Orthod 1986:410-419
function reguiotor of Frdnkei. Am J Ortnod 1985 299-310
4. Clements and Jocobson : The MARS appliance. Am J Orthod
32. Sessie, Woodsioe, Bourque, Gurzn, Powell, Voudcura
1982. 445-455,
Metoxas, and Al:u : Effect of functional applionce: on jow
5. Creekmare and Rodney : Frdnkei applionce therapy. Am J
muscle activity. Am J Orrhod 1990; 222-23i
Orthod 1983; 89-108
33. Torek Zreik ; A Fixed-Removable Herbst Appliance - Clin
6. Crcekmore and Rodney: Frankel applionce therapy. Am J
Orthod 1994; vol : 246-248
Orthod 1983 ; 89-108
34. Terry G. Dischinger : EdgewisB Bioprogressivo Herb?
7. Folck ond Frankel : Effect ot Frdnkei applionce in treatmont of
Applionce. J Clin Orhod 1989; 608-617
mandibular retrusion. Am J Orthod 1989; 333-341
35. Valant and Sinclair : Treatment effects of Herbs; appliance.
8. Frankel and Frfinkel : A rejoinder. Am J Orthod 1987;
Am J Orthod 1989; vol : 138-147
435-436
36. Vargervik and Harvold : Activator treatment. Am - Orthod
9. Harvold and Vargarvik : Marpliogenetic response 1o ectivotor
1985; 242-251
treatment. Am J Orthod 1971; 478-490
37. Wiestander : Intensive treatment severe Class !
10. Ingervall and ThOer: Muscle activity during first year of
malocclusions with a, headgear Herost appliance ^ early
activator ireotmeni_Am J Orthod 1991; 361 -368
mixed dentition. Am J Ortnod 1984; 1-13
11. Larry W. White : Current Herbst Appliance Therapy. J Clin
38/ Wjes lander : long-term effect of treatment with
Ortnod 1994; 296-309
headgcar-Herbst applionce In ecnfy mixed dentition Am J
12. Luder : Skeletol profile changes refotcd to two pot- terns of
Orthod 1993 ; 319-329
activator effects. Am J Orthod 1982; 390- 396
39. WindmJ'ler : Evaluation of acrylic-splint Herbi' applionce. Ain
13. Mo m and ras and Allen ; Mandibular response 1o orthodontic
J Orthod 1993; 73-84
treatment with the Bionator appliance. Am J Orthod 1990 ;
40. Woodside, Metaxas, and Altuna : Influence of functional
113-120
appliance theropy on glenoid fosse remodeling. Am J Orthod
14. Marc H. Cooper ; Clinicol Aid: Motivating Frankel Patients. J
»987; 181-198
Clin Orthod 1984; 285-285
15. McNomaro and Huge : Functional regulator fFR-3) of Frdnkei.
Am J Orthod 1985; 409-424
16. McNamaro and Huge : The Frdnkei appliance (FR-2. Am J
Orthod 19B1; 478-495
17. McNamara, 8ookstein, ond Shaughnessy : Skeletal and
denial chances following functional regulator therapy. Am J
Onhod 1985 ; 91
18. McNamaro, Howe, ond Oischinger : Comparison of Herbs»
and Frankel appliances. Am J Orthod 1990; 134.144
19. Michel Amoric : Technique Clinic: Tharmoformed Herbst
Appliance. J Clin Orthod 1995; 173-173
20. Nelson, Harkness, and Herbison : Mandibular chonges
during functional applionce treotment. Am J Orthod 1993 ;
153-161
21. Noro, Tanne, and Sakuda : Orthodontic forces exerted by
activators. Am J Ortnod 1994; 169-179
22. Osven : Morphologic changes in transverse dimension using
Frdnkei appliance. Am J Orthod 1983; 200-21 7
23. Owen : Morphologic changes in the sagittal dimension using
the Frankei applionce. Am J Orthod 1981;
573-603
24. Pancherz : Cass II correction in Herbst aoplior<^ n-eotm. Am
J Orthod 1982; 104-113
25. Pancherz : Class II relapse after Herbst treatment. Ar J
Orthod 1991; 220-233
26. Pancherz : Muscle activity in Class II, Division malocclusions
treated by bite jumping wth the Herbs appliance. Am J
Orthod 1980; 321-329
27. Pancherz : The Herbst appliance. Am J Orthod 1985 vol ; 1
-20
I
n orthodontic practice, forces employed are
basically of two types. One is an orthodontic force
that moves teeth efficiently and the other an
orthopaedic force that affects the deeper cronio-facial
structures. Orthodontic forces are those that are
applied to the teeth by means of wires and other active
components of a removable or fixed oppliance. The
forces produced by these appliances are light and
range from 50-100 grams. The orthopaedic forces on
the other hand are heavy forces of over 400 grams

Orthopaedic Appliances
that bring about o change in the skeletal tissue.

BASIS FOR ORTHOPAEDIC APPLIANCES

Forces applied to the teeth have the potential to

radiate outwards and affect the nearby skeletal
structures. For such skeletal changes to occur, the
forces employed should be over 400 grams. Thus the
orthopaedic appliances utilize the teeth as handles to
transmit the forces to the adjacent skeletal structures.
In order to produce skeletal changes, consideration
should be given to the amount of force applied ond the
duration of force.

Amount of force
Heavy forces of over 400 grams totally compress the
periodontal ligament on the pressure side and cause
hyalinization which prevents tooth movement. These
heavy forces are conducted to the skeletal structures
to produce an orthopaedic effect.

Duration of force
Intermittent forces ranging from 12-14 hours a day are
believed to bring about minimum tooth movement but
maximum skeletal change. Thus most extra-oral
orthopaedic applionces ore worn 12-14 hours a day.
Increase in the duration of wear results in an increase
in the dental effects. The commonly used orthopaedic
appliances are head gear, face mask and chin cup.
HEAD GEAR The junction is the rigid joint of inner and
outer bow. It con be simple soldered, wire wrapped
Head gears are the most commonly used extra- oral
soldered or a welded joint. It is placed at the midline of
orthopaedic oppliances. They are used during the
the bows. When asymmetric forces are needed, the
growth period to intercept or correct certain skeletal
joint can be shifted from the midline.
malocclusions os well as to distalize the maxillary
dentition or maxilla itself. Head gears also form one of
The force element
the important adjuncts to control or gain anchorage.
It is that part of tne assembly which provides the force
They derive anchorage from the cervical orthe cranial
to bring about the desired effect. This may comprise of
regions.
springs, elastics and other stretchable materials. The
The head gear - face bow assembly hcs
force element connects Ihe face bow to tne head cap
three main components.
or ncck strap.
1. Face bow
2. The f o rce el e ment The head cap or cervical strap
3. The head cap or cervical strap
The appliance takes anchorage from the rigid bones of
the skull or from the back of Ihe neck by means of a
Face bow
head cap or neck strap or a combination of the two.
The face bow is a metallic component that helps in
The selection of this depends upon the individual
transmitting the extra-oral forces on to the posterior
patient needs.
teeth. The face bow consists of outer bow, inner bow
and the junction (figl). Principles in the use of head gears
The outer bow is made of 1.5 mm stiff round
Head gears have the ability to move the dentition and
wire and is contoured to fit around the face. The outer
the maxilla in all Ihe three planes of space. The
bow can be short, medium or long.
following factors should be considered when planning
Short - Outer bow is lesser in length than inner bow.
the use of head gears.
Medium - Outer bow length is equal to inner bow.
Centre of resistance of the dentition : The inner bow
Long - Outer bow is longer than inner bow.
of the face bow is generally attached to the maxillary
The distal end of the outer bow is curved to
first permanent molars through
form a hook thot gives attachment to the force element.
The inner bow is made of 1.25 mm round
stainless steel wire ond contoured around the dental
arch and molars. The inner bow is inserted into the
buccal tubes fixed on the maxillary first molars. Stops
are placed on the inner bow mesial to the molar tubes
to prevent the inner bow from sliding too far through the
tubes.

F y t Fucebow (A) Outer bow |8i Inner bow (Q Jurction


buccal tubes on these teeth. Thus the force acting on
the molars tends to displace them. A decision should
be made as to whether bodily movement or tipping of
the teeth is required. The centre of resistance for a
molar is usually at Ihe mid-root region. Forces applied
through the centre of resistance of the molors results in
their bodily movemenf (fig 2). If the force is applied
below the centre of resistance, it causes a distal crown
tipping while if it is above the centre of resistance it
causes distal root tipping.
Centre of resistance of moxido : The centre of
resistance of the maxilla os a whole should also be
considered when planning for head gears. It is beleived
to exist at Ihe poslerosuperior aspect of
zygomaticomaxillary suture {fig 4). Under clinical
conditions the centre of resis'ance of the dental arch as
a
whole should be considered. This is located between
Fig 2 Relation o; lino o:.force end the center of
resistance ot -he maxil cry rrolarfA) line of forcc
passing through "He center cf resis'cnco CCU58S
ncd ly movement cl -he nolo' (B! Line of ;orce cassing
above the cen-e' cf resis'arcc of ihe molar ccuses
distal root lipping (C) Lire o' fee e passing below the
center of resislarce of the molar causes distol crown
tipping
the roots of the premolars. Forces oussing Ihrough the
centre of resistance of Ihe maxilla produce translation
of the maxilla in a distal direction while forces passing
above or below this point cause rotation of the moxillo.
The pom,' of origin of the force ; Head gears derive
anchorage from the occipital region of the cranium or
the cervical region (back of the neck). Occipital head
gears produce a superior and distal force on the teeth
and maxilla, while cervical head gears produce on
inferior and distal force on the teeth and maxilla. Thus
an appropriate point of origin (or site of anchorage)
should be selected based on what type of tooth and
maxil la r/ movement would be beneficial for a given
potient.
 Point of attachment of force : The point of attachment and the upper dental arch. If the line of force passes
through the centre of resistance of
368/ Orthodontics - The Art and Science
refers to the hook present on the distal end of the outer

Fig 3 The length and

angulation of the oj'er bow
can affect the line of force.
A, B, and C represent
varying lengths and
arigulctions of the outer
bow. But oil rhe three of
ihem produce o • ine of forcc
that posses •hrough the
center of resistance of ihe
Fig '1 Center of resistance of naxi lary molar.
the maxila end the dental
orch

bow to which the force element is attached. It is

possible to alter the direction of the force to the maxilla
and the maxillary dentition by altering the point of
attachment. This con be done by varying Ihe length of
Ihe outer bow or by varying the angle between the inner
and outer bow (fig 3, 6, 7}.
Types of head gears
Based on fhe site of anchorage, head gears can be of
three types :
1. Cervical head gears
2. Occipitol head gears
3. Combination head gears

Cervical head gears : These head gears obtoin

anchorage from the nape of the neck (fig 5.a}. Cervical
head gears cause extrusion of the maxillary molars
leading to an increase in the lower facial height. They
also move the maxillary dentition and the maxilla in a
distal direction. These head gears are generally
indicated in low mandibular angle cases, as an
increose in lower facial height would be beneficial in
such patients.
It is important to cons id e r the relation of the
line of force to the centre of resistance of the maxilla
 type of
head
gear

the
produces a distal and superiorly directed force on the
maxilla,
maxillary teeth and the maxilla.
no
Combrnat/on head gears ; In this type of head gear,
rotation
occipital and cervical anchorage are combined {fig
of the
5.c). When the forces exerted by both ore equal, a
maxilla
distal and slight upword force is exerted on the
occurs. maxillary dentition and the maxilla. By varying the
proportions of the total force derived from the head cap
and the neck strap, the resultant force direction can be
altered.

1/9es of head gears

Orthopaedic effect : Forces applied onto the maxilla
can be used to restrict its downward and forward
growth. The distal force in such a case should be
applied through the centre of resistance of the maxilla.
B
It has been suggested thot forces in the range of
Fig 5 ;A) Cerviccl heod gecr (B) Occipital ncad gear (C)
Combination head gear 350-450 gms on each side for a minimum of 1 2 - 1 4
However when Ihe line of force passes below Ihe hrs/doy are required. Orthopaedic effects from
centre of resistance of the maxilla we can expect a extra-oral forces are best tapped in Ihe pre-adolescent
clockwise roration of the maxilla. Similar years.
considerations apply to the dental arch.
Ocdp/tcl need gears : These head gears derive
anchorage from the back of the head (fig 5.b). This
 Anchorage o eg me.'? iati o n : Extra-oral forces are Mo/or rciation : In order to derotate a molar, the molar
used to reinforce anchorage when those obtained from has lo be bonded with the buccal tube placed distally
end then subsequently repositioned. Correction is

Retai
l* cl
IT8>il
B

UfHKf
CKX

?
achieved by adjustment of the inner bow so dem
L»8 oj-i
3l'c«e that it produces a rotational force on the

A
Fig 6 Rclcrion of force vecor lo cen-e' 0: resis'oncs v/nen cersrlr.nl head gea's are jsec.(v\) ~he ' na ct force posses be'ow ihs cere' of resistance of cot
n the maxilla and the dcivit'or. "lis produces clockwise rotation of both -he mcx Ho end he centi-ion. {BJ Tie he of force passes aelow the center of
-osis-cnce of the no* I c aid cbove iha- of the den'ition. This prodjees cloclfwise ro'aticn o: rnaxi la and anticlockwise rotation o; the dentition.

intrc-orcl sources arc insufficient. The head gear molar. .As soon as the correction is achieved, the face
should be worn for approximately 10 hrs/day for this bow should be readjusted to apply a direct distal force.
purpose and force values of 300 gms/sideare usually Space maintenance : A most effective method of
sufficient. In Ihe maxilla, anchorage reinforcemeni is maintaining arcn length is by the use of extra- oral
achieved by restricting rhe mesial movement of forces. The mesial movement of molars is prevented
molars.
and the face bow does not interfere with erupting teeth.
DisJcr/izafion of molars : Distal movement of upper In this situation, doily wear of op proximately 8 hrs is
molars maybe required for correction of molar relation sufficient.
or to gain space for correction of crowding or retraction
of anteriors. Exlra-oral forces can effectively be used
for this purpose when worn fora minimum of 14 hrs per
day.
Unilateral distalization of molars can be
achieved using extra-oral force by varying Ine length of
the outer bow. Tne larger force is applied on the side of
tne longer bow. Asymmetric head geors used for the
above purpose are generally cervical or combination
tyoe.
 Orthopaedic Appliances 371

p
ig 7 Relation of force vector to center cf resis-cnce v/nen occipital head gears are used.(A) The he of force posses be ow 'he center of res'stcnce o: bo'h ihe maxilla ore
tie denti'ion. This coduces clockwise rotator of boln the moxillc and the dentit'or. (B) The I rs of force passes below Ihe center c-f res;stance of ihe rroxillo and above tnat
of -he deTi'ion. This a'odeces c ockw'se 'otction of maxilla end anticlockwise ro'otioi of tie dert'tioi.

FACE MASK traction of the mcxilla using extra- oral elastics which
generate large amounts of force upto 1 kg or more.
Head gears are generally used for the purpose of
reinforcement of anchorage or for maxillary
indications
distalization. However, when an anterior
1. It can be used in a growing patient having a
protractor/force is required, a protraction head gear is
prognathic mandible and a retrusive maxilla. It
used. Facial mask therapy has gained popularity in the
aids in pulling the maxillary structures forward and
last decade. The arinciple of pulling force on the
pushing the mandibular structures backward.
maxillary structures with reciprocal pushing force on
2. II can be used for bending rhe condylar neck for
the forehead or mandible through foetal anchorage is
stimulating temporo-mandibular joint adaptations
simple and mechanically sound enough to be used as
to oosterior displacement of the chin.
a therapeutic procedure for treatment of prognathic
syndromes, maxillary retrusions, clefts and mandibular 3. It con also be used for selective rearrangement of

prognathism. the palatal shelves in cleft oatients.

Hick'nam (1972} claims lie wos the first lo use

o reverse head gear. However, this modality was made
popular by Delaire around the same time.
A reverse pull head gear basically consists of
o rigid extra-oral framework which tckes anchorage
from tne chin or forehead or both for the anterior
4. It can be used in correction of post- surgical Frequency of use : Most authors recommend 12-14
relapse after osteotomies (or uncontrolled hours of wear a day.
post-surgical adaptations}.
5. It can be used to treat certain accessory problems
Parts of a reverse pull head gear
associated with nose morphology sucn as lateral The reverse pull head gear consists of the following
deviations. parts

Chin cup : Most protraction head gears obtain

S/tes of anchorage
Anchorcge for the purpose of mcxillan/ retraction can
be obtained from forehead, chin or from forehead &
chin.
Anchorage from chin : In this type of protraction head
gear which is commonly used in Britain, chin cup with
posts are employed. As tne anchorage is obtained
solely from the chin, the force is transmitted to the
condylar cartilage and thereby has a disadvontoge of
altering the growth of the mandible.
Anchorage from skufJ ; Certoin forms of reverse pull
head gears obtain anchorage only from the forehead.
The disadvantages include patient discomfort while
sleeping, cost and time required in fabrication and
fixing.
Anchorage from chin <& forehead r This face mask
makes use of anchorage from both the forehead and
chin. Anchorage is spread over a larger orea. Thus no
excessive force is exerted onto the growth cartilage.
However, the disadvantages with this applionce are
difficulty in speech and compromise in aesthetics and
comfort due to its size.
anchorage from the chin as well as the forehead. The
chin cup is used to take anchorage from the chin area.
It is usually connected to the rest of the face mosk
assembly by means of metal rods. The chin cup can be
ready-made or can be fabricated from an impression of
the patient's genial region.
Forehead cap : The forehead support or cap or strap is
used to derive anchorage from the forehead.
Elastics : Elastic force is used to appfly a forward
traction on the upper arch. Vertical posts of the chin
cup are used to attach the elastics onto the molar tubes
or hooks soldered on the orch wire. This sort of traction
is purely for tooth movement.
Intra-oral appliance : The most common type of
protraction device is a multibanded appliance with rigid
wire. Traction hooks are placed either in the molar or
premolar region. McNamara advocates a banded
R.M.E. along with the protraction device which more or
less resembles the banded Herbst appliance.

Biomechanics! considerations
Amount of force : The amount of force required to
bring about skeletol changes is about I pound (or 450
gms) per side.

Direction of force : Most authors recommend a 15-20°

downward pull to the occlusal plane to produce a pure
forward translotory motion of the moxilla. If the line of
force is parallel to the occlusal plane, a forward
translation as well as an upward rotation takes place.

Duration of force : The time taken to achieve desired

results is proportional to the amount of force utilized.
Low forces (250 gm/side} take 13 months to produce
desired results. However, very high force values like
1600-3000 gms reduced treatmenttimeto 4 - 21 days.
Fig 8 (A) Cerv'ccl head gear
(B) Combination pull head geor
(C) Occ'pital head gear (D) Deloir face
mas< (E) Cl'i n cup with head gear Afte'
placement, the junction of the face bow
is between tne lips (G! Head cap (H)
Force elerncnl -I! Siancordfocebow
 Fig 9 Dei aire type of foce rrosk

Me id fro me : The main component of a face mask
assembly is the metal frame. It connects the various
components sucn as the chin cup and forehead cap. It
also hos provision to receive elastics from the intraoral
appliance. The design of the metal frame differs bosed
on the type of face mask.
wire framework which is squarish and kept o way from
the fccc.- It hos a forehead cap and a chin cup with a
wire running in front of the mouth used for elastic
attachment.
Tub.:nger mode.1 : This is a modified type of Deloire
face mask. It consists of a chin cup from which

Types of reverse pull head gear originates two rods that run in the midline and is
shaped to avoid the interference of nose. The superior
Protroction head gear by Hickham : Developed in the
ends of the two rods house a forehead cap from which
early 60's, this appliance uses the chin and top of the
elastics encircle the head. In addition, a cross bar
head for anchorage. The force distribution is as follows
extends in front of the mouth which can be used to
- 15% head, 85% chin. It consists of two short arms in
engage elastics. The forehead cap and cross bar con
front of the mouth to engage maxillan/ protraction
be odjusted by sliding along the rod frame-work to suit
elastics. II also has a chin cup from which originates
the individual patient, (fig 10)
two long arms. The two long arms run parallel to the
tower border of 'he mandible and go vertically up from
the angle of mandible and end behind the ears. An
elastic strap is attached lo ^he end of the long arms to
encircle the head.
The advantages of the appliance include
relatively better esthetics and comfort than others
Fig 0 Tubinger ot race mask

with the option of unilateral force applicability. By

adding a rubber cushion under one arm, force to that
side can be allered.

Face mask of Defa.re : This was popularized by

Delaire in the 60's and also uses the chin and forehead
for support (fig 9). The appliance is made up of a rigid
 Orthopaedic Appliances , 375

Fig 11 Pe'it tyoe of face rrosk

Petit type of face mask : This is also a modified form

of Delaire face mask (fig 11). It consists of a chin cup
ond a forehead cap with a single rod running in the
midline from foreheod cop to chin cup. A cross bar at
the level of the mouth is used to engage elcstics. The
advantage of this model is that the forehead cap, chin
cup and the cross bar can be adjusted to suit the
patient.

CHiN CUP

The chin cup or the chin cap as it is sometimes refered

to is an extro-oral orthopaedic device that covers the
chin and is connected to a head gear. It is used to
restrict the forward and downward growth of the
B
mandible. The chin cup-face bow assembly consists of
Fig 11 (A) Occipital put chin cup (B) Vertical pull chin cup
a chin cup that covers the chin, a head cop and an
adjustable elastic strap that connects the chin cup with
the heod cap.

Types of chin cups

Chin cups are of two types. They are the occipital pull
chin cup and the vertical pull chin cup.
OcrfpifaS pufi1 chin cup ; This tyoe of chin cuo derives
anchoroge from the occipital region of the heed (fig
6.a). This is the most commonly used type of chin cup.
It is used in Class III malocclusions associated with
mild to moderate mandibular prognathism. They are
very successful in patients who can bring their incisors
close to
an edge to edge position at centric relation. They are
also indicated in patients witn slign^y protrusive lower
incisors as they invariably produce lingual tipping of Ihe
lower incisors.
Vert.'ca.9 pui'i1 chin c up : This type of chin cup derives
anchorage from the parietal region of the head (fig
6.b). It is indicc*ed in patients with sleep mcndibjlar
plane ongle and excessive anterior facial height.
These patients usually exhibit an cnterio»"open bite.
Fabrication of the chin cup
Chin cups are either fabricated individually for the
patient or pre-fabricoled commercially available chin
15. Roberts ard Stbte.ny : Use of face niosk in treatment
o: maxillary skeletal retrusion. AT J Orthod 1988 ;
388-394
16. Rune et a : Dosteroanterior Taction in moxil onasol
dysplasia. Am J Orhod 1982 ; 65-70
17. Sa kern oto : Effective timing for application of
orhopedic fo'ce in skcleto Class III mclocclusion. Am
J Orthod 1981 ; 41 1-416
18. Sakamoto, Iwase, Uka, end Kokamura : A
rocntgerccephalometric study of ske etal changes
during and after chin cup treatment. Am J Orhod 1984
; 341-350
19. Wende I, Nando,Sokcnoto, or.d Nakamura: Tne
effects of chin cup -heropy on the mandible. An J
Ortnod 1985; 265-2/4

cups can be used. The fabrication of chin cup requires

on impression *o be taken of the chin area. The cast is
poured and tne chin cup fabriccted using self cure
acrylic resins.

Force magnitude and duration of wear

At 'he time of appliance delivery a force of 150- 300
grams per side is used. Over the next two months Ihe
;
o'ce is gradual ly increased to 450- 700 crams per
side. The pa-ient is asked to wear the appliance for
12-14 hours a day to cchieve the desired results.

References
5. Hocevor : Face frame onchoroge for closing soccas
by protraction. Am J Orthod 1 988 ; 516-524
6. Hocevor : Orthodontic force systems. Am J Orthod.
1982 ; 277-291
7. Jocobson A: A key to the undemanding of cxtro oral
forces. Am J Orthod 1979; 75 : 173-181
8. Michael R Morcotte : Biomechanics in Orrho- dontics.
BC Decker Inc, Phlodelph o, 1990
9. Mcndc : A modified protraction heedgear. Am J
Orthod 1980; 125-139
10. Nando : Protract on of maxiila in rhesus monkeys by
controlled extraoral forces. Am J Orlhod 1978 ;
121-141
1 1. Profitt WR: Contemoorary Orthodontics, St Louis, CV
Mosby, 1986.
12. Ritycci end Nor da : Effect of chin cup the'apy on
croniol base and m dfoce. Am J Orthod 1986 ;
475-483
13. Rooert E Moyers : Hand oook of Orhodontics, Yecr
book medicol publishers, nc,l 988.
14. Robert J Nico , : Bioengeneering Analysis of
Orthodontic Mecnarics : Lea ond -'ebiger. Phi a-
delohic, 1985

9 Bovyden DtJ; Theoretica considerations o; heod-

gear •heropy : A literature review, ^art I . Mechonical
principles, Br J Orthod 1 978; 5 :145-152.
T
reatment plan is an outline of all the measures
that can be best instituted for a pat'ent so as to
offer maximum, long term benefits.
Patients seek orthodontic treatment for a
voriety of reasons. The orthodontist should plan out a
treatment modality based on thorough examination
and sound diagnosis in a systematic foshion. As no
simple formulo cook - book approach exists, each case
should be assessed and a customized treatment plan
formulated to suit the individual patient.

SE7T/WG UP GOALS

From a patient's point of view, the basic need for

orthodontic treatment is imorovement in esthetics and

treatment Planning
function. The orthodontist, has an added goal in the
form of treatment stability. The orthodontist snould aim
at providing quality treatment that will remain relatively
intact for many years to come after the therapy's
completed.
Most patients are satisfied once the anterior
teeth are straightened. But it is the responsibility of the
orthodontist to educate the patient on the importance
of mov'ng teeth to positions that stand for stability. The
orthodontist should not succumb lo the temptation of
terminating the treatment as soon as the anterior teeth
are straightened as such treatment invariably results in
unstoblc dental positions that tend to relapse.
In many cases achieving all the three goals
i.e., esthetics, function and stability may be quite
difficult. The orthodontist should strike o balance in
'ulfilling the major esthetic desires of the patient within
the bounds of keys that stand for stability.
 Orthodontics - The Art and Science

ENLISTING THE TREATMENT limitation to the corrective procedures to be

OBJECTIVES
The orthodontist should enlist the problems thot hove
to be ottended to in o decreasing order of priority. The
problem list helps in setting up objectives and possible
solutions to the problem.
While setting up the objectives, the potient's
chief complaint and parental desires should be given
adequate weightage. Most potients seek treatment to
improve esthetics or function. If the orthodontist
considers certain other objectives more important, for
an overall solution to the problem or to achieve long
term stability, then adequote explanation should be
given to the patient.
The orthodontist must be realistic in setting
up objectives. They should reflect the potient's needs,
the doctor's own level of competence, patient co-
operation, etc.,.
undertaken arc may also predispose to relapse of a
treatec malocclusion. Comprehensive orthodontic
therapy should thus involve removal of the cause.
Wnile this is possible in cases where the etiolog» is
obvious, it may not be possible if the cause is elusive
or unknown.
PLANNING THE FINAL INTERINCISAL
RELATIONSHIP
Establishment of an ideal inter-incisal relationship is
one of the pn'me objectives that should be planned.
C/ass I Incisor relationship
In a patient presenting with a Closs I malocclusion, the
interincisal relation is usually satisfactory. Thus
provision should be made in the treatment plan to
preserve the integrity.of this relationship (fig 1 .a}

ASSESSMENT OF GROWTH POTENTIAL Class II, division 1 Incisor relationship

In a patient presenting with Class II, division 2
Tne growth status of an individual is an important factor
malocclusion, the severity of the presenting skeletal
that should be considered while planning treatment.
discrepancy usually determines the choice of
A patient who is still growing presents the
treatment and mechanics. If these potients present
orthodontist with numerous options that exploits the
with a underlying Class I skeletal pattern, then
individual's growth potential. The orthodontist can
retroclination of the rnaxillory incisors may be suficient
modulate growth of the dento-facial structures, con
to produce a normal interincisal relationship (fig 1 .b).
guide teeth into more favourable positions and can
In case of a mild Class II skeletal pattern, a
undertake therapeutic procedures to prevent and
camouflage treatment by
intercept malocclusions. In an adult, Ihe treatment
options are limited to moving teeth and surgical
correction.
The growth status of the individual should
Ihus be determined prior lo treatment planning so as to
carry out appropriate treatment procedures.
ASSESSMENT OF ETIOLOGIC FACTORS
The etiologic factors responsible for the malocclusion
should be determined anc adequate steps should be
planned for their elimination. The continued presence
of the etiologic factors can constitute a severe
D

Fig 1 Planning the finol inter-incisal rela-ion (A)

Closs I inter-incisa' relation should he
maintained |B) Mild Closs II treated by
retrcclina'ion of upper incisors
(C) Class II treated by retroclination and bodily
movement of upper incisors
(D) Severe Class II treated by
functional appliances or surcery JEJ Mild Closs
II, div 2 ireated by palatal root torque of upper
incisors (F) Class II, div 2 with severe skeletal
class II treated by proc'ining the upper incisors
followed by growth modification or surgery (G)
Closs III with forward path of closure responds
well to proclination of upper incisors (H) More
severe Class III may require proclination of
upper anteriors and rovoclirotioo of lower
anteriors.
retroclination or bodily lingual movement of the maxillary
incisors using fixed appliances may produce satisfactory
results (fig 1 .c). This may often require extraction of some
teeth to produce satisfactory results. Severe Class II
skeletal patterns often require growth modification (in the
growing) or surgical treatment (in case of non- growing
adults (fig l.d). Growth modification is done by use of
myofunctional appliances such as activator, bionator,
herbst appliance, etc.,.
Class II, division 2 incisor relationship
In Class II, division 2 cases that present with a Class I or
mild Class II skeletal pattern, uprignting the maxillary
incisors by application of a pclatal root torque may produce
Ihe desired inlerincisal relation (fig 1 .e). However in case
of a underlying severe Class II skeletal oattern, it may be
advisable to procline tne mcxillary incisors to produce a
Class II, division 1 pattern, followed by growth modification
(fig 1 .f). Incase of non-growing individuals surgery may be
required.
Correction of crowding : Correction ot crowded teeth
requires space. The rule of thumb is that for even/ mm of
crowding, a mm of orch length (space} is required.
Rotations : Rotated anterior teeth occupy lesser arch
length. Hence space is required for derotating these teeth
which is calculated by subtracting the distance between
the proximo, surfaces of adjacent teeth from the total
mesio- disial width of the rotated teeth.
Leveling the curvc of Spee : One of the common features
associated with skeletal malocclusion is on increased
curve ol Spee. A flat arch occupies more spoce than one
with on excessive curve of Spee. Some provision shoulc
thus be made in the treatment plan to provide space for
levelling. Failure to do so results in proclination that is
unstable.
Correction of proclination : Retraction of proclined
teeth requires spoce. In case of spaced dentition, the
existing spoces can be made use of to correct the
proclination. If the dentition is no: spaced, then alternate
ways of gaining space should be planned. For every one

Ctess ill Incisor relationship mm of reduction in proclination two mm of space is

required.
Class III patients who present with a forward path of
closure usual y present a better prognosis. In these Molar correction ; Presence of an unstable molar

patients, referred to as postural or pseudo Class III relation at the end of treatment is a cause of instability. The

relationship, removal of the occlusal interference by molars should be moved to achieve good iniercuspation.

proclination of the maxillary incisors Vs'ould often produce Space for anchorage loss: Most tooth movements
a satisfactory interincisal relation (fig 1 .g). When the are accomplished by appliances thai anchor on to certain
underlying Class III pattern is very severe, a stable other teeth in the dental arch.
interincisal relation is often acheived by proclination of
moxillary incisors ond retrod i nation of the mandibular in-
cisors (fig 1 .h). However natural compensations that might
have occured (i.e. rerroclination of lower incisors ond
proclined upper incisors) may affect the prognosis. In very
severe Class III cases surgical correction may have to be
considered.
PLANNING SPACE REQUIREMENTS

Most malocclusions require space to move teefr to more

ideal positions. The following are some of the conditions
that require space for correction
 Treatment Planning 381
Some amount of movement of the anchor teeth should be Class II occlusion, 't may be necessary lo extract in both
expected. While trying to retract tne onterior teeth, the the upper as well os the lower arches. In these patients, a
molors also invariably move forward to a certain extent. Class I molar and canine relation should be achieved at
This loss of space is colled anchorage loss. Studies have the end of the treatment (fig 2.e ond f)
shown that in extraction cases, almost 40% of the space is Ir Angle's Class III, it is beneficial to ovoid
lost by mesial movement of the posterior anchor teeth. extraction in the upper arch as it may retard the forward
The orthodontist should sum up +ie space developmen* of the maxilla. Angle's Class III cases are
required to correct the malocclusion. Once the total space preferab'y treated by extraction only in the lower arch or by
requirement is known, the different avenues to acquire the extraction in both arches. In case only lower teeth ore ex-
needed space should then be explored. Some of the tracted, at the end of treatmerta Class III molar re ation
methods of gaining space include : and a Class I caninc relation is ochicved ffig 2.g and h).
a. Use of existing spacing However if exlraclionsare planned in both the upper as
b. Proximal stripping well as the lower arches, we should have a Class I molar
c. Exponsion and canine relation at the end of the treatment (fig 2.i and
d. Extraction j).
e. Distalization
PLANNING ANCHORAGE
f. Uprighling of molars
g. Derotation of posterior teeth
Anchorage consideration formsan important part of the
h. Proclination of anteriors
treatment planning exorcise. All efforts should be taken lo
(For more details on acquiring space refer lo
minimize unwanted tooth movements. Fcilure to plan
chapter 21).
anchorage invariably results in failure of treatment

PLANNING EXTRACTIONS mechanics.

The anchorage demand for an individual
Extraction of teeth has become on integral por of patient depends on the following factors :
comprehensive orthodontic procedure. Teeth are often
Number of teefb berng moved : The greater the number of
extracted whenever there is arch length-tooth material
teeth being moved, the greater would be the demand on
discrepancies resulting in crowding or proclination. In
anchorage.
addition teeth are also extracted to correct inter-arch
relationship.
Whenever extractions are planned in a Closs I
skeletal or dental pattern, it is vitally important that
extractions are done in both the upper and the lower
arches so os lo mointain the buccal occlusal relationship
(fig 2.a and b}.
In most Class II cases, the upper dental arch is
forward I y placed orthe lower arch placed back. Thus by
extracting only in the upper arch it is possible to reduce the
abnormal upper production ond also to discourage Ihe
forward develocment of the upper arch. Whenever ex-
tractions are done only in the maxillary arch, we would
have at the end of the treatment a Class 11 molar relation
and a Class I canine relation (fig 2.c and d;. In case o:
lower arch crowding or when the mo ars ore not in full1
F:g 2 Plonning extroctions |A end (B) In Class I malocclusions extractions should be done in both the upper aid lower crchcs. {C) ond (D) In Class
II malocclusions if cxt-cct'ors are done only in the jpperarch, we would have a Class I con:ne relation and a Class II molor relation at the end of
treatment. (EJ and (F) In Class II malocclusions if extractions are cone in both upper and lower arches, we should have n Closs I canine and mo'cr
relation ct the end of treatment. (G) and |HJ In Class III malocclusions if only lower teeth arc extracted, we would have a C'css I canine relatior and
a Class III molar relation ct the end of treatment. (I) and (J) In Class III malocclusions if extrcctions a'c done in odh upper and ower arches, we
should have a Class I canine and molar rela'ion at the end of treatment.

Type of teeth : Tooth movement involving multi- roofed maximum anchorage demand, adequate
posteriors offergreater strain on anchorage than tooth reinforcement of the anchorage should
movement involving smaller teeth.

Type of foofb movement : Tipping tooth movements

are less demanding on the anchorage than bodily
tooth movements.

Duration of Treatment : Complicated orthodontic

treatment of prolonged duration strain the anchor teeth,
resulting in greater anchorage loss.
Once the anchorage demand is known it is
possible to Classify the case as maximum, moderate
or minimum anchoragedemand case. In cose of
384 Orthodontics - The Art and Science
be planned (see cnapter 17). Continuation of growth pattern Continuation of the
growth pattern that has caused a skeletal malocclusion
SELECTION OF APPLIANCE after orthodontic therapy results in resurfacing of the
malocclusion ofter treatment.
The next step in treatment planning is the selection of Thus retention should be planned keeping in
appliance, which is besed on a number of factors. mind all the factors that may predispose to relapse. In
Growth Potential : Growing patients who exhibit addition to the use of retainers some adjunctive
skeletal malocclusion should be treated with procedure might have to be carried out so as to aid in
appliances lhar modulate the growth so that the retention.
existing skeletal problem is solved or at least not
worsened. RE-EVALUTION

Type of tooth movement : Removable appliances

The treatment plan should be re-evaluated at regular
can be used in patients requiring simple tipping
intervals during the active phase of treatment so as to
movement. Whenever bodily tooth movements are
confirm whether the objectives that were set up are
required, fixed orthodontic applionces should be used.
being fulfilled. Changes might have to be made in the
Patients requiring comalicated room movements
treatment plan if the desired changes are not taking
including rotation, root movements, axial movements
place or if unforeseen problems arise.
(intrusion or extrusion) are best treated with fixed
References
appliances.

Ora/ Hygiene : Maintenance of good oral hygiene is an

essential part of orthodontic treatment. I lowever fixed
appliances piace an additional demand as they pose
greater risk of caries, deca cification, plaque
accumulation, etc.,.

Cost : Removoole appliances ore by far less

expensive tnan fixed appliances as they take less
chair side time and use limited material to fabricate.

PLANNING RETENTION

It is now accepted that teeth once moved, tend to go

back to their initial position. The potential for relapse is
increased by the presence of certoin factors which are
listed as follows :

Stretched periodontoi ligament ; The stretched

gingival fibres are a frequent cause of relapse in case
of rotated teeth, since these fibres take a long time to
reorganize around their new positions. Thus odequate
retention for an appropriate period should be planned
depending on the type of malocclusion.

(Jnsfabfe occlusion : Teeth placed in unstable

position at the end of orthodontic therapy tend to
relapse.
Given in this chapter is the management of a number material can result in midline diastema. This
of common malocclusions including midline diastema,
spacings, crowding and rotation of teeth.

MANAGEMENT
OF MIDLINE
DIASTEMA

Midline diastema
refers to an anterior
midline spacing
between the two
maxillary central

ement of Some
Malocclusions
incisors. It
is one of
the most
frequently
seen
malocclusions that is considered easy to treat but often
difficult to retain. The midline spacing can be a result of
a number of causes.

Causes of midline diastema

Transient malocclusion: Midline diostema can occur
due to a variety of causes. It is very often seen as an
incipient malocclusion that is self - correcting. A midline
spacing can occur as a part of the generalized spacing
seen in the deciduous dentition. The spacings seen in
the deciduous dentition is normal and helps in
accomodating the larger sized oermanent teeth. A
midline spacing can occur during the mixed dentition
period associated with ihe eruption of the permanent
can:nes i.e. the ugly duckling stage (fig 1). As the
developing permanent canines erupt, they displace the
roots of the Icterol incisors mesially. This results in
transmitting of the force on to the roots of the central
incisors which also get displaced mesially. A resultant
distal divergence of the crowns of the two central
incisors causes a midline spacing. This condition usu-
ally corrects by itself when canines erupt and the
pressure is transferred from the roots to the coronal
area of the incisors.

Tooth maferiaJ - arch length discrepancy: A

dispcrity in which the arch length exceeds the tooth
Fig 1 Ugly duckling stage (A & (QTransient midline diostemo os a resu.t of erupting canines. |B) & (D) Radiographs of the patient

includes conditions such as missing teeth, microdontia,
macrognathia and extractions with resultant drifting of
adjacent teeth.
Abnormal f renal attachment: The presence of a
thick and fleshy labial frenum can give rise to a midline
diastema. This kind of frenal attachment prevents the
two central incisors from approximating each other due
to the fibrous connective tissue interposed between
them.
Pressure frabifs: Habits such as thumb sucking,
tongue thrusting etc., olso predispose to midline
diastema.These patients generally present
proclination and generalized anterior spacing.
appearance of a midline spacing is an important
prognostic sign during rapid maxillary expansion and it
indicates the opening ol Ihe in- termaxillarysuture (fig
3). ftacfa/ predisposition: The presence of midline
spacing also hos a racial and familial background. The
Negroid race shows the greatest incidence of midline
diastema.
0/agnost/c aspects
A proper history & clinical examination is necessary as
in any other malocclusion. A blanch test is performed
to diagnose a fleshy labial
with

Midline pathology: Spacing in the midline can be

caused by soft tissue and hard tissue pathologies such
as cysts, tumors and odontomes. Presence of an
unerupted mesiodens between the roots of the two
central incisors also predispose to midline diastema.
Iatrogenic: Midline diastemas can occur when certain
therapeutic procedures are undertaken. The
 Management of Some Common Malocclusions 387

E F
Fig 2 (A) & (B) Midline diastema due -o a thick maxillary laaiol frenum. Note rhe Interdental notching seen in the periapical
radiograph (C) & (D) M'dlinc diastema due to irissiig cteral "ncisors (E) & (F) Midline diastema due to peg la'erals
328 Orthodontics - The Art and Science
Fig 3 Midline dios'erna seen in o pntiant undergoing .'Cpid maxillary
expansior.
frenum. It is done by pulling tne upper lip outwards.
Presence of a thick ond fleshy frenum is confirmed by
the blanching of the tissue in the incisive papilla region
palatal to the two central incisors. Presence of a
notching in the inter-dental alveolar bone as seen on a
radiograph is also diagnostic of a thick and fleshy
frenum. Midline radiographs are a valuable aid in
diagnosing midline pathology that cause spacing.
Tooth material-arch length discrepancies can be
determined using model analysis.
Treatment of midline diastema
The treatment of midline diastema is done in three
phases.
1. Removal of cause
2. Active treatment
3. Retention
The first phase involves removal of the etiology.
Habits should be eliminated using fixed or removable
habit breakers. Unerupted mesiodens should be
extracted. Frenectomy should be performed to excise o
thick fleshy frenum. Any midline pathology should be
treated as indicated.
The second phase consists of active treotment. It
can be done using removable appliances or fixed
appliances.
Removable appliances to treat midline diastema:
Simple removable appliances incorporating finger
springs (fig 4) or a split labial bow (fig 5) can be used to
close a midline spacing. Finger springs can be given
distal to the two central incisors. An alternative would
be to use a split labial bow made of a 0.7mm hard
stainless steel wire. The labial bows arc made to
extend upto the distal aspect of the opposite central
incisor.
Fixed appliances to treat midline diastema: Fixed
appliances incorporating elastics or springs bring about
the most rapid correction of midline diastema. Elastics
can be stretched between the two central incisors in
Fig 5 Split labial bow for treatment of midline diastema
»W Management of Some Common Malocclusions
*

/V

c D

Fig 6 Treatment ot mid ire diastema using fixed appl P) M shaped iance (A| Closed coil spring \B) Elastics (C) Elastic chain
spr'ngs

order to close the space (fig 6.b, c). Elastic thread or
elastic chain can be used between the two central
incisors for the same purpose. An alternative is to
strctch a closed coil spring (fig 6.0) between the two
central incisors. M shaped springs incorporating three
helices (fig 6.d) can be inserted into the two central
incisor brackets.This spring is activated by closing the
helices.
The third phase of treatment involves retoining
the treated malocclusion. Midline diastema is often
considered easy to treat but difficult to retain.Thc key
to its successful management is the elimination of the
etiologic foctors involved. Most orthodontists
recommend long term retention using suitable
retainers. Since prolonged retention is indicated, it is
advisable to use lingual bonded retainers (fig 7.6). The
other retainers that can be used include banded
retainers, Hawley's retainers, etc.,. tfo/e of cosmetic
resforafions; Esthetic composite resins are generally
used to close midline diastema especially in adult
patients. It requires gradual composite build up on the
mesial surface and stripping of the distal surface (fig 8)
of centrals and laterals in order to achieve a natural
shape and size of the teeth. Prosthesis / crown :
Presence of peg shaped laterals or teeth with other
anomalies of shape and size require prosthetic
rehabilitation. Missing teeth should be replaced with
fixed or removoble prosthesis.(fig 9)
F g 7 Midi re diastema tiou'ed with fixeu uupliance. (A) & (B)
^e-rectrnent (Q Post-treatment (D) Retaired wilh a fixed lir gua I
retainer
Fig 8 Composite restoration of o
midline diastema {A) Campos te
build up on the mesial aspect of the
central incisors and stripping of tne
distal surface (8j Composite build up
on the mesial aspect of tne lateral
ino'sors ond stripping of the dis'ol
surface (C) Compos te build up on
tho mesial aspcct of the canines
 Fig 9 Midline diastema as a result of peg laterals trea'ed with f'xed appl c nee and crowns given for laterals
SPACING e. Presence of unenjated suoer-numerary teeth or
other pathology ond cystic lesions between the
The presence of spacing between teeth is one of the
teeth car cause spacing.
commonly seen manifestations of a Class I
f. Premature loss of permanent teeth con cause
malocclusion. The presence of spacing is a normal
spacing.
feature in deciduous dentition and is considered as a
positive prognostic sign. In the permanent dentition Diagnosis
presence of spocing between the teeth is abnormal.
The routine orthodontic diagnostic aids should be
The space can be in a localized area or the entire arch
employed for diagnostic purposes. Model analysis can
can exhibit spacing.
yield valuable information about arch length-tooth
Etiology material discrepancy. Radiographic examination

The following are some of the causes of spacing: should be carried out to diagnose bony pathology or

a. Generalized spacing usually occurs as a result of unerupted teeth that may cause spacing.

disproportion between arch length and tooth

Treatment
material. Presence of increased arch length or a
Removal of the etiology : The cause for the spacing
reduction in tooth material can result in space
should be diagnosed end adequate steps taken to
between the teeth. Conditions such as
eliminate the same. In case of spacing as a result of
oligodontia and microdontia therefore lead to
abnormal pressure habits, habit breakers maybe
spacing.
employed to intercept the habit. In case of presence of
b. Spacing can occur as o result of alteration in
bony pathology or cystic lesions, they should be
tooth morphology. Abnormal tooth form • such as
eliminated.
peg shaped laterals can predispose to spacing.
c. Deleterious oral habits such as thumb sucking Use of removable arid fixed applionces : Active
and tongue thrusting can cause spacing in the removable appliances incorporating labial
onterior region.
d. The presence of an cbrormally large tongue, a
condition termed marcoclossia can predispose
tospacirg.
 Fig 1C Pre end ocst-trearment chctcgrophs of O Calient with spacing treated
witn fixed orthedonte appliance

bows can be used to close spaces that occur in

Etiology

conjunction with proclination. Fixed appliances clong The following are some of the causes of crowding :
with elastic chains or elastic thread are most effective a. Arch length - tooth material
in closure of generalized spacing. discrepancies due to decreased arch length or on
increase in tooth material.
Use of crowns and prosthesis : Spacing that occurs
b. Presence of supernumerary or
as a result of microdontia can be treated using suitable
extra teeth can result in a crowded orrongement of
crowns. A condition that is quite frequently
teeth.
encountered involving the maxillary lateral incisors are
c. Prolonged retention of deciduous teeth can result
peg shaped or small teeth with resultant spacing
in eruption of their successors in an abnormal location.
between the rest of the teeth due to drifting. In such
The presence of an over-retained deciduous tooth
cases, the space for the lateral incisor can be regoined
along with its permanent counterpart can cause
using a removoble appliance incorporating finger
crowding.
springs or fixed appliances incorporating an open coil
d. Abnormalities in size and shape of teeth can lead to
spring. The space regained can be used fora
a crowded arch. Teeth that are o b normally I org e can
prosthetic crown on the lateral incisor.
predispose to crowding.
A similar condition is the absence of teeth,
e. Premature loss of a deciduous tooth invariably
such as maxillary lateral incisors. In such cases the
results in drifting of adjacent teeth into the extraction
rest of the teeth con be consolidated together and a
space. An example of such a condition is the early loss
space left in the lateral incisor region which can be
of second deciduous molars. In these cases, the first
replaced by a fixed or removable partial prosthesis.
permanent molar drifts into the extraction space. Thus

CROWDING the second premolars do not have adequate space to

erupt and may do so in an abnormal position
Crowding is another common manifestation of a Class
predisposing to
I malocclusion. Crowding usually occurs as a result of
disproportion between tooth size ond arch length. A
relative decrease in arch length or an increase in tooth
material can result in crowding.
Fig 11 Pre and post-treatmert photographs of a oa'iert v/Jth crowding treated v/ith fixed orthodontic applicnce following ext-art'on o; the fou' '"irst
prcrrokrs [A| JB) and (C) P'e tfeatmert photcg'ophs (D) (£) end (F) post-treatment plio'ograo'ns

Gaining spoce r Crowded teeth require space for their

crowding.
normal alignment. On an average for every 1 mm of
crowding, an equal amount of space is required for
D/agnosfs
correction. Thus the amount of crowding should be
Clinical examination should be carried out to determine
calculated and the means of obtaining this space
Ihe extent and location of crowding. Model analysis
should be determined. The various methods of gaining
can be of use in determining the amount of arch length
space include
- tooth material discrepancy. The possible cause for
the crowding should also be determined.
Treatment
 4
proximal stripping, expansion, extraction, molar a. iViesio-lingua I or disto-buccal rotation
distalization, derotation and uprighting of posterior b. Disto-lingual or mesio-buccal rotation

394 Orthodontics - The Art and Science

Fic 12 Pro a id post-:rectrneni photographs of a patieni wiih crowding treated with fixed ortnodontic cpplionce fa lowing extrcdion of the four first premolars
(AJ (B) ard |Q Prelieotment photographs (D) (E) end (F) Fixed appliance placed one ni-ino archwires used for cl gnmeni of crowded teeth (G) |H! and (I)
Post-treatment photographs

teeth and proclination of anteriors. The indication for Anterior teeth that a re rotated occupy less
each of these methods has been discussed in detail in space and therefore require additional space for their
an earlier chapter. derolalion. Posterior teeth occupy more space when

Use of removobh applies nee r Once the provision for they are rotated. Thus space is gained when posterior

space is made, teeth can be moved to normal teeth arederotated.

non-crowded positions by using removable appliances

Treatment
that incorporate coil springs, canine retractors, labial
Space management : Treatment of anterior tooth
bows etc.,.
rotation requires space. Provision should
Use of fixed opplionces : Fixed appliances con be
used to treat crowding. Fixed appliances that make
use of multilooped archwires or resilient nickel -
titanium wires are very effective in correction of
crowding.
ROTATIONS

Rotations are tooth movements that occur around their

long axes. Two types of rotations are possible :
Fig 13 Ro'cliors |A) biloleral rotated maxillary 'irs* premolars |B) 180'^ rclatiai cf maxillcr; r;cht second premolar (Q ard [D] 90^ rota-ion of maxillary
cemra ncisors.

Fig 14 Treotment of rotations (A} Ro'a'ion wedges used *o

correct rotation (B) Mild rotations can be treated by using
resilient arch wires aid engaging -he crch wire 'nto 'he bracket
slot (CI Elosfc tnread used to dero'ate premolcr. It is attached
to the lingual cttachment and wrapped around "he tooth and
tied to rhe arichwire. (D) A couple used to 'reel rotation by
engaging elastic threads both bucel!y arc lingua ly.
 Fig 15 Denotation spring ergoged through lie vertical slot in the bracket,
iney ccn bring about derotation of 'ho tooth eround its long oxis.

henco be made in the treatment plan for obtaining the
required space.
Use of removab/e app/iances : Mild rotation can be
treated using a removable appliance that incorporates
a double cantilever spring [1 spring) along with a labial
bow.
retention is required to achieve stability of treatment.
Pericision or circumferential supracrestal fibrotomy is
an adjunctive surgical procedure where the gingival
fibres are incised to prevent relapse.
References

Use of fixed appliances : Whenever multiple rototions

of teeth are present, the appliance of choice should be
a fixed appliance. Derotation can be done by a number
of ways. Rotation wedges are available that can be
wedged between the arch wire ond the tooth (fig 14.a).
Mild rotations are effectively treated by use of resilient
arch wires such as nickel titanium. Their super
elasticity allows engagement of the wire into the
bracket slot. This brings about alignment and
derotation of the tooth (fig 14.b). Elastic thread can be
used to rotate the tooth around its long axis. They are
engaged to lingual ollachments and are wrapped
around the tooth in the direction of the derotation and
tied to the arch wire bucally (fig 14.c}. A couple force is
also effective in treatment of a rotated tooth. This is
brought about by use of elastic threads both bucally
and lingually as shown in fig I4.d.
In case of brackets that have a verticol slot,
derototion springs as shown in figure 15 can be used
for derotation of the tooth.
Retention of rototions ; It is usually said that rototions
are easy to treat, but difficult to retain. They hove a
very high risk of relapse due to the stretching of the
supra-alveolar and transeptal gingival fibres which
readapt very slowly to the new position. Thus long term
A
ccording to Angle's classificotion, Class II
malocclusion indicates that the mandibular
arch is in a distal relation to that of the
maxilla. Class II malocclusion is choracterizcd by a
6.
against the palatal surface of the upper incisors.
This is called lip trap. The presence of a short
upper lip along with lip trap increases the
tendency for the upper anteriors to procline.
Patients often lack an anterior lip seal due to the
short upper lip. Restoration of normal lip seal is
essential to maintain the teeth in their

Class II

Class II molar relationship where the disto-buccal cusp

of the upper first permanent molar occludes in the
buccal groove of the lower first permanent molar (fig 1
&2). It can occur in two main forms : Class II, division 1
and division 2. The only similarity that both these forms
exhibit is the Class II molar relation.

CLASS //, DIVISION 1 MALOCCLUSION

Class II, division 1 malocclusion is a condition

exhibiting Class II molar relationship with proclined
maxillary onterior teeth.

FEATURES

1. The patient exhibits a Class II molar relotion. The

molar relation can vary from an end on
molar to one that is a full fledged Class II.
2. The classical feature of a Class II, division 1
malocclusion is the presence of proclined
maxillary anteriors with resultant increased
overjet.
3. The patient exhibits a convex profile.
4. Due to proclined upper anteriors, the lower
anterior teeth fail to make contact with the palatal
surface of the upper anteriors. Thus they are free
to erupt leading to an increased overbite and
excessive curve of Spee.
5. The patient may have a short hypotonic upper lip.
In addition the patient may place the lower lip
39

rig 1 Class II, division 1 malocclusion |A) (BJ

and (C) Intraoral frontal and ojcca^ view's.
Nolo the prodi nation cl toe moxillory
anteriors. (D) Occbsal view snowing tne
narrowing of the arch due to excessive
buccinotcr aciion (E) Lip t'ap and
hyperactive rncntalis activity ore typiccl of
Class II, division 1 malocclusion

corrected position.
7. Most Class II, division I cases exhibit abnormal
muscle activity. They exhibit abnormal buccinator
activity leading to a constricted, narrow upper crch
which predisposes to posterior cross bite. A
hyperactive mentclis activity is another
common finding in Class II, division 1
malocclusion.
8. Class II, division 1 malocclusion can sometimes be
associated with proclined lower anteriors. This is
a natural compensation that has taken place to
reduce the overjet.
 Management of Class II Malocclusion

Fig 2 Skeletal Class II due to (A) Maxillary

prognathism (B; Mandibular rct-oarath:srr (C) Combination of A & 3

SKELETAL FEATURES Irradiation : Exposure of a pregnant woman to

A Class II malocclusion moy be complicated by the
presence of abnormal skeletal relationship of the
maxilla and the mondible. The abnormal skeletal
radiation is another cause of altered development of
the dento-facial complex.
/nfro-ufer/ne fetal posture : One of the factors thot

features most often found are (fig 2): seems to play a role in molding the cranio-facial region

1. Maxillary protrusion is the intra-uterine fetal posture. Abnormal posture

2. Mandibular retrusion such as hands across Ihe face is found to affect

3. Maxillary protrusion and mandibular retrusion mandibular growth.

ETIOLOGY Natal factors

Trauma can sometimes bo induced by improper
Class II malocclusion can occur due to a variety of forceps opplication during delivery. This results in
causes. Broadly the etiologic factors can be classified trauma to the condylar region. The
as : temperomandibular joint in such cases can get
1. Prenatal factors
ankylosed or fibrosed leading to underdevelopment of
2. Natal factors
the mandible.
3. Postnatal factors
Pos t natal factors
Prenatal factors
There are a number of conditions that con influence
Hereditary : The size, position and relationship of the
the normal development of the dento- facial complex.
jaws are to a large extent determined by the genes.
The following are some of them :
Thus Class II malocclusion exhibiting skeletal
a. Traumatic injury to the mondible and
anomalies such as a prognathic moxilla or a
tempero-mandibular joint.
retrognathic mandible can be due to hereditary cause.
b. Long term irradiation therapy of the skeletal
Teratogenesrs : Administration of certoin drugs during cranio-facial region.
pregnancy can result in perverted or abnormal c. Infectious conditions such as rheumatoid arthritis
development. The drugs that are capable of such an can influence mandibular growth.
effect are called teratogens.
 Table 1 Flowchart for treatment of Class II malocclusion

Class II malocclusion

Growing Patient

Dental Class II Dental Class II Skeletal Class II

Maxillary Mandibular. Mild to moderate Sever

prognathis ra;ragnatnis Class II Non growing Patient e Class
m m II
Skeletal Class II
Maxillary
prognaihisrn | Orthodontic Maxillary Mandibular
.Headgear mandibular camoflage prognathis retrognathis
to restrict: retrognathism by m m
maxillary
extraction of
growth
some teeth
Heacgear and Myolu notional
myofunctional therapy
therapy
.Surgical Surgical
maxillary mandibular
Orthodonijc advancement
setback
treatment as
needed
b.
c.
d. Abnormol function such os oral respiration, d. Reduction of overjet
abnormal swallowing and habits such os thumb e. Reduction of overbite
sucking prevent normal muscle activity. These f. Correction of crowding and locol irregularities
patients hove a low tongue position leading to Correction of unstable molar relationship
unrestrained activity of the buccinator group of Correction of posterior cross bites if any
muscles. Normalizing the musculature

TREATMENT OBJECTIVES the teeth and to establish stable incisor and molar
relationship. The foil owing are the treatment objectives :
In Class II, division I malocclusion, the major treatment
objectives are to relieve crowding and irregularity of
 TREATMENT OF SKELETAL
CLASS II MALOCCLUSION

There are three basic approaches lo Ihe treatment

of Class II, division 1 malocclusion. They are : 1.
Growth modification \ 2. Camouflage
 Management of Class II Malocclusion ^ 401

Fig 3 (A) ond [B| Skeletal Class II due -o mandibular relrogna'hism treated curing g-owH period by aefvater appliance «C; end (D) Skeletal Class H
riue tc mand'bi.la' re-rognatnism trocfcd by -'erbs' aoo ionce IE) and (F) F c 6 S<olotd Class II due ro mandibular reVocnahism treated by Jasper
jjmpe*-

functional and orthodopaedic appliances to reduce the

severity of the skeletal relationship. These treatment
procedures are usually carried out during the mixed or
early permanent dentition period prior to the cessation
of growth.
A r important pre-requisite for these growth
modification procedures is to accurately diagnose the
underlying skeletal discrepancy.
 ideal requirements lor camouflage
4Q2 Orthodontics - The Art and Science
Analysis of lateral cephalograrns ccn help establish the i Patient too old for successful grov/th
skeletal malrelationship. ; modification

Correction of mand'ib.'u/ar deficiency : Class II

using myofunctional appliances
malocclusion complicated oy mandibular deficiency or
2. Mi id 'o moderate s^eletai Class lj
retrognalhisrn is treated during the mixed dentition malocclusion
period by use of myofunctional aoplia.nces such as 3. Reasonably well alligned teeth so that the
extrac
activator (fig 3. c,b) or functional regulator, In case the tion space is available for retraction and not
patient is at the end of the growth period, fixed lor
correction of crowding '
functional appliances like Herbst appliance «fig 3. c,d)
4. Good vertical facial proportions with neither
or Jasper Jumoer (fig 3. e,f) is indicated.
deep
Correction of rnax.'i'ar/ prognathism .; Class II bite or open biite>

malocclusion exhibiting maxillary prognathism can be

intercepted by Ihe use of face bow with headgear to
restrict further maxillary growth. to have a favourable effect on the facial esthetics of the

In some potients, Class II malocclusion is individual.

complicated by the presence of both maxillary Spoce requirement in the upper crch is
essentially to reduce the overjet, overbite and to
prognathism as 'well as mandibulor deficiency. In such
correct minor loco! irregularitiesofteeth. Extraction in
patien-s an appliance such as activator with headgeor
the lower arch may be necessary to correct unstable
is used to restrict mcxillory growth ond promote
molar relation, correction of crowding, deep bite and
mandibular growth.
minor local irregularities.
Camouflage The teeth that are most frequently extracted
are the first premolars. In case of a well aligned lower
In potients who are beyond growth, it is not possible to
arch with a Class II molar relation with excellent
undertake growth modification procedures. Thus the
inter-cuspotion, it is possible to reduce the overjet ond
underlying skeletal discrepancy can be camouflaged by
obtcin stable results by extracting first premolars only
orthodontic tooth movement. This is often done by
in the upper arch (Fig 5). In case space is required in
extraction of certain tee^h ano moving the res* of the
the lower arch to correct unstable end on molar relation
teeth into the spoce created.
or lower crowding, rotations or excessive proclination,
With extraction of teeth ir is possible :o obtain
both upper ond lower first premolars are to be
correct molar and incisor relationship despite the fact
extracted.
tnat the underlying skeletal discrepancy is not
In minimum anchorage cases, where the
addressed. Thus the concept implies that major
space requirement is not much, the second premolars
skeletal changes are not possible af-er the ccssction of
can be extracted to encourage mesial movement of the
growth and rhal rhe orlhodonlisl achieves the best
buccal segment.
possible occlusion under the given limitations of tne
Orthodontic camoflage may also be done in
skeletal jaw relation. The repositioning of the teeth is
some patients by distal driving of the maxillary molars.
likely
This is done in mild Class II malocclusion prior to
eruption of Ihe second molars.
 --------------------------------------------------- c --------------------------------------------------------
r
ig 4 Pre aid posi-treotmenl photographs of a pctienl having mandibular 'c'rognaliism trea'ed os;ng Herbs' nppliarce •A; Pret'eairrev ohoiog'cphs
(Bl Photographs of ihe appliance in th« moulh (C) Pos'-t'calrnen* pholog'ophs
Fig 5 (A) (D) ^elreohienl phonographs of a patieni rreoted by comoflage by extract or of upper first premolars. |E) - (Hj aosl treatment photographs
of the- same patient.
Management of Class II Malocclusion

Surgical correction
In patients exhibiting severe skeletal malrelationship,
surgery may be the ideal treatment modality. Based on
the underlying skeletal pattern a maxillary set bock or a
mandibular advancement- is undertaken after the
completion of growth.

Correction of deep bite and crossbite

Class II malocclusion can be associated with anterior
Fig 6 Class II d.ivis'on 2 malocc'ts on
deep bite. This can be -reated ir -rhe following ways :
a. Use of removable anterior bite ploncs to 7pe include re*roclined centrals as we! as lateral
encourage vertical development o; tne posterior inciso's end very rarely include retroclined carines as
dento-alveolc segments. well.
b. By using fixed applionccs to intrude the upper and Retroclration of upper incisors in c Class II,
lower anteriors. division 2 malocclusion is usjally a natural
Crossbites are o common feature of Class II, dento-alveolar compensation fora Class II skeletal
division 1 malocclusion. They occur as a result of the pa-tern ir. order to decrease the overjet.
following factors :
a. Abnormal buccinatior muscle activity due to Features of Class II, Division 2
lowered jaw and tongue posture con cause
Mild forms of Closs II, division 2 malocclusion nay be
constriction of the maxillary arches.
perfectly acceptable wi*h regard to function as well cs
b. If the mandible is brought fon/^ord by use of
facial appeorarce. In severe coses, the bi'o is often
functional appliances the broade' segment of the
ven," deep and poses the risk of periodontal traumc in
mandible is made to occlude with the narrower
tne upaer palatal and lower labial aspects. The
segment of the maxillary arch leading to a
following are the features of Class II, division 2
posterior crossbite.
malocclusion :
Crossbites are treated using appliances
a. Molars in disto-occlusion
incorporating screws or springs that expand the
b. Retroclined cenkal incisors and rarely of other
maxillary arch.
anteriors as well.
The correction of deep bite and crossbite
c. Deep over bite
have been discussed in de'ail in the following chapters.
d. Pleasing straight profile
CLASS II, DIVISION 2 MALOCCLUSION e. Brood square foce
f. Backward path of closure
The Class II, division 2 malocclusion is a condition g. Deep mentolabial sulcus
characterized by a Class II molcr relationship with h. Absence of abnormal muscle activity
retroclined upper centra I s that a re overlapped by the
lateral incisors (fig 6). Variations of the classical Treatment objectives

The treatment objectives include :


a. Relief of gingival trauma
b. Correction of incisor
Orthodontics - The Art and Science
relationship
c. Relief of crowding and local irregularities
d. Correction of buccol segment relationship
The role of extraction in the treatment and
correction of the buccol segment relationship is
essentially the same as was described for Class II,
division 1 malocclusion. The deep anterior overbite
and retroclination that is characteristic of division 2
malocclusion is treated by :
a. Reduction in incisal overbite and
b. Alteration of incisal inclination
The deep over bite is reduced by use of
onterior bite plane or fixed appliances incorporating
anchor bends or reverse cun/e of Spee. The incisor
inclination often necessitates the use of torquing
springs to move the upper incisor roots linguolly and
the crowns buccally.
Role of functional appliances
During the mixed dentition period, it is possible to
procline the maxillary incisors thereby converting a
Class II, division 2 into a malocclusion that resembles
Class II, division 1. This can be followed by the use of
functional appliances as described for Class II, division
I malocclusion.
U. Parcherz : Activity
of -he temporal
ond mosse'er
muscles in
Class I, Division 1 malocclusions. Am J Orthod 1980 ;
679-63B
15. Panchcrz : Muscle activity in Class II, Division I malocclusions
treated by o te jumping wi'h -he Herbst aoolionce. Am J
Orthod "930 ; 321-329
16. Pancherz : S<elefcl arc dental changes conl-ibj'ing to C OSS I
correction in activator treotmert. Am J Ortnod 1984 ; 125-134
17. Parker, Nanda, ord Currier : Treatment of ceop aite
malocclusion changes. Am J Ortnod 1995 ,
382-393
18. Pfciffer and Groaety : Combined orth oped ic-ortno- donric
treotmert. Am J Orthod 1 982 185-201
19 Profit WR: Contempora'y Orthodon'ics, St Louis. CV Mosby,
1986-
20 Regan and Subte ny : Correction of severe Cioss II
malocclusion. Am J Ortnod 1989 ; 192-199
21. Robe't £ Meyers Hand book of Orthodontics, Year boo< med
col publishers, inc. 1988.
22. Robertson : Treatment changes in children heated with
functior reyulato' of Frdrkel. Am J Orthod 1983; 299-310
23. Rutter and Wi : Co'rec'ion of Class II. Division 2 malocclusions
through the use of the Bionator Oppliarcc: Report o: tv/o
cases. Am J Orthod 1990; 106-112
24. Seely : Treatment o: crowded Class II malocclusion. Am J
Orhod - 993 ; 298-303
25. Soso, Graoer, and Mjller: Postpharyngeal lymphoid tissue in
Class I and Class II malocclusions. Am J Orthod 1982;
299-309
26. Thomas V. Graber, Robert I Vonarsda I : Oithodon- t'cs cjrrent
principles and techniques, Mosby yecr book Ire, 1994
27. Ward : Argle Class I, Division I malocclusion. Am J O'I hod
1994 42B-433

Ref e re nce s
6. Fidler, Arun. Joondeph. end bttle : Relapse o: Class I, Division
1. Am J Onhod 1995 ; 276-285
7. G ore ly, Pet-es, and 3of?a : Condylar posi'ion and C ess II
deec-fci-e, no-overjet maloccljsion, Arr. J
Onhod 989; 428-432
8. Graber TM : Ortnodon-ics : Prircioles and prcdice
WB 5ok.ndsrs,l 988
9. He'schcopf : Cass II Division 2 mclocc J$ion Ncnex-ract or.
An-. J Ortnod 1990 ; 374-380
10. Hin<le : Surgical treatment of Class II, Division 2
malocclusion. Am J Orthod 1989 ; 1 85-1 91
1 1. Ker ura Hi-st : Craniofacial charac'eristics of Subjects wirh
normal end posrormal occ usions. Am J Orthod 1967
.-207-212
"2. Meistro I, Carcialosi, Lopez, and Cobral-Ange cs : Konextroclion
Regg treatment of Class II malocclusions. Am J Orthod 1986 ;
286-295
13. Nasiopoulos, Taft, and Greerbem : Cepholometric study of Ooss
II, Division 1 treotment. Am J Orthod 1992; 276-280
 Management of Class III
Malocclusion
A
malocclusion that is very easy to identify but
is often difficult to Ireat is the Class III
malocclusion. This condition represents a
pre-normalcy where the mandible is in a mesial
relation to the upper arch. According to Angle a Class
III molar relationship refers to a condition where the
mesio-buccal cusp of the upper first molar occludes
between the mandibular first and second molars.
Although this definition represents a typical Class III
relationship, the lower molar can be in a mesial
relationship to a varying degree. This kind of
malocclusion finds highest incidence in Japan and
Korea.
FEATURES OF CLASS ///
MALOCCLUSION
The following are the features of a Class III
malocclusion :
The patient has a Class III molar relationship
(figi).
The incisors may be in an edge to edge
relationsh:p or an anterior crossbite may occur.
It's not uncommon to find a normal inciscl
relatiorsnip
The upper arch is frequently narrow and short
while Ihe lower arcn :s broad. Thus posterior
crossbites are c common feature of Class III
malocclusion. This tendency is exaggerated due
to the mesial sagittal relationship of the lower arch
due to which the broader part of the mandibular
arch opposes the narrow part of the upper arch.
It is common for the upper teeth to be crowded as
the arch is narrow ond short while, the mandibular
arch is often spaced.
The oatient has a concave profile due to the
presence of a prominent chin.
Vertical growers exhibiting an increased inter-
maxillary height may have an anterior open bile.
In some potients a deep overbite moy occur.
A type of Class III malocclusion referred to as
(A) ond |B) Class II malocclusion
 pseudo Class III malocclusion is characterized by
Fig 2 Developing class III rnaloccluson

the preserce of occlusal prematurities resulting in

a habitual toward positioning of the mandible.
These pat'ents may exhibit a forward path of
closure. Tnje Class III rra'occlusion tnat exhibits underlying
skeletal imbalance is usually inherited. Class III
SKELETAL FEATURES OF CLASS ///
malocclusions are said to have a very strong genetic
MALOCCLUS I ON
basis. The other causes of a pre-normalcy include

Class III malocclusions are quite often associated with habitual forward positioning of the mandible due to

underlying skeletal ma I re lotions h i os. The following occlusal prematurities or enlarged adenoids.
are some of Ihe commonly seen skeletal features (fig
DIAGNOSIS
3):
a. A short or retrognathic maxilla The diagnostic procedure should help in determining
b. A long or prognanthic mondible the type of Class III malocclusion i.e.
c. A combination of the above
ETIOLOGY
Kill Orthodontics - The Art and Science

A A -• A
Fig 3 Clcss III skeletal pattern due -o (A) Maxilfcry deficiency (B| Mond bular excess |C) Combination of A & B.

Class III malocclusion

Norvgrowing Patient
Growing Patient

Skeletal Class III Dental Class III Dental Class III Skeletal Class

Maxillary Mandibular Mandibular Mild to moderate Severe

retrognathism prognathism and :■. prognathis Class III Class
maxillary retrognathism m III

Face mask to appliances for Surgical

protract Class 111 maxillary
maxilla Orthodontic advancem Mandibul
Chin
camoflage by ar
Face mask cup ent
followed by extraction ot prognathi
therapy
sm
chin some teeth to
cap > Maxillary restrict ■I
myofunctional retrognathis maxillar Orthodontic Surgical
m y growth treatment as mandibul
needed ar set
back
Fig 4 Patient with maxillary deficiency -r«otfid with fscc mask (A), (B) & {C) Pret'ea'ir ent photographs (D), |E) & |F; Posl-'rea'ment photograph
Fig 5 (A} Pre treatment photographs o' a patient hovir.g maxillary retrognctnism trea-ed with face mask (Bj The patient seen v/eoring the applionce
(C) Tne in-racml splirt with RiME to aid in crch expansion
 Management of Class III Malocclusion

PjMM
'■SK'^1

H^gfll

IjlB
' i ''10 jCWuM^^^l

MIIIM
.'JoKy' 1
' • ^^■HOOoOiVxIft*» ■ *"
7-1
D

10 Carlorti : Differential diagnosis and trectment planning of surgical orhodontic Closs III
malocclusion. Am J Orthod 1981 ; 424-^36
 Fig 5 (D) Post treotirer pho'og-cphs.
dental or skeletal, true or pseudo. The clinical examination should include
observation of poth of closure. In addition, study models and radiographs should
also be token. A lateral cephalogram offers valuable information on the skeletal
nature of the malocclusion.

TREATMENT

Class III malocclusion should be recognized and

treated early due to the following reasons :
a. Recognizing the malocclusion at an early age makes it possible to
intercept the obnorrnal skeletal pattern so as to reduce the severity of
m m m'i i p n

v . - y^ i
the developing malocclusion.
b. The Class III malocclusion characterized by anterior crossbites often V
results in retarded maxillary growth due to locking of Ihe maxilla within
the mandible.
c. The occlusal forces on the mandibular incisors Fig 6 C a:s III closl CS
.f
exerted by the maxillary incisors in cross bite
encourage the continued forward growth of mandible
Interception during growth
further worsening the pre- normolcy.
Class III malocclusion with an underlying skeletal mol
relationship requ're early treatment to intercept the
developing skeletal malocclusion. The
sum 111«
Orthodontics - The Art and Science

following are some of the growth modulation are a result of mandibular prognathism are treated by
procedures that can be carried out: mandibular set back procedures.
a. Frankel III, a myofunctional appliance can be
Treatment of pseudo Class III
used during growth to intercept a Ciass III due to
Pseudo Class III malocclusion that occurs as a result
maxillary skeletal retrusion.
of occlusal prematurity improves on removal of the
b. Reverse activator.
cause.
c. Chin cuo with high pull head geor is used to
intercept Class III malocclusion due to mandibular Refe re nce s
prognathism.
d. Severe Class III malocclusions that are a result
of maxillary retrusion can be treoted by reverse
head gear (or face mask) to protract the maxilla
(fig 4 &5).

Treatment of anterior cross bite

Mild anterior crossbites can be treated using lower
anterior inclined planes or removable applionces
incorporating screws designed for anterior expansion.

Treatment of posterior cross bite

Class III malocclusions are often accompanied by
posterior cross bite. The posterior cross bite can be
treated by rapid maxillary expansion.

Role of extractions
Class III malocclusion characterized by lower arch
length deficiency and anterior cross bite can be treated
by extracting the lower first premolars followed by fixed
mechanotherapy. Class III intermaxillary elastics,
should be used to retract the lower anteriors (fig 6). In
cose of arch length deficiency involving both the
arches, the first premolars should be extracted in both
the upper and Iower arches.

Treatment of severe Class III

after growth

Severe Class III malocclusion after growth completion,

is treated by surgical and corrective
procedures. Class III due to maxillary deficiency is
treated by maxillary advancement procedures such
as le Fort I osteotomy. Class III malocclusions that
 Etiology of anterior open bite

M
alocclusion can occur in three planes of
space i.e. sagittal, transverse ond in the
vertical plane. Open bite is a malocclusion
that occurs in the vertical plane, characterized by lack
of vertical overlap between the maxillary and
The etiology of anterior openbite is multifactorial. No
single factor con account for most open bites. Anterior
open bites can occur due to a variety of hereditary ond n
on - hereditary factors. The following are some of the
etiologic factors responsible for anterior open bites : i)
Prolonged thumb-sucking habit might be a

Manageme of
nt ien Bite

mandibular dentition. Open bites can occur in the

onteriorand the posterior region and are called anterior
open bite and posterior open bite respectively.
The diagnosis, treatment, and successful
retention of treated open bite malocclusion continue to
be a chollange to clinicians. Many potential etiologic
factors arc implicated os causes of open bite including
unfavorable growth patterns, digit-sucking habits,
tongue and orofacial muscle activity, heredity,
orofaciol functional matrices, imbalances between jaw
posture, occlusol and eruptive forces ond heod
position. A detailed understanding of its etiology and
developmental process is thus essential in its
management.
ANTERIOR OPEN BITE

Anterior open bite is a condition where there is no

vertical overlap between the upper and lower anteriors
(Fig 1). Anterior open bitos ore esthetically unattractive
particularly during speech when the tongue is pressed
between the teeth and lips.
Classification of anterior open bite
Anterior open bite can be classified os :
a. Skeletal anterior open bite
b. Dental anterior open bite
 Management of Open Bite

M$mm

Fig 3 Skeletal cnterior open bite (A| Due to counter-clockwise moxillory rotation (B) Due to dockv/se mondibu'or rotction [CJ Due lo combination
of A & 6 |D| Due -o vertical maxillary excess

likely cause of open bite. The posture of thumb f. The potient may have o short upper lip with
positioning, the intensity, and the frequency of excessive maxillary incisor ex-posure
sucking, all have an influence on the nature and
severity of the open bite.
ii) Tongue thrusting is also implicated for so m e
cases of open bite.
iii) Of all the possible etiologic factors that have been
studied, perhaps the greatest importance focuses
on nasopharyngeal airway obstruction and
associated mouth breathing.
iv) Inherited factors such as increased tongue size,
and abnormal skeletal growth pattern of the
maxilla and mandible can also be
responsible for open bite malocclusion.

Features ot skeletal anterior open bite

A potient hoving a skeletal anterior open bite may
reveal the following features (fig 2).
a. Increased lower anterior facial height
b. Decreased upper anterior facial height
c. Increased anterior and decreased posterior facial
height
d. A steep mandibular plane angle
e. Small mandibularbody and ramus
418 Orthodontics - The Art and Science
f. The potient often has a long and narrow face action on the upper and lower posterior leeln. Patients

Fig 4 Habil breaker ;A; Removable (Bj Fixed

g. Divergent cephalometric alanes exhibiting a downward and backward rotation of the

h. Steep anterior cranial base mandible with increased vertical growth, benefit from
i. Cepholometric examination may reveal a therapy using a vcrticol pull-head gear with chin cup if
downward ond forward rotation of the mandible. trected during the mixed dentition period.
In some patients, an upward tipping of Ihe Orthodontic fherapy : Mild to moderate open biles con
maxillary skeletal base can be observed. Another be successfully managed using fixed mechanotherapy
common feature is a vertical maxillary increase in conjunction with boxelcstics. This form of elastic
(fig 3). application consists of an elastic that is stretched to
extend between ihe upper and lower anteriors. This
Features of dental anterior open bite
brings about extrusion of the upper and lower
Dental anterior open bites do not oresent with the
anteriors. II may not be advisable lo resort to this form
skeletal complications mentioned above. The following
of therapy in severe skeletal open bites.
are the features of dental open bite :
Surgica.1 correction : Skeletal open bites in ..adults
a. Proclined upoer anterior teeth.
ore best treated by surgical procedures involving the
b. The upper and lower anteriors fail to overlap each
maxilla and the mondible.
other resulting in a space between the maxiliary
arid mandibular anteriors.
c. The patient may have a narrow maxillary arch due
to lowered tongue posture due to a habil.

Treatment of anterior open bite

Remove.1 of trie causc : Open bites that hove been
diagnosed due lo habits such as tnumb sucking or
tongue thrusting, require their interception using
oassive habit breaking appliances. The habit breaker
can be either a rcmova ble or a fixed type of cri b {fig
4}. Persi stence of tne cause will offer a severe
limitation in the corrective procedures.

Myofunctional therapy : Skeletal anterior open bites

con be treated during growth using functional
oppliancessuch as F.R. IV or a modified activator.
These appliances incorporate bite blocks interposed
between the posterior teelh, that have an inmjsive
 Management of Open Bite 419

Fig 5 {A}, -8) aid (Q P'Clreawent photogrophs of 0 potion- with anterior ooen bile . (0) A f'xed hcbi'
breaker was used to intercept tongue thpjs- in Ill's pctiftit. (E), |F| and (GJ Pno'cg-aphs of the same po'ient
necrirc completion oc treatment.
Fig 6 Anterior open b te Vested v/i'h fixed cpp.iance and extraction of upper arid lower second premolars. (A) & {8) Pre-rectmen' photographs \C, fD-
Appliance h place J,£J & ;FJ Nearir.g completion of treatment
POSTERIOR^OPEN BITE

Posterior open bite is o condition characterized by lack

of contact between the posteriors when the teeth are in
centric occlusion. It mostly occurs in a segment.of the
posterior teeth.
Causes of posterior open bite
There ore two possible causes of posterior open bite:
(!) mechanical interference with eruption, either before
or after the tooth emerges from the alveolar bone, or

Fig 7 Posterior open bite in a patient having a lateral tongue thrust.
(2) failure of the eruptive mechanism of the tooth so
that the expected amount of eruption does not occur.
• '' Mechanical interference with eruption may be
caused by ankylosis of the tooth to the alveolar bone,
which can occur spontaneously or as a result of
trauma, or by obstacles in the path of the erupting
tooth. Examples of such obstructions prior to
emergence are supernumerary teeth
nonresorbing deciduous tooth roots or alveolar bone.
WIMMMMiW-Wl E WM&
After the toolh emerges from the bone, pressure from
soft tissues interposed between the teeth (cheek,
tongue, finger) can be obstacles to eruotion (fig 7).
Ankylosed teeth are usuclly in infraocclussion and are
said to be submerged (fig 8).
The second possible cause of eruption
failure is a disturbance of the eruption mechanism
and itself. These patients have no other recognizable
disorder, and no mechanical interferences with
422 Orthodontics - The Art and Science

eruption seem to exist. The condition may be the cause of

posterior open-bite which does not respond to
orlhodontictreatment

Treatment
The primary aim of treatment should be to remove the cause.
Lateral tongue spikes are a valuable aid in control of lateral
tongue thrust. Once the habit is intercepted, a spontaneous
improvement often follows. The posteriors can be forcefully
extruded. In cases of posterior open bite due to
infra-occlusion ofonkylosed teeth, it is besttreoted by crowns
on posteriors to restore normal occlusal level.

References

1. Bass : Ort-iacedic cooidination of dertofocial development n skeletal

Closs II moloccljsion in con- junct'on with edgewise therapy. .Am J
Orhod 1983 ; 466-490
2. Frankel ond -rankel : Functional opprcacn to treatment of skeletal
open b'le. Am J Orthod ' 983 ; 54-68
3. Grader Ifv'i : Orthodontics : Principles end practice. WB Sajncers,
1988
4. Lopez-Gov'to, Vv'a ten, L the, and Joondeph : Anterior oper-b'te
ma'occlusion. Am J Orthod 1985 ; 175-186
5. Nondo : Pat-ens ot vertical growth in :aco. Am J Orhod 1988 ; 103-116
6. Profitt V.'R: Contemaorary Orthodontics, S' .OJIS, CV Mosby, • 986.
/. Rei-zik, P.<iref, Vvainv/': Sjrgical trectment of skeletal onterior opcn-b:-e
deformities with 'ig d internal fixation 'n mandible. Am J Orthod 1990 ;
52-57
8. Robert E Movers : Hand boo* of Orthodontics, Year book medical
njblishers, inc,1988.
9. Row cy, Hill, and V/'nl$r: The associat'on bet.veen cnterior open-bite
and amelogenesis imperfecta. Am J Orhoc I 982 ; 229-235
10. Safirstein end Burton : Open-bite. Am J Orthod 1983 ; 47-55
11. Sclzmar JA : Pract'ce of Orthedon'ics. J8 Lippincott company, 1966
12. Thomas M Grabc, Robert L Vonarsdall : Orthodontics CLrrent
arincioles and techniques, Mosby year book Inc . 1994
 'N

. n-■
'V

Crossbite

C
rossbite is a term used to describe involve permanent teeth, however, this malocclusion is
abnormal occlusion in the transverse well documented in the deciduous dentition, too. An
plane. The term is also used to describe anterior crossbite can involve a single tooth or an
reverse overjet of one or more anterior teeth. entire segment of the arch.
Graber has defined crossbite as a condition
Posterior crossbite
where one or more teeth may be abnormally malposed
bucally or lingually or labially with reference to the This refers to an abnormal transverse relationship
opposing tooth or teeth. between the upper and lower posterior teeth. In this
condition, instead of the mandibular buccal cusps
CLASSIFICATION OF CROSSBITE occluding in the central fossae of Ihe maxillary
posterior teeth, they occlude buccal to the maxillary
Crossbite can be classified based on location as:
buccal cusps. Thus posterior crossbite occurs as a
a. Anterior crossbite
result o: lack of co-ordination in Ihe
1. Single tooth \
2. Segmental
b. Postorior crossbite
1. Unilateral (fig 1 .b)
2. Bilateral {figl.c}

Based on the nature of the crossbite os : 1. Skeletal

crossbite
2. Dental crossbite
3. Functional crossbite

Anter/or c/ossfr/te
Anterior crossbite is defined as a malocclusion
resulting from the lingual position of the maxillary
anterior teeth in relationshio with the mandibular
anterior teeth. Most the cases reported in the literature
1

424 Orthodontics - The Art and

Science

Fig 1 C'ossbites in Ihe t'arsversa plane (A| No'ma I transverse relet on

(8) '~ri'o>cral cross bito (C) B lateral cross bre {D) Buccal non
occlusion Lir QUO I non occlusion

'ateral dimension between the upper and the lower

Skeletal crossbite

arches. Skeletal crossbite is associated with a discrepancy in

Posterior cross bites con be unilateral
involving one side of the arch or bilateral which
involves both sides.
Buccal non - occ/usioo : This is a form of posterior
crossbite v/h e re the maxillan/ posteriors occlude
entirely on Ihe buccal aspect of the mandibular
posteriors (fig l.d). This condition is also called os
scissors bile. Lingual non - occlusion: This is a form
of posteriorcrossbite where the maxillary posteriors
occlude entirely on the lingual aspect of the
mandibular posteriors (fig 1 .e).
the size of the maxilla and the mandible. This kind of
crossbite is usually inherited or may result from
defective embryological development. They may
present either in the anterior or the posterior region.
Skeletal anterior cross bites are usually os a result of
retarded maxillary growth or a maxilla that is
backwardly positioned (fig 2). It can also occur as a
result of excessive mandibular growth. Skeletal
posterior cross bites are usually characterized by a
narrow upper arch.

A B
Fig 2 Skeleta crossbites r the a-re rc-p os-eric r plcre |A) anterior crossbite due to mox'tta"/ crcgnath:STi |8) anterior crcssbi'e dje to Tiarcibula'
progncth'srr (C) ai'e'io' crossbi'e due to -*iaxT3Pf 'B*rogna'hisr> and maroibtlar prognathism
Denta/ crossJb/te
Dental crossbites are usually localized conditions
where one or more teeth are abnormally related to that
of the ooposing arch. A variety of factors nave been
reoorted to cause a dental anterior crossbite, including
a lingual eruption path of the maxillary anteriors,
trauma to the decidjous dentition in which there is
displacement of the tooth buds, delayed eruption of
the deciduous dentition and supernumerary tee*h.
Tooth material arch - length discrepancies can result in
crowding and lingual positioning of upper teeth leading
to a dental crossbite.
Functional crossbite
Presence of occlusal interferences can result in
deviation of the mandible during jaw closure. This con
present as a un;lateral posterior crossbite. Habitual
forward positioning of tne mandible (pseudo Class III)
may lecd to an anterior crossbite. Pseudo-Class III
results from an early dental interference that forces the
mandible to move forward to obtain maximum
intercuspation. An cccquired muscular reflex pafern
during closure of the mandible is involved in functional
crossbites.
ETIOLOGY OF CROSSBITE
Cross bites of the anterior or posterior region con
Management of Crossbite 425
C
occur as a result of a number of causes:
1. Persistence o* a dcciduous tooth often results in
palatal defection of its erupting successor causirg
single tooth anterior crossbite.
2. Crowding and abnormal displacement of one or
more teeth aso result of arch length-tooth mcterial
discrepancies may cause dental cross bites.
3. Presence of hobits such as thumb sucking end
mouth breathing can cause lowered tongue
position. Thus the tongue no longer balcnces the
forces exerted on the teeth by the buccal group of
musculature. This disharmony between the
external and internal muscle forces can result in
narrowing of the upper arch leading to posterior
crossbite.
A. Retarded development of maxilla in sagittal as well
as transverse direction can cause cross bi'es in
the anterior or posterior region.
5. Narrow u p oe r arch resulting from decreased
growth stimulation in the mid-palatal suture.
6. Collapse of maxillary arch as seen in congenital
defects such as clefts of the palate.
Fig 3 Crossbi'es (A) & (B) .Anterior s'ngle tooth crossbite (Q & (D) Anterior segmental crossbite (E) &(F) Posterior crossb'te |G) &
(H) Anterior and posterior crosso'le
428 Orthodontics - The Art and Science

wooden stick resembling an ice cream slick. It is ploced

inside Ihe mouth contacting the palatal aspect of the
tooth in crossbite (fig 5}. The blade is made to rest on
the mandibular tooth in crossbite which acts as a
fulcrum and the patient is asked to rotate the oral port
of'the blade upwards and forwards.
This is continued for ] - 2 hours for about 2
weeks. Most developing cross bites that ore
recognized by the dentist at an early stage can be
successfully trected by this form of therapy.

Cat/en's appliance or lower anterior inclined

plane

Inclined planes constructed on the lower anterior teelh

can be used to treat maxillary teeth in crossbite (fig
6).The inclined plane can be made of acrylic or cast
metal and con be designed to

Fig 5 TcnguB clade used to tree- developira anterior

cross bite

7. Sagirta discrepancies of the jaws such cs a

toward I y positioned mandible results in the wider
port of the mandibular arch occluding •villi a
narrower pari of the maxillary orch.
8. Unilateral hypo or hyperplastic growth of any of
Ihe jaws can cause crossbite.

TREATMENT OF ANTERIOR CROSSBITE

Fig 6 {A) Cctier's appliance (Bj Side view ct Cat

Use of tongue biade
an's appliance
Developing single tooth anterior cross biles con
be successfully treated using a tongue blade. It
can be used in ease there is sufficient space for the
tooth to be broucnt out. The tongue blade is a flat
 bite plane to help in jumping the bite. The use of Z
spring is indicated only when there is adequate space
for labializotion of the teeth in crossbite.

Treatment of skeletal anterior crossbite during

Fig 7 Removable appliance hccrpcrcring Z springs far treafmcrt of
uppe' lotera's :n crossbite
treat a single tooth in crossbite or a segment of the
upper arch in crossbite. The inclined plone is designed
to have a 45c angulation which forces the maxillary
teeth in crossbite to a more labial position.
It is indicated when cdeouote space exists in
the arch for the alignment of the maxillary teeth in
crossbite. They ore to be used only in those cases
where the crossbite is due to a palatolly displaced
maxillary incisor.
The lower anterior inclined plane has o
number of disadvantages which include :
1. The potient encounters problems in speech during
the therapy.
2. The patient has to put up with dietary restrictions.
growth period
termination of growth by using a protraction face mask
(reverse head gea') (fig 1 OJ.These :ace masks helps
in orotractior of'■he maxilla thereby normalizing the
skeletal crossoite.
Excessive mandibular growth leading to
skeletcl anterior cross bites should be intercepted by
use of chin cap.
Fixed appliances for treatment of anterior
crossbite
Dental anterior crossbite involving one or two teeth
can be treo'ed with fixed appliances using multi-
looped crchwires.
TREATMENT OF POSTERIOR CROSSBITE
Crossbite elastics
Single tooth crossbite involving the molars can be
treated using el c sties that are stretched between

3. If the appliance is used for more than 6 weeks it

can result in anterior open bite due to supre-
emption of the posteriors.
4. The appliance may need frequent recementation.

Use of double cantilever spring (Z spring)

Anterior cross bites involving one or two maxillary tooth
can be treated using a double cantilever spring (fig 7}.
In case o* a deep over bite the spring should be given
along with a posterior
Skeletal anterior crossbite tnat occurs as c result o: a
retro-positioned rraxilla should be treated before fig D CrossbitB etas'ics
the maxillary palatal surface end mandibular buccal segmen: are formed. The two segments are connected
surface (fie 8).These elastics extend throjgh the bite by one or more jack screws. The smaller segment ot
and ore indicated if su^icient space exists for moving the plate adjoins the area in crossbite whereas the
the tooth into Ine arch. arger segment is used for anchorage.1
These elastics are to be worn day and night.
Fixed app//ances
The treatment should not be continued for more than
six weeks as tne elastics can extrude the teeth. Unilateral cross bites can a so be treated by using fixed
appliances. Asymmetrically cxpanocd
Coffin spring
The Coffin soring wos des'gned by Walter Coffin. It is a
removable appliance that consists of an omega shaped
wire of 1.25mm diameter placed in Ihe mio - palatal
region. The free ends of the omega are embedded in an

Fig 9 JAJ Hyrcix appliance used for exparsion of maxillary crch (BJ Qucti hel>x cppl once.-

acrylic plate tnat covers the slopes OT the pc ate. The

spring brings about dento-alveolar expansion.
However, it is capable of skeletal changes when used
in young patients.

Quad helix
The quad helix is a spring that consists ot four helices
(fig 9 B). The quad helix is capable of denlo-alveolor
exponsion of the molar as well as premolar region. It
con bring about skeletol expansion when L-sed in
younger patients.
Rapid maxillary expansion
Bilateral skeletal crossbite cnaractorizcd by a deep
palate, nascl obstruction and narrow maxilla can be
treated by rapid maxillary expension where in Ihe
mid-palata surure is split. This is cone by us'ng
appliances tho: incorporate screws that ere to be
activated at regular intervals.(tig 9 A)

Removable plates
Unilateral cross bites can be treated using removable
applicnces incorporating jack screws. The appliance
consists ot o split acrylic plate, a jack screw and Adam's
clasps on the posterior teeth to reta'n rhe plate. A labial
bow can also be incorporated into the appliance for
minor spoce closure and retraction.
The desired cffcct is achieved by sectioning
the plate in such a way that a small segment and larger
I 1

Management of Crossbite

Fig 10 (A), \&) cnd(C) P'8 Vedlmenl photog'Cphs oi n ca-ient with arrcic cross bile reeled '"ith fixed orhodontic cppl onos. (Dj. IE) ond{F) 3osl
Ireo'rrenl oio'ogranhs of the sane patien4.
432 Orthodontics - The Art and Science

References

1. Bell : Maxillary expansion in relation to rote of expansion and

pofients age. Am J Orthod : 982 ; 32-37
2. Bell : Maxillary expansion using a quad-helix oppli- anco. Am
J Orthcdl981 ; 152-161
3. Boas, Ccpclozzu, Si va : RME in primary and mixed
den-itions. Am J Orhoc 1991 ; 171-179
4. f^ank and Engel : Effects of maxillary quad-helix appliarce
expansion on cepha'-ornetric measurements. Am J Orthod
1982 ; 378-389
5. Graber TiVl : Orthodontics : Principles and practice. W8
Sounders, 1988
6. Greenbaum end Zacnrisson : Efface of oalofal expansion
-herapy. Am J Orthod 1982 ; 12-21
7. Haas : JCO Interviews: Dr. And rev/ J . f Clin Orthod
1973;227-2<15
8. Hacs : Palatcl expansion: Jest the beginning af dentofocial
orthonedics. Am J Orthod 1970 ; 219-255
9. Hass : Rapid exparsicn of the maxillary dentai arch anc the
nasal cavity by oaening the mid oolotol suture. Angle Orthod
1961; 31 : 73-9C
10. Hass : lorg term cast treatment evoleot'on of rapic palata'
expansion. Angle orthod 1980; 50 : 189-217.
11. Hass : Treatment of maxillary deficiency by opening the
midpalatcl sjtj'e. Angle Orthod 1 965; 65 : 2C0-217.
"2. Howe : Palatal expansion using a bondee appli- cncc. Am J
Orthod 1982 ; 464-468
13. Prcfitl WR: Ccnternpcrary Orthodontics, St Louis,
CVMosby,1986.
14. Robert E Moyers : Hand ucok of Ortnodantics, Year boo'<
medical publishers, inc. 1988.
15- Thomas M Grabcr, Robert I Vonarsdall : Orhodon- rics current
crinciplcs and techniques, Mosby year booklnc , 1994
16. UrboniaK, Brantley, Prults, Zussmon, one Post : In vitro force
delivery ol qjad-helix appliance. Am J
Orthod 1988 ; 311-316
 ■V 'g -W
':
Management
of Deep bite
T
he maxillary dental arch being larger than the
mandibular arch allows the maxillary anteriors
to overlap the mandibular anteriors. This
overlapping of the mandibular teeth occurs in both the
horizontal as well as vertical direction. The horizontal
overlap is called overjet while the vertical overlap is
termed overbite. Thus some degree of vertical
overlapping or overbite is a normol feature of human
dentition. However, some patients present with
excessive overbite. Such a condition where there is an
excessive vertical overlapping of the mandibular
anteriors by maxillary anteriors is called deep bite.
Deep bite is one of the frequently seen
malocclusions that can occur along with other
associated malocclusions. It is said to be one of the
most damaging malocclusions when considered from
the view point of the future health of the masticatory
apparatus and the dental units.
Graber has defined deep bite as 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. Deep over bite can be of
two types : incomplete over bite and complete over
bite. Incomplete over bite is an incisor relationship in
which the lower incisors fail to occlude with either the
upper incisors or the mucosa of the palate when the
teeth are occluded (fig 1 .b). Complete over bite on the
other hand is o relationship in which the lower incisors
contact the palatal surface of the upper incisors or the
palatal tissue when the teeth are in centric occlusion
(fig 1 .c).This kind of deep bite often results in trauma
of the mucosa palatal to the maxillary incisors.

CLASSIFICATION

Deep bite can be broadly classified inlo two types.

1. Skeletal deep bite
2. Dental deep bite
 F"g 1(A) Normal overbite (B) Incomplete overbid |C) Complete overbite

Ske/eta/ deep bite incisors is usually seen in Class II malocclusion. The

Skeletal deep bites are usually of genetic origin. This
kind of deep bite is caused by upward and forward
rotation of the mandible. The deep bite can be further
worsened by a downward and Toward inclination of
the maxilla (fig 3). These skeletal deep bites arc
characterized by the presence of the following features
: to infra- occlusion of the molars. The presence of a
a. Patients exhibit a horizontal growth pattern.
b. The anterior facial height is reduced.
c. A reduced inter-occlusal clearance (freeway
space).
d. A cephalometric examination reveals thct most of
the horizontal cephalometric. planes such as
mandibular alane, F.H. plane, S.N. alane etc., are
parallel to each other.
presence of an increased overjet allows the lower
incisors to over- erupt until they meet the palatal
mucosa. These patients hence exhibit an excessive
curve of Spee. The inter-occ usal clearance is usually
normal as the molars are fully erupted. Deep bife due
to infra-occlusion ot molars: Deep bites can occur due
lateral tongue posture or lateral tongue thrust may
prevent Ihe molars from erupting tothoir normal
occlusal level. It can also occur due to premature loss
of posterior teeth. Deep bites caused by infra-
occlusion of molars are characterized by the presence
of partially erupted molars (i.e. reduced crown height)
and large inter-occlusal clearance.

Dental deep bite

This kind of deep bite is characterized by Ihe absence

of any skeletal complicating features which are seen in
skeletal deep bites. Dental deep bites occur due to
over-eruption of anteriors or infra-occlusion of molars.

Deep br'fe due to over-eruption of anteriors : Dental

deep bite associated with over-eruption of lower
DIAGNOSIS' certain factors that help in deciding whether to intrude
the anteriors or extrude the molars.
The routine diagnostic aids such as clinical

Management of Deep Bite 435

Fig 2 S<elfrol deep bite

Lip relationship
Patients with deep bite who exhibit a short upper lio or
a gummy smile should be treated by intrusion of the
anteriors. In patients exhibiting normal upper lip with
only 2 - 3 mm of maxillary incisal edge exposed, it is

examination, study models and lateral cephalogram ideal to extrude the molars.

are used for ihe diagnostic exercise. The orthodontist

should be able to differentiate skeletal deep bite from
dental deep bite. Lateral cephalometric analysis of the
skeletal pattern helps in diagnosing a skeletal deep
bite. These patients show a reduced mandibular plane
angle as well as a reduced anterior facial height.
FACTORS TO BE CONSIDERED IN TREAT-
MENT OF DEEP BITE

Deep bites are usually corrected by intrusion of the

anterior teeth or by extrusion of the posterior teeth.
The orthodontist should decide which of Ihe two
modclities is indicated for o given patient. There are
Consideration of vertical facial relationship
Fiy 3 Skeletal deep bite (A} Normr.l skeie-al relafionship (B| Skeletal deep bite due to upward and forward rotation of the mcn.diblc -|C) Skeletal
deep bite due to downward and forward rotation of the maxil a (D) Skeletal deep bite duo to combinotion of B & C

Extrusion of one or more posterior teeth usually results
in downward and backward rotation of the mandible.
Thus an increase in anterior facial height occurs. This
can be a benefit in treating skeletal deep bites with
excessive horizontal growth and upward rotation of
mandible.
can result in fatigue of the muscles of mastication
which get stretched and predispose to relapse. The
presence of a normol inter- occlusal clearance is
therefore an indication for intrusion of the incisors
rather than extrusion of molars.

Consideration of Inter-occlusal space

The average inter-occlusal space is 2-4 mm in the
premolar region. Presence of an increased
inter-occlusal space is an indication that Ihe molors are
not fully erupted. In such patients the deep bite can be
treated by extrusion of the posterior teeth.
The orthodontist should not reduce a normal
inter-occlusal clearance by extrusion of molars as it
 timk' k11t ><H I &&

Management of Deep Bite

Fig 4 Anterior bit© alone (A} A clearance of 1.5 - ^rrrn should exist between the uppe' and lower posterior *eeth.( bite plane I Anterior

TREATMENT OF DEEP BITE inter-occlusal acrylic is trimmed gradually to encourage

the eruption of the posterior teeth. Bionator can also be
Deep bites can be treoted using removable, fixed or
used for a similor purpose.
myofunctional appliances.

Fixed appliance therapy

Removable appliances
Fixed orthodontic appliances can be used to intrude the
Anterior bite plane is the most commonly used
removable appliance for treatment of deep bite (fig 4). anteriors. The following are some of the methods used

The anterior bite plane is a modified Hawley's in fixed appliances to treat deep bite.

appliance with a flat ledge of acrylic behind the upper Use of anchorage bends : Anchorage bends are given
anteriors. When the patient bites, the mandibular in the arch wire mesial to the molar tubes so thot the
incisors contact the bite plane thus disoccluding the anterior part of the arch wire lies gingival to the bracket
posteriors which are free to erupt. slot (fig 5.a}. Thus when these arch wires are pulled
The anterior bite plane consists of Adam's occlusally and engaged into the brackets, a gingivally
clasps on the molars which help in retaining the directed intrusive force is exerted on the incisors which
appliance. A labial bow is also incorporated to counter reduces the deep bite.
any forward component of force on the upper anteriors.
The height of the anterior bite plane should be
just enough to separate the posteriors by 1.5 to 2 mm
(fig 4.a). As the posterior teeth erupt the height of the
bite plane is gradually increased.
Myofunctional appliances
Deep bite cases diagnosed to be due to infra- occlusion
of molars can be treated by an activator designed and
trimmed to allow the extrusion of these teeth. The
Use ot

A B
Fig 5 Airivio- bite plane (A) Anchorage bend -or in-rjs on ot anterior teeth -3) Archv/ira v/th reverse curve of Saee

crrc.bw.ves v/rth reverse curve O. 11 " Spee r Res i activated by giving a V bend
lien-arch wires that have been curved ir. a cirection
opposite to that of the curve of Spee can be used to
intrude anteriors (fig 5.b). When thcsearch wires are
insetted into the molar tubes, the anterior segment
curves gingivally. Tnis anterior segment is forced
occlusally into Ihe bracket slot resulting in an intrusive
B
forcc en tne incisors. Fig 6 (A)U'ility arch jsed for intrusion o: ante' ors IB) V bene given fa'
Use of uJfhty archcs : Utility arches arc arch wires that adivanon of utility arch Ipr anteror ini'usion

are bent is such a way that they bypass the buccal in the buccal segment of the wire so as to produce a

segment and are engaged on :he incisors [fig 6.A). intrusive forcc on the anteriors (fig 6.B). References
These arches can be used to perform a number of
tooth movements Including intrusion of incisors,
protraction or even retraction of incisors. They are

1. .Boll, Jacobs, end Logan : treatment o: Class I! dfiep bite bv

orthodontic and su-gical means. Am J Oithod 19 1984 ; 1-20
C
lefts involving the lip ond palate ore the most mandibular arch, plays a vital role in the development
commonly seen congenital deformities that of the ncso-maxillory complex.
occur at the time of birth. They are usually not
life threatening
unless associated
with some
syndrome having
other systemic
complications.
Nevertheless, clefts
are beset with
numerous problems

agement of Cleft
lip
that
the patient, parent and the doctor have to tackle. Clefts
of lip and polate can occur individually or together in
various combinations. They can also occur along with
congenital defects that affect other parts of the body.
The aim of this chapter is to give a general overview of
this congenital deformity and elaborate on the role of
the orthodontist in its management.

INCIDENCE

The incidence of cleft lip and palate is found to be

different among different roces. Studies reveal an
incidence of 1 in every 600 - 1000 births.
The Negroid race has the least incidence (one in every
2000 births) while the Mongoloids have the highest
incidence. Cleft lip is common among males while clef?
palate Is more common among females. Unilateral
clefts account for 80% of the incidence while bilateral
clefts occount for the remaining 20%. Among the
unilateral clefts, clefts involving the left side ere seen in
70% of Ihe cases. The reason why the left side is more
often involved is nol yel known.

EMBRYOLOGICAL BACKGROUND

The foce is formed by the fusion of a number of

embryonic p'ocesses thai -'orm around the primitive
oral cavity or stomodeum. Around the fourth week of
intra-uterine life, five branchial arches develop at the
site of the future neck. The first arch, called the
 The mesoderm covering the developing Another possible etiologic factor is teratogenesis.
forebrain proliferates and overhangs the slomodeum. Teratogens are certain drugs or agents that cause

On either side of the stomodeurn is the developing disturbed growth and development in the foetus. Some

mandibular arch, ihe dorsal end of which gives off a of the known teratogens are : Rubella virus Cortisone

bud called the maxillan,/ process. With the formation of Mercalopurine Methotrexate Valium Dilantin

the nasal pits, the ■frontonasal process gets divided

Multifactorial etiology
into a medial nasal process anc two lateral nasal
Recent studies have shown that the etiology of cleft lip
processes. The upper lip and maxilla is thus formed by
and palate cannot be attributed solely to either genetic
the fusion of the maxillary process with the medial and
or environmental factors. It seems to involve more than
lotero'' nasal processes.
one factor. They argue that unless a person is
. The palate is formed by the contribution of the
genetically susceptible, the environmental foctors may
maxillary process and frontonasal process. The
not by themselves cause clefts.
maxillary process gives off palatal shelves that grow
medially. The union of trie two palatal shelves is PREDISPOSING FACTORS
prevented initially by rhe presence of the tongue. Thus
the shelves grow vertically down. Sometime during the A number of foctors are believed to increase the risk of
7th week of intra-uterine life, rhe tongue descends and cleft lip and polatc incidence.

the palatal shelves become more horizontal. By around

Increased maternal age
81/2 weeks the two shelves are in close approximation.
The palate forms by fusion of the maxillary shelves with Women who conceive late have an increased risk of

each other and with the frontonasal process. Failure of having an offspring with some form of clefting. The
cause remains unknown.
fusion results in clefts of the palate.
The mandibular process gives rise to the
Racial
lower lip and [aw Defective fusion or incomplete fusion
Some races are more susceptible to clefts thon others.
between the various processes leads to different types
Mongoloids show the greatest percentage
of clefting.

ETIOLOGY OF CLEFT LIP AND PALATE

Cleft lip and palate are believed to occur due to genetic

and environmental factors. Many workers are of the
view tnat clefts occur due to o number of causes and no
single etiology can be pinpointed.

Heredity

Heredity has long been considered an imoortont

etiologic factor for cleft lip end aaiate. A study
conducted by Drilien reported that 1 in 3 children with
clefts had some relatives with similar congenital
defects. Clefts of the lip and palate can be transmitted
as a dominant or a recessive trait.

Environment
 Group /// - Alveolar clefts : They ore complete clefts
of incidence. Blood supply
involving the palate, alveolar ridge end the lip. They
Any factor that reduces blood supply to the
nasomaxillary area during embryologicol development
Management of Cleft Lip and Palate \ 441
can be subdivided into : Unilateral Bilateral Median

'C D
Fig 1 (A' Unilcforal clef) involving lip ond clveolus (B] Uni'ctera' clef involving l!p aid palate (C| Bilatoral c u t invc'vir.g I'p and paiote (D|Median
cilcft involving palate only

predisposes to clefts.

CLASS/F/CAf/ON OF CLEFT LIP

AND PALATE

A number of classifications have been put toward by

various authors.

Dav/s and Ritchie classification (1922)

This is a morphological classification based on the
location of the cleft relative to the alveolar process.
They have classified clefts into three groups :

Group I - Pre alveolar clefts : They are clefts involving

only the lip & arc subclassified as : Unilateral Bilateral
Median

Group /i - Post olveolar clefts : This group comprises of

different degrees of hard and soft palate clefts that
extend upto the alveolar ridge.
Veau's classification (1931)

Orthodontics - The Art and Science

He has classified clefts into four groups :

Group ? : They are clefts involving the soft palate only. Left Right
Fig 2 ScKcharct and Peer's
Group 2 : They are clefts of the hard and soft plate symbolic classification

extending upro the incisive foramen.

Lip
Group 3 : They are complete unilateral clefts involving Kernahan's stripped 'y' classification :
the soft palate, ihe hard palate, lip end the alveolar This is another symbolic classification put forward by
ridge. Kern a ha n ond Stark (fig 3).

Group 4 : They are complete bilateral clefts affecting The classification uses a stripped Alveolus
J
the soft pafate, the hard palate, the lip and alveolar Y' having numbered blocks. Each block

ridge. represents a specific area of the oral cavity.

Block 1 and 4 - Lip

Classification by Fogh Andersen (1942)
Group 7 : They are clefts of the lip. It can be subdivided
into :
Single - Unilateral or median clefts
Double - Bilateral clefts
Hard palate
Block 2 and 5 - Alveolus
Block 3 and 6 - Hard palate anterior to the
incisive foramen Block 7 and 8 -
Hard.palate posterior to incisive foramen

Groop 2 : They are clefts of the lip and the palate.

They are once again sub- classified into: Single -
Unilateral clefts Double - Bilateral clefts

Group 3 : They are clefts of Ihe palate extending upto

the incisive foramen.

Schuchardt and Pfelfer's symbolic classification

This classification makes use of a chort made up of a
vertical block of three pairs of rectangles with on
inverted triangle at the bottom (fig 2). The inverted
triangie represents the soft palate while the rectangles
represent the lip, alveolus and the hord palate as we go
down. Areas affected by clefts are shaded on the chart.
The advantage of this classification is its simplicity
while the disadvantages include difficulty in writing,
typing and communication.

Soft palate

Total cleft

Partial cleft
 Right Left
A cleft lip and palate patient is afflicted by a number of
problems. They can be broadly classified as :
1.
Management Cleft Lip and Palate \ 443
ofDental
2. Esthetic
3. Speech and Hearing A. Psychologic

Dental problems
The presence of the cleft is associated with division,
displacement and deficiency of oral tissue. Cleft lip and
polate patients can have one or more of the following
features (fig 4}..
Congenially missing teeth (most commonly
the upper laterals)
Presence of nata I o r n e o nata I teeth
Presence of supernumerary teeth
Ectopically erupting teeth
Anomalies of tooth morphology

Fig 3 Kemohon's s'ripped 'Y' classificotion Enamel hypoplasia

Microdontia
Fused teeth
Block 9 - Soft palate
Aberrations in crown shape Macrodontia

The boxes are shaded in areas where the Mobile and early shedding of teeth due to

cleft has occurred. poor periodontal support

Posterior andanterior crossbite
Lahshal classification Protruding premaxilla

This is o simple classification presented by Okriens in Deep bile

1987. LAHSHAL is a paraphrase of the anatomic areas Spacing/crowding.

affected by the cleft.

L lip
A alveolus
H hard palate
S soft palate
H hard palate
A alveolus
L lip

This classification is based on the fact that

clefts of lip, alveolus and hard palate can be bilateral
while clefts involving the soft palate are
usually unilateral. Areas involved in the cleft are
'denoted by specifically indicating the alphabet
standing for it. For example, L - - S - - - stands for cleft
of right lip and soft palate.
L A - S - -L stands for cleft of right lip, alveolus and soft
palate together with left cleft lip.

PROBLEMS ASSOCIATED WITH CLEFTS

 Fig ^ Dcrkil problems ossociolec with deft lip end polale

Estftetfc problems result of heoring impairment, speech problems and

The clefts involving the lip can result in facial frequent absence from school.
disfigurement varing from mild to severe. The oro-facial
MANAGEMENT OF CLEFT
structures may be malformed and congenially missing.
LIP AND PALATE
Deformities of nose con also occur. Thus esthetics is
greatly affected.

Hearing and speech

Cleft lio and palate are sometimes associated with
disorders of the middle ear which may affect hearing.
The presence of hearing problems can cause
difficulties in language uptake and speech.

Psychological problems
Cleft lip and palate patients are under lot of
psychological stress. Due to their abnormal facial
appearance they have to put up with staring, curiosity,
pity, etc.,. They also face problems in obtaining jobs
and making friends. Studies have shown that these
patients fare badly in academics. This is usually as a
Children bom with cleft lip and palate have a number of
problems that have to be solved for successful
rehabilitation. The complexity of the problem requires
alse roofing
Management
that a number of health care practitioners co-operate to
ensure comprehensive care of the patient. This led to
the concept of a multidisciplinary cleft palate team
comprising of the pediatrician, pedodontist,
orthodontist, oral and maxillofacial surgeon,
prosthodontist, social worker, genetic scientist, ENT
surgeon, plastic surgeon, psychiatrist ond a speech
pathologist.
The individuals of the cleft palate team
should be flexible and respect each other's opinion.
The cleft lip and palate team has been described as a
close, co-operative, democratic, multi- professional
union devoted to Ihe single cause of patient well being.
The management of cleft lip and palate can
be divided into the following stages :
Stage one
This comprises of the treatment done from birth to 18
month of age.
Stage two
This is from the 18th month to the fifth year of life. It
generally corresponds to the primary dentition stage.
Stage three
This includes treatment that is carried out during the
mixed dentition stage. It spans from the sixth to the
eleventh year of life.
Stage four
This includes treatment done during the permanent
dentition stage i.e. 12 - 18 of age.
STAGE ONE TREATMENT
The treotment modalities carried out during the first
stage include:
Fabrication of a passive obturator
Presurgicol orthopaedics Surgical
management of cleft lip Surgical
management of cleft palate
Passive maxillary obturator
The maxilla n/ obturator is on intra-oral prosthetic
device that fills the palatal cleft and thus provides a
£
againstLip
of Cleft which
and child can \
the Palate 455(fig 5}.
suckle
It thus reduces the incidence of feeding difficulties such
as insufficient suction, excessive air intake and
choking. It also provides maxillary cross arch stability
preventing the arch from collapsing.
The o b lu rotor is fabricated using cold cure
acrylic after selective blocking of all undesirable
undercuts. Clasps can aid in retention. In case of
insufficient retention, wings made of thick wire can be
embedded in the acrylic and made to follow the check
contour extraorally. These wings can be stabilized
against the cheeks using micropore adhesive tape.
Presurglcal Orthopaedics
The aim of pre - surgical orthopaedics is to achieve an
upper arch form that conforms to the lower arch(fig
6).The absence of variable amount of lip tissue and the
division in the alveolus and palate results in outward
disolacementofthe premaxilla (in case of bilateral
clefts} or the greater segment (in case of unilateral
clefts). The orthodontist should try to correct those
displacements by extra- oral strapping across the
premaxilla, attached directly to the face or to some form
of head cap (fig 7). A micropore adhesive tape can also
be strapped across the premaxilla.
In case of a narrow, collapsed maxillary arch,
the expansion can be achieved by a suitable appliance
incorporating expansion screws or springs.
The advantages of a presurgical orthopaedic
phase arc :
a. It reduces the size of the clefts thereby aiding in
surgery.
b. Partial obturation of the cleft assists feeding.
c. Improved speech as size of the defect is reduced.
d. It reassures the parents at a crucial time.

Fig 5 Passive maxillary ob'urator witn wings for retention
Surgical Hp closure
It is not within the scooe of this book to discuss Ihe
surgical procedures undertaken. However
ortnodontist should know at what tim e the surgery
should be performed. Surgeons have for a long time
disagreed on the timing of deft lip surgery. Some prefer
early surgery soon after birth while others recommend
a lote lip surgery.
The early school suggests that surgery
snould be performed within 45 days of birth. According
to them, tne child soon ofter birth shows a marked
immunity to surgical shock. The early surgery also
Fig 6 Pre - surg'cal ortnopaedics {A) In bilateral clefs rhe disploced
prerroxillo is re adapted lo conform
B lo Ihe crch (B) In unilcto'cl clefts
the displaced greater segment is reodapted to contofm to the orch
F"g 7 Pre • surgical orthopaedics by extra-orni strapping o cross ihe
premaxilla.
improves the facial appearance and therefore improves
child acceptance and reduces parent apprehension.
the The late school suggests that surgery should
be postponed till the completion of dentition.They
reasoned that the tissues would be oble to grow ond
mature thereby giving the surgeon more muscle mass
to work on.
Millard has suggested the rule of ten. Surgery
should not be performed less than 10 weeks of age,
when the body weight is not less than 10 pounds and
the blood hemoglobin not less than 10 grams%.
Surgical palate closure
The palatal repair should be attempted between 12 - 24
months of age. This facilitates normol speech, hearing
ond improves swallowing. The palatal repair can be
accomplished by using bone transplants that are taken
from rib, iliac bone, mandibular symphysis, tibial bone
or outer table of parietal bone.
STAGE TWO TREATMENT
This comprises the treatment carried out during the
primary dentition. The procedures carried out during
this phase are:
 Fig 3 Pafo'i' 'ti Ih cleft lip end pela-e (A, (BJ & (C) h'racrol photographs shewing "he dertal problems inducing crowding and anterior
crossbite (E) No'e tie surgically treated deft lip {F) Maxillary deficiency is clearly noticed in •he pro'ile view (D) & |G) Rad'ograpiis of
Ihe some pctient
a. Adjustments in the intra-oral ooturator
accommodate the erupting deciduous teeth.
b. To maintain a check on eruption pattern ond
timing.
c. Oral hygiene instructions.
d. Restoration of decayed teeth.
No orthodontic treatment is usually initiated
during this phase as the benefits desired would be lost
as soon as the deciduous teeth ere shed.
STAGE THREE TREATMENT
Stage three includes treatment carried out during the
mixed dentition phase. The orthodontic procedures
usually carried our are :
1. Correction of anterior crossbites using removable
or fixed appliances. The anterior crossbite should
be corrected to avoid functional mandibular
displacements ond retardation of maxillary growth
due to locked- in maxillo. Removable appliances
incorporating Z spring can be used to treat the
anterior crossbite.
2. Buccal segment crossbites are also treated using
quad helix or expansion screws.
STAGE FOUR
This stage consists of treatment during the permanent
dentition. The patient is treated using a fixed
orthodontic appliance. All local irregularities like
crowding, spacing, crossbites and over jet / overbite
problems are corrected. Patients wjth hypoplastic
maxilla maybe given face mask to advance the maxilla.
Prosthesis can be given in cose of missing teeth after
completion of orthodontic therapy.
Following the orthodontic
procedures, the patient should be put on a retention
phose to maintain the orthodontic corrections. Most
cleft lip and palate patients require long term if not
permanent retention for the following reasons :
1. Incdequcte bone support -
2. Absence of some teeth
3. Presence of stretched scar tissue
to The key to the successful rehabilitation of o
cleft lip and palate pctient includes fiexibiliry ond a
multidisciplinary approach. More than this the patient
should be treated with sympathy and concern.
References
1. Andlin-Scbocki, Eliasson, and Paulin : Bone gracing in oa'ierts
wilh cleft lio and clcft aalcte. Am J Orthod 1995 ; 144-152
2. Bckni, Fadane I:, and Subtelny : Treatment of y lateral cleft l p
ana palate. . Am J Orthod 199" ;
297-305
3. Bhalojni SI : Dental Anatomy, Histology and Development,
Ar,-a publishing house, New Dchi, 199£
-Bishara, Vs'ilson, Perez. O Connor, and Periche Dentoi'ccial
findings in child with unrcpcired mecian cleft of lip. Am J
Ortnod 1985 ; 157-162
5. Helms, Spcidcl, and Denis : Effect ot timing on alveola*- cle;1
bone grafts. Am J Orthod 198/ ; 232-240
6. Kerr, Vs'elch, Mccre, Tekieli, ond Ruscello : Funct'oral
regulctor therapy ;or c eft palate patents. Arr. J Orhod 1 981 ;
508-524
7. Kinrebrew and Kent : lore definitive correction of 'tie onrocial
cleft. Am J Ortnod 1983 rlC^-114
8. Nokosima end Ichinosc : Craniofacial structjres of ca-cnts o-
children with clett lip end/or palcte. Am
J Orthod 1963 ;140-146
9. Pro-itt WR: Cortemcorary Orthodontics, St Louis, CV (vies oy,
1966.
10. Robert E Moyos : Hand ucok of Ortnodontics, Year book
mecica publishers, inc,1983.
11. Roaers and Subtelny : Use of face mas* in treolmcT ot
moxilary skeletal retrusion. Am J O-tncd 19S8 ; 388-394
12. Roserstein : A new concept in the cor y orthoped c treatrr.ent
of c eft lip and palate. Am J Orthcd 1969; 219-229
13. Rure : Movement of iroxilla-y scgmcirs cfter expansion ard/or
secondary bore grafting n cleft lip ane' aalate. Am J Ortnod
1980 ; 643-653
14. SlovkJn and Melnic'c : Moiemal nf ucrcos cn ccigcii tal cran
ofacial malformations. Am J Orthoc 1982 , 261-268
15. Ten catc AR : Orul Histology : Development Structure end
Furctior, C.VMosoy, 5" IOv<is,1960
treatment
S
urgical orthodontics is a term that refers to
surgical procedures carried out as an adjunct
to or in conjunction with orthodontic treatment.
These surgical procedures are usually carried out to
eliminate an etiologic factor or to correct severe
dento-facial abnormalities that cannot be satisfactorily
treated by growth modification procedures or
orthodontic camouflage.
Surgical orthodontic procedures are broadly
classified as minor surgical procedures and major
surgical procedures. While most minor procedures are
an integral part of orthodontic therapy, the major

Surgical Orthodontics
procedures are aimed at treatment of severe skeletal
malocclusion or dento- facial deformities that cannot
be satisfactorily treated by orthodontic treatment alone.
Table 1 gives the list of minor and major surgical
orthodontic procedures. There should be good
co-ordination between the oral surgeon and the
orthodontist when undertaking such procedures.
EXTRACTIONS

Extractions are the most commonly undertaken minor

surgical procedures in conjunction with orthodontic
therapy. Extraction performed as a part of orthodontic
therapy include therapeutic extraction, serial extraction
and extraction of supernumerary carious or malformed
teeth.

Therapeutic extract/on
Therapeutic extraction is undertaken as a part of full
fledged orthodontic treatment mainly to gain space.
Prior to therapeutic extraction a thorough diagnostic
exercise is essential. The indications for extraction of
different teeth as a part of orthodontic treatment have
been discussed in chapter 23. Extraction should be as
atraumatic as possible. During the procedure, care
should be taken to preserve the integrity of the
alveolus. Any break or loss of either the buccal or the
lingual bony plates may prevent ideal positioning of the
 Minor Procedures extraction procedure, care should be taken not to
t. Enactions damage the adjacent teeth or roots. The tooth is
a. Therapeutic exlraction . b. Serial approached by a buccal or palatal flap depending upon
extraction its location. After careful elevalion of the flap, adequate
c. Extraction ol carious leesh
amount of bone is removed using rotary cutting
d. Extracfon of malformed
instruments. The impacted or supernumerary tooth is
teeth
removed and the extraction socket inspected for any
e. Extraction of supernumerary teeth
pathological tissue. The flap is repositioned and
f. Extraction ot impacted teeth
sutures placed fora week.
2. Surgical, uncovering of leelh
3. Frenectomy '
SURGICAL UNCOVERING OF
4. Pericision
IMPACTED TEETH
.5. Transplantation of teeth 6. Cordotomy Major procedures
1. Orthodontic surgeries 2/ Cosmetic surgeries
The presence of impacted teeth in the dental arch can
3. SurgKaJ-corrections in cleft lip ard palate patients
cause minor dental irregularities due to deflection of
4. Surgical assisted rapid maxillary expansion
adjacent teeth. Impaction of teeth usually occurs as a
result of arch length discrepancy or presence of
mucosal and bony barriers that prevent their eruption.
teeth during orthodontic therapy. Pre-operative
The most commonly impacted tooth is the maxillary
radiographs are a valuable aid in planning and
permanent canine. In many coses it is possible for the
execution of extractions.
orthodontist to guide the impacted canine into its
Ser/a/ extract/ons normal location in the dental arch after adequate
Serial extraction involves removal of some deciduous surgical exposure. The following steps are undertaken
teeth followed by specific permanent teeth in an in the management of an impacted tooth :
orderly sequence to guide the rest of the permanent
teeth into a more fovorable position. Serial extraction Location of the tooth

is usually carried out during the mixed dentition Evaluation ot favourability

period when a severe arch length deficiency exists Evaluation of space adequacy

which prevents normal alignment of the whole Surgical excision and bone removal

complement of teeth. Fixing orthodontic attachments

Extraction of supernumerary, Impacted

and ankylosed teeth

The presence of supernumerary, impacted and

ankylosed teeth are important local causes of
malocclusion. The most commonly seen
supernumerary teeth are the mesiodens.
Supernumerary teeth can also occur in the incisor,
premolar and molar region. Impactions in the maxilla
generally occur in the canine region.
Prior to the removal of these teeth their exact
location and their relationship with adjacent structures
should be ascertained by radiographs. During the
Fig 1 Surgicol orthodontic treatment of a uneruptec ceniral nciso-" (A)
frontal intrc-oral view o; o 12 ye-ar old ca'ient with uncruptod upper righ' cenlrol incsor. j3) ponoromic radiograph of the same patieni (C) ond (Di
surgicol exposure of the unerupted incisor (E) orthodontic trea'ment in urogross ;F) orthodont'c treatment nearing completion

Location of the tooth In many cases the orientation of the impacted teeth
The exact location of the impacted tooth has to be may be such that surgical orthodontic guidance of the
determined. This can be done using the Clark's tube tooth into the arch may not be possible. The
shift technique or the right angle technique using two favourability should be examined prior to undertaking
films. Most impacted teeth present a bulge of the procedure. It is considered favorable whenever
corresponding to their location which should be the apex of the canine is close to its normal position.
examined clinically by inspection and palpation.
£va/uat/on of favourabilfty
452 / Orthodontics - The Art and Scicncc

Fig 2 (A) end (6; Pret'ea'mert photeg'ophs of a patient with a polafclly irrpacted
carine soon after sjrgiccl exposure (C) ord \D) Post t'ea-mert photcgrcphs of tne same pclicnt.

Evaluation of space adequacy The crown of the impacted tooth is exposed by

When the impacted tooth is guided into the dental arch,
adequate space should be present for its normal
alignment. In many cases involving the impaction ot
permanent canines the deciduous canines are
over-retained. Tnese teeth have to be extracted to
excision of the overlying soft tissue ond removal of
bony covering. The bone should be removed upto the
maximum height of contour.
Fixing orthodontic attachments

accommodate the permanent canines. In certain
patients, the space intended for the permanent canine
may be lost by migration of the adjacent teeth. In such
cases, space for the permanent canine is created by
consolidating the rest of the teeth ond possibly
extracting a premolar.
Surgical excision and bone removal
In most cases of favourably impacted canines, once
the soft tissue and bony tissue is removed, the canine
erupts on its own. In some cases, orthodontic guidance
for eruption of the teeth into the arch moy be required.
Attachments are placed on the impacted
 tooth to guide the erupting tooth into the arch. Some of
Surgical Orthodontics .453 K®
the attachments that can be placed on the impocted
canine are : o. A metal crown with a hook b. A celluloid
crown with an attachment bonded to il c.

fig 3 Surgical crthodon'ic treatr-ieit of a 13 year old pat ent w'Yn irrpactee rncxillary left can nc (A| Pnetrea'ment maxillary occlusal photcgrcph. Note
the bulge produced by the conire.|8) ^odiegmph of Ihe same patient (C) Alignment in progress (D) Soon of'er surgical exposure of the canine (E)
end (F) Ncaring completion o: 'rectment.
Bondable orthodontic brackets or buttons
A ligature wire is wound around the
attachment and the other end tied to a removable or
fixed orthodontic appliance. The wire is gradually
tightened at regular intervals to guide the erupting
tooth.
FRENECTOMY
Many cases of midline diastema are believed to be
caused and maintained by abnormalities of the
maxiilary labial frenum. The presence of a thick, fleshy
end fibrous frenum prevents tne two maxillary central
incisors from approximating each other. In these
patients the frenal tissue may cross over and get
attached in the inter-maxillary suture area on the
palatal aspect.
Frenectomy is a surgicai procedure
performed to excise the frenum and remove the deeply
embedded fibrous tissue. Controversy exists regarding
the timing of the surgical procedure. According to
some, frenectomy should be performed prior to
orthodontic closure of the midline diastema. According
to another school of thought, frenectomy should be
performed after space closure as it reduces the risk of
scar tissue formation that ccn prevent closure of the
midline space.
Regardless of Ihe timing when the procedure
is performed the following points should
remembered.
a. The frenum should not merely be clipped. It
should be totally excised, to tne bone level.
b. Any palatally attached fibrous tissue should be
removed.
c. Fibrous tissue attached to the inter-maxillary
suture area should be removed.
d. The mucosa of ihe lip is undermined to prevent
reattachment of the -'ibrous tissue.
CORJICOTOMY
Corticotomy is a surgical procedure usually
undertaken in patients having denial procl i nation with
spacing. This technique involves the sectioning of the
dento-clveolar region into multiple small units to hasten
orthodontic tooth movement. Labial flops are raised
and interdental bony cuts are made parallel to the long
axes of Ihe teeth. Those cuts maybe joined together by
a horizontal bony cut above the apices of the roots.
Core should be taken not to totally separate tne
individual units. Following the surgery orthodontic
tooth movement is initiated using fixed appliances.
PERICISION
Pericision or circumferential supra-crestal fibrotomy,
as it is often called is a minor surgical procedure thai is
undertaken to counter ihe relapse tendency of the
stretched gingival fibres. The trans-sepial and alveolar
crestol group of gingival fibres remain stretched and do
nol readily readapt to Ihe new tooth position following
correction of rotations hence causing relapse.
Pericision involves surgical sectioning of
these fibres by passing a sharp narrow scalpel through
the gingival sulcus around the tooth to a depth of 2 mm
apical to the alveolar crest. Pericision is generally
undertaken asan adjunctive retention procedure after
the correction of rotations.
ORTHOGNATHIC SURGERIES
be
Orthognathic surgeries are major surgical procedures
carried out along with orthodontic therapy lo correct
dento-facial deformities or severe oro-iacial
disproportions involving the maxilla, Ihe mandible or
both in combination. Denlo-facial de:ormities can be
congenital, developmental or accquired in nature and
can affect the maxilla, the mandible or both the jaws.
The etiology of dento-facial deformities can be
classified into the following three groups: 1. Known
specific cause a. Prenatal
 E. Mandibulofacial dysostosis
b. Postnatal
Surgical Orthodontics .455 K®
2. Hereditary F. Facial clefting syndrome

3. Environmental G. Achondroplasia.

Refer to Table 2 for the list of possible H. Craniosynostosis syndrome

I. Pierro Robin syndrome POSTNATAL
etiologic factors. Orthognathic surgery basically
A, Injury to nasal septum 8. Injury to condyle
involves planned fracturing of the facial skeletal parts
C. Injury tc ramus
ond repositioning them as desired. They should be
D. Injury to areolar bone and leeth
performed as a team with the oral surgeon and the
E. Missing muscles
orthodontist being important members of the team.
F. . Condylar hyperpiasia
Orthognathic surgeries can be performed in
II HEREDITARY
the maxilla as well as the mandible to correct jaw
A. Mandibular prognathism E.g,
discrepancies in all the three planes of space. Refer to
Hapsburg syndrome
Table 3 for the various procedures. B. Inter-racial mixing
The planning and execution of orthognathic III ENVIRONMENTAL A Effect of

surgeries are done in a methodical manner. The posture

following are the steps involved in orthognathic B. Respiratory influence
surgery: C. Elfcct of biting torce
a. Diagnosis (Pre-operative evaluation)
b. Pre-surgical orthodontics The patient's social status should also be evaluated.
c. Mock surgery
Cepholomeiric evaluation : Cephalometric
d. Surgery and stabilization
evaluation is an important tool in determining the
e. Post-surgical orthodontics
nature and severity of the skeletal problems. The
Pre-operative evaluation commonly used cephalometric analysis are the

Pre-operative diagnosis is very important for the Burstone analyses and the quadrilateral analysis.

success of orthognathic surgery. The diagnosis is Frontal cephalometric analysis helps in determining

aimed at determining the nature, severity and the facial asymmetry.

possible etiology of the dento-facial deformity. Radiographic exam/notion : Prior to the surgical

Genera/ medico/ evaluation : The patient's general intervention the following radiographs are mandatory.

medical history should be recorded to rulo out medical

disorders. The patient's overall dental health should be
evaluated. Pulpo- periodontal problems should be
relieved prior to the surgical intervention. Socio -
psycho/og/caf eva/uoh'on : The patient is assessed to
determine whether he / she is aware of the existing
dento-facial deformity and whot he / she expects out of
the surgical therapy. This helps in determining the
patient's motivation.

I SPECIFIC CAUSES

PRENATAL CAUSES
A. Felat alcohol syndrome
B. Reiinoic acid and thalidomide Iherapy .
C. Hemifacial microsomy
D. Goldenha^'s syndroms
 1. Intro-oral periapical radiographs : These appliance. However segmental crossbites with narrow
radiographs help in determining the condition of the maxillary arch require some form of arch expansion
456 Orthodontics - The Art and Science procedure such are rapid maxillary expansion with
teeth and alveolar bone. Presence of pathology around hyrax appliance or expansion using quad helix
the tooth can also be determined using these appliance. As a general rule orthodontic expansion or
radiographs. contraction to co-ordinate the upper and the lower
2. Panaromic radiographs : Panoromic radiographs arches should be carried out prior to the surgery so as
offer a wide view of the entire dentofacial region to provide correct post-operative occlusal
including the tempero- mandibular joint. These interdigitation.
radiographs are useful in evaluation of bony 3. /ncisor mc/rnoMons ; Proclined upper incisors in
pathologies, evaluation of the temperomandibular joint Class II, division 1 may need to be retracted to more
and the maxillary sinuses. normal axial inclination. Similarly retroclined incisors in

3. Submento-vertex view : A radiograph routinely Closs II, division 2 have to be proclined.

used is the submento vertex view, to determine the 4. Decompensation : Most severe skeletal jaw

bucco-lingual thickness of the mandible as well as discrepancies are partly compensated by change in

degree of deformity of the face. axial inclination of the anterior teeth. For example,
mandibular retrognathism is associated with proclined
Sfudy model evaluation : Study models are helpful in
lower anteriors to partially offset the skeletal
the evaluation of occlusion from all directions. They ore
discrepancy. Class III patients with prognathic
used to assess inter-arch and intra-arch discrepancies.
mandible usually exhibit lingually tipped lower incisors
TMJ evaluation : The temperomandibular joint is to compensate for the skeletal relation. Pre-surgical
evaluated by inspection, palpation, auscultation and by orthodontics should correct these positions of
radiographic examination to evaluate joint movements compensation to position the teeth correctly over their
and any pathology. supporting bone. This procedure is called
decompensation.
Pre-surgtcal orthodontics
The objective of pre-surgical orthodontics is to prepare Since most patients require postsurgical
the patient for the intended orthognathic surgery and orthodontic treatment, it is unnecessary
not to make the occlusal relationship as idea] as
possible.
The following procedures are undertaken as part of
pre-surgical orthodontics. ?. Toofh o/jgnmenf wifhrn
the arches r Spacings and rotations are to be
eliminated during the presurgical orthodontic
treatment. Simple correction can be achieved by
removable appliances. However fixed appliancsare
preferred as they offer better control and it is possible
to align several teeth. Space may be needed for these
manoeuvres which can be gained by interdental
stripping or even extractions. Extractions during
presurgical orthodontics is generally undertaken to
relieve moderate to severe crowding within the dental
arches and to occomodote segmental bone cuts.
2. A/ferotior? and co-ord/natton of the arches; Local
crossbites involving an individual tooth can be
corrected with removable or fixed orthodontic
 Surgical Orthodontics .457 K®

Treatment options
Mandibular prognathism
A. Sagittal splii osteotomy with mandibular set back (fig 6) /B. Oblique syb
condylar (sub sigmoid) osteotomy.

Mandibular reirognathism.A. Sagittal split osieotomy with mardibula' advarra-nenl (fig 4)

B. A forward slid rg genioptasty of the chin
may be required in addition

Horizontal chin deficiency Geniop'asly (fig 12)

Maxillary retrusion or hypoplasia

Lefort I osteotomy with maxillary advancemenl (fig ?i

Maxillary protrusion Bi maxillary

Maxillary segmental (a^te-'vor/ set back (fig 5)
protrusion
Maxillary afd mandibular s6g mental osteotomy for set fcscfc of anterior
maxilla and mancile ifg 11)

Maxillary deficiency & mandibular excess A. leforl I ostooiomy.of maxilla to advance

and impact maxilla. -
B. Sagittal split osteotomy with mandibular &ei back - fig 8)

Maxillary vertical excess Leforl t osteotomy with maxillay impaction (fig 10)

Open bites A. Dento-alveolar open bites

Minor dento-alveolar open biles can be treated by maxillary anterior
segmental osteotomy. Larger dento-alveolar open bites may requi.'o
additional mandibular segmental osteotomy
B. Skeletal open bite (with Angle's Class I or II)

These patients usually have vertical mamillary excess. Le forte I osteotomy with
maxillary impaction is done. .;
C. Skeletal open bite (with Angle's Class III)
These patients may not usually have a vertical maxillary excess. They have
increased length of ramus and mandibular bcdy. Sagittal split osteotomy: Is done
lo d'Sp'ace mandibular body upwards and backwards. If there is an associated
maxillary retro,gnalhism a le forte I with maxillary advancement is done. In case

the paiior.t also exhibits a vertical maxiilary excess, 1hen le Forte I v/tih maxillary
impaction is done.

Deepb'ite Lower anterior dento-alveolar segmental osteotomy to bring the lower incisor
segmenl downwards and towards.
Fig A S<ele:al Class li malocclusion dee 'o mandibular Fig 5 Maxillary protrusion t.-eared by maxillary segmentai (anterior!
vetrognalhism treated by sog:"al splir osteatorny with mandibular set bock.
advance men*

Re 7 Class III skeletal pa-tern due to mcxillary refusion or

hypoplasia treated by ie Fort I osteotomy with maxillary
advancement

mandibular set back.

Fig 8 Class III skeletal pattern due to maxillary re*rusion or Fig 9 Skeletal open bites clong wi'h Ooss II skeletal patten reaurc
hypoplasia and mandibular prognaihisri treated by I e Fort I le Fo^t 1 with maxillary impaction with sagitel split osteotomy for
os'eotomy with mcxillcry advancement and sagittal spli' osteotomy mandibular advancement .
with rnondibUar set back
Fig 10 Long face is usuolly associated with vertical maxilicry
excess. They are treated byle Fort 1 with rnexillary impaction.
Fig 1 1 Bimoxillory protrusion requ-'e maxillary and mand:bulor
segmcn'cl osteotorry for set back ot cnterior moxillo ord rrondiblc

tW
. _
 COSMETIC SURGERIES
They are surgical procedures carried out to improve
the esthetic appearance of the patient. These
surgeries can involve the nose and the chin. Cosmetic
surgery of the nose is colled rhinoplasty. They are
undertaken to correct abnormal configuration of the
nose. Cosmetic surgery of the chin is refered to as
genioplosty.

References

Fig 52 Horizontal chin deficiency often require genioplosty.

to carry out extensive pre-surgical tooth movement

that ca n be accom pi ished m ore easily a nd q u ickly
during or after the surgery. Pre-surgical orthodontic
preparation should never extend more than one year.

Mock surgery
Soon after the completion of pre-surgical orthodontic
treatment a mock surgery is performed on the upper
and lower models mounted on a hinged oronatomical
articulator. The models are cut and repositioned in the
desirable position. The segments are secured in their
new position using sticky wax. The mock surgery thus
helps in evaluation and possible modification of the
surgical treatment plan. It also helps in the preparation
of an occlusal splint.

Surgery and stabilization

The next step involves the surgical fracturing and

repositioning of the bony segments. The teeth of the
upper and lower arches are wired in occlusion to
splints. The orthodontic arch wire and brockets can be
used for the intormaxillary fixation. Intermaxillary
fixation usually spans for 6-8 weeks following which
the splint is removed.

Post - surgical orthodontics

Soon after the surgery, a phase of post-surgical
orthodontic treatment is initiated. During this phase,
the final detailing of the occlusion and esthetic root
paralleling is carried out. Most cases of post-surgical
orthodontics are completed by 4-6 months.
I t is proved beyond doubt that teeth moved through
bone using any orthodontic appliance have a
tendency to return to their original position.
Retention has been defined by iVioyers as 'maintaining

Fig 1 Couses attributing 'o relapse

and Relapse
SCHOOLS OF RETENTION

Over the years various philosophies hove ces- put

forward to explain post-treatment sfobl ix These ore
referred to as the schools of reter?fcr_

newly moved teeth in position, long enough to aid in

stabilizing their correction.12Relapse has been defined
as the loss of any correction achieved by orthodontic
treatment.' Retention of teeth in ideal functional and
esthetic position following orthodontic treatment poses
the greatest challenge to the orthodontist. Quite often
we come across cases that require more skill in
retaining the teeth than in regulating them. Retention is
too often lightly considered.
Stabilizing the treatment results by retention
procedures is an integral part of orthodontic therapy
and therefore provision should be made in the
treatment plan for adequate retention keeping in mind
the destabilizing factors (fig 1).

12 Graber TM : Orthodontics ; Principles and practice. WB

Saunders, 1988
The o c cluslo n scftoo/
According to Kingsley, proper occlusion is a key factor
in determining the stability of the newly moved teeth.
The importance of this factor in scfe guarding the
stability in the new position has been agreed upon by
several other authors and research workers.
The apical base school
The apical base school has been formulated around
the writings of several authors including Alex
Lundstrom, McCauley and Nonce.
Alex Lundstrom in the mid 1920's suggested that
the apical base is an important foctor in the correction
of malocclusion and maintenance of the stability of
treated cases. McCauley added thatthe inter-canine
ond inter-molar widths should be maintained during
orthodontic therapy to minimize retention problems.
Nance noted tnat the arcn length cannot be
permanently increased too major extent.
The mandibular incisor school
Grieves and Tweed have suggested that post-
treotment stability was increased when mandibular
'ncisors wore placed upright or slightly retroclined over
the basal bone.
The musculature school
The dentition is encapsulated from outside and inside
by muscles. Accordingto Rojers, functional muscle
balance is necessary in order to ensure post-treatmen)
stability.
CAUSE'S OF RELAPSE
Numerous are the causes attributed to relapse. No
single factor can be said to be the sole cause of
relapse. In most cases relapse occurs due to a
combination of causes (fig 1).
Periodontal ligament traction
Vine never teeth are moved orthodontically, the
periodontal principal fibres and the gingival fibres that
encircle the teeth are stretched. These stretched fibres
can contract and are thus a potent cause of relapse.
The principal fibres of the periodontal ligament
rearrange themselves quite rapidly to the new position.
Studies have shown thct the principal fibres reorganize
in about 4 weeks time. The supra-alveolor gingival
fibres on the other hand take as much as 40 weeks to
rearrange around the new position, and thus
predispose to relapse. After comprehensive
orthodontic treatment, teeth require 4-5 months of
full-time retention so as to allow the reorganization of
periodontal ligament fibres. After this period, retention
should be continued on a reduced basis for a further
7-8 months so as to allow the more sluggish gingival
fibres to readapt to the new tooth positions.
Relapse due to growth related changes
Patients with skeletal problems associated with Class
II, Class III, open bite or deep bite malocclusion may
exhibit relapse due to continuation of the abnormal
growth pattern after orthodontic therapy. Studies have
shown that the original growth pattern resurfaces or
dominates if the orthodontic treatment is completed
prior to ihe completion of growth. Hence, prolonged
retention is indicated until active growth is completed.
Bone adaptation
Teeth that have been moved recently are surrounded
by lightly calcified osteoid bone. Thus the teeth are not
adequately stabilized and have a tendency to move to
their original position. The bony trabeculae are
normally arranged perpendicular to the long axes of
the teeth.
However during orthodontic treatment, they get
aligned parallel to the direction of force, During the
retention phase, they revert bock to their normal
arrangement.
Muscular forces
Teeth are encapsulated in all directions by a blanket of
muscles. Muscle imbalance at the end of the
orthodontic therooy can result in reappearance of the
malocclusion. The orthodontist should aim at
harmonizing the muscles at the conclusion of the
orthodontic treatment so as to increase the stability of
the treatment results achieved.
Failure to eliminate the original cause
The cause of the malocclusion should be determined
at the time of diagnosis and adequate treatment steps
should be planned to eliminate the same or reduce its
severity. Failure to remove the etiology can result in
relapse.
Role of third molars
The third molars erupt very late in the develooment of
dentition. They erupt in most cases between the age of
18-21 years. By this time most patients would have
completed their orthodontic treatment. The pressure Proper occlusion is a potent factor in holding teeth in
exerted by the erupting third molars is believed to their corrected positions'. Post-treatment
cause late anterior crowding, predisposing to relapse.

Role of occlusion
Good intercuspation of the upper and the lower teeth is
an important factor in maintaining the stability of
treated cases. The centric relation and centric
occlusion should coincide or the slide from centric
should be not more than 1.5 - 2 mm in order to have
greater stability of the treatment results. Presence of
certain occlusal mannerisms such as clenching,
grinding, nail biting, lip biting etc., are important causes
of relapse.
THEORIES OF RETENTION

Riedel has summarized the different concepts and

philosophies existing into nine theories. To this list of
nine theories Moyers has added another theory that is
mentioned here as the tenth theorem.

Theorem 1
Teeth that have been moved tend return to their former
position'.There now seems to be a general agreement
that teeth tend to go back to their original position after
orthodontic tooth movement. The causes for this
relopse are many and a single etiology cannot be
highlighted.

Theorem 2
Elimination of the couse of malocclusion will prevent
relaose'. The cause for the malocclusion should be
identified at the time of diagnosis and adequate steps
should be formulated in the treatment plan to eliminate
it. Foilure to remove the cause increases the relapse
potential. This theorem can only be applied in cases of
malocclusion where the cause is obvious such as
thumb sucking, tongue thrusting, etc., and not in any
malocclusion where the cause is elusive.

Theorem 3
'Malocclusion should be over-corrected as a safety
factor. Many orthodontists recommend overcorrection
so as to give leeway for a certain amount of relapse.
This has been practiced in treating certain conditions
such as rotations, treatment of Class II/ Class III
malocclusions. There is, however, no available data to
validate this theorem.

Theorem 4
stability is increased by good occlusion. The 'If the lower incisors are placed upngnt over basal bone they
orthodontist should not restrict treatment to achieving a are mc.'e litety to remain in good alignment*. Theorem 7

4fi4 Orthodontics - The Art and Science

good inter-cuspation when the jaws are closed bur
should aim further at a good functional occlusion i.e.
harmonious occlusal contacts during functional
Theorem 1
movements of the jaw.

Theorem 5 'Corrections carried, ou: during periods of growth are less likely
to r6;'apse'. Theorem 8
'Bone and adjacent tissues must be allowed time to
'The farther tte teeth have been moved, Ihe lesser is the risk
reorganize around newly positioned teeth. When teeth
ot relapse".
ore moved orthodontia I ly, numerous changes occur in
Theorems
the bone and surrounding tissues. It takes
'Arch form, particularly in the mandibular arch, cannot be
considerable time for the reorganization to be
permanently altered by appliance therapy'. Theorem 10
completed. The new osteoid bone formed around
'Many Ireaied malocclusions require permanent retaining
recently moved teeth offers inadequote retention.
devices'.
Similarly the periodontal as well as the gingivol fibres
take time to reorganize.
the active growth period allow the tissue systems to
Theorem 6 adapt well and therefore reduce the relapse
potential.
'If the lower incisors are placed upright over basal bone
they ore more likely to remain in good alignment'. Most
Theorem 8
stable results are obtained by placing the mandibular
'The farther the teeth have been moved, the lesser is
incisors upright over the basal bone. The mandibular or
the risk of relapse. The farther a tooth has been
occlusal plane is used as the reference plane. The
moved the lesser is the risk of it returning to its
orthodontist should aim at positioning the lower
original position. Although this sounds logical,
incisors perpendicular to the mandibular plane or even
retrociined.

Theorem 7
'Corrections carried out during periods of growth are
less likely to relapse'. Orthodontic therapy should be
iniliated at the earliest possible age. Early treatment
procedures involving growth modulation, aimed at
intercepting skeletal ma/relations, prevent full fledged
malocclusions and compensation (both dental and
skeletal) from occuring.
Such treatment modalities corried out during
'Teeth that have been moved tend to return lo their former
position'.
Theorem 2
. 'EUminatpn of tte cause ot malocclusion will prevent re'apse'.
Theorem 3
.'Malocclusion should be over^cprrected as a safety factor'.
Theorem 4
'Proper occlusion is a potent factor in holding teeth in their
corrected positions'. Theorem 5
'Bone arxJ adjacent tissues must be allowed time to reorganize
around newly positioned teeth'. Theorem 6
it is desirable to guide the erupting teeth to intercept
future malocclusion. Such teeth require lesser tooth
movement by comprehensive f'xed mechanotherapy
and also a reduced retention period and hence have
a lesser risk of relapse.
Theorem 9
5. The lower cuspid root apex must be positioned
slightly buccal to the crownapex.
6. The lower incisors should be slenderized as
needed after treatment.
By obsen/ing Ihe six retention keys described by
Raleigh Williams, it is possible to eliminate lower

'Arch form, particularly in the mandibular arch, cannot incisor retention following fixed appliance therapy.

be permanently altered by appliance therapy".

TYPES OF RETENTION
Alteration of existing arch forms results in increased
risk of relapse. According to McCauley, the mandibular Ma'occl jsion occurs due *o numerous causes and they
inter-canine and inter- molar widths are present themselves in various ways. While some
uncompromising. Thus they should be considered as treated malocclusions do not require retention, other
fixed landmarks and the rest of the arch built around malocclusions mcy need o certain period of retention to
them. ensure stability. Retention can be of three types :
1. Natural or no retention
Theorem 10
2. Limited or short term retention
'Many treated malocclusions require permanent
3. Prolonged or permanent retention
retaining devices. This theorem was subsecuently
added by Moyers. Certain malocclusions might require Natural or no retention
the patient to be fitted with a permanent retaining Some of the conditions that do not require any
device. This is true in cases that have not been treated retention include:
to achieve occlusal goals that stand for stability. a. Anterior crossbite
b. Serial extraction procedures
RALEfGH W/UMMS - KEYS TO
c. Blocked out or highly placed canines in
ELIMINATE LOWER RETENTION
Class I extraction cases
Raleigh williams put forward 6 keys to eliminate lower d. Posterior crossbite in patients having
retention and acheive lower arch stability following steep cusps.
orthodontic trectment. The following are the 6 keys:
1. The incisal edge of the lower incisor should be
ploced on the A-P line or I mm in front of it. This
position of the lower incisor ensures stability
following treatment. It also creatcs optimum
balonce of soft tissues in the lower third of the
face.
2. The lower incisor apices should be spread
distally to Ihe crowns more than is generally
considered appropriate and the apices of the
lower lateral incisors must be spread more than
those of the central incisors. In o'her words the
lower inciso' roots should be diverging.
3. The ooex of the lower cuspid should be
positioned distal to the crown.
4. All -our lower incisor apices must be in the same
labiolingual plane.
Limited or short term retention Hawley's appliance
Most cases treated routinely in the orthodontic clinic The Hawley's appliance was designed in 1920 by
fall into this category. Retention is recommended to Charles Howley. If is the most frequently used retainer.
allow the bone and other periodontal tissues to The classic Hawley's retainer (fig 2.a) consists of
readcptto their new location. clasps on the molars and a short labial bow extending
1. Class I non-extraction with dentol arches showing from canine to canine having adjustment loops.
proclination and spacing. This simple design can be modified in several
2. Deep bites ways to suit specific requirements. The labial bow can
3. Class I, Class II, div. 1 and div. 2 cases treated by be made to extend from one first premolar to the
extraction. opposite first premolar (fig 2.b). This design helps in
closing spaces distal to canine. Another modification is
Prolonged or permanent retention
to solder the bow to the bridge of the Adam's clasp.
Cases that require indefinite or prolonged retention This design avoids the risk of spoce opening up
include : between the canine and premolar due to the
a. Midline diastema cross-over wires (Fig 2.c). Fitted labial bow can also be
b. Severe rotations used to offer excellent retention. Anterior bile planes
c. Arch expansion achieved without ensuring good can be incorporated to retain or correct deep bite
occlusion coses. The advantages of this appliance include ease
d. Certain Class II, div. 2 deep bite cases of fabrication due to simple design and minimal patient
e. Patients exhibiting abnormal musculoture or discomfort due to reduced bulk. In addition it is
tongue habits acceptable to most patients as it is relatively
f. Expanded arches in cleft palate patients inconspicuous,

RETAINERS Begg retainer

This retainer was popularized by R R. Begg. It consists
Retainers are passive orthodontic appliances that help
of a labial wire that extends till the last
in maintaining and stabilizing the position of teeth long
enough to permit reorganization of the supporting
structures after the active phase of orthodontic
therapy.
The type of retainer to be used depends on
various factors such as tne type of malocclusion
treated, the esthetic needs, patient's oral hygiene,
patient co-operation, the duration of retention, etc.,.
Graber has put forward certain criteria that a good
retainer should possess.
1. The retainer should retain all teeth that have been
moved into desired positions.
2. The retainer should permit normal functional
forces to act freely on the dentition.
3. It should be self - cleansing and should permit oral
hygiene maintenance.
4. It should be as inconspicuous as possible.
Retainers can be classified into :
1. Removable retainers
2. Fixed retainers

REMOVABLE RETAINERS

They are passive appliances that con be removed by

the patient and reinserted at will.
erupted molar and curves around it to get embedded in
acrylic that spans the palate {fig 2.d). The advantage of
this retainer is that there is no cross-over wire between
the canine and premolar thereby eliminating the risk of
space opening up.

Fig 2 (A) Howle/s retainer (Bj Hawlc/s retainer with long labial bow (C] Hawley's retainer with labial bow scldereo to Adam's clasp (D) Begg
wrop-oround retainer

C Up - on retainer / spring aligner

This appliance is made of a wire framework that runs
labially over the incisors and then passes between Ihe
canine and premolar and is recun/ed to lie over the
lingual surface (fig 3}. Both the labial as well as the
lingual wire segments arc
 FIXED RETAINERS

These retainers ore fixed or fitted on to the teeth and

Orthodontics - The Art and Science connot be removed and reinserted by the patient.

The fixed appliance

The fixed appliance that was used for orthodontic
correction can be left in place to serve as a retainer.

Banded canine to canine retainer

This type of retainer is commonly used in the lower
anterior region. The canines are banded and a thick
wire is contoured over the lingual aspects and soldered
to the canine bands (fig 6). The bands predispose to
poor oral hygiene and are u n esthetic.

Fig 3 Clip on retainer labia & lingucl views

embedded in a strip of eleer acrylic. The retainer can

be used to bring about, correction of rotations
commonly seen in the lower anterior region. In such
cases where it is used as an active retainer, it is
fabricated on o cast wherein the teeth are placed in Fig A Invisible retainer
ideal positions by wax set up.

Wrap around retainer

This is an extended version of the spring aligner that
covers all the teeth. It consists of wire that passes
along the lebial as well as lingual surfaces of all
erupted teeth which is embedded in a strip of acrylic.
This type of retainer is not routinely used in orthodontic
practice. It finds application in stabilizing a
periodontally weak dentition.

Kesiing tooth positioner

The tooth positioner was described by H.D. Kesiing in
1945. Il is made of a thermoplastic rubber like material
that spens the inter - occlusal space and covers the
clinical crowns of the upper and lower teeth and a small
portion of the gingiva. The tooth postioner needs no
activation at regular intervals ond is durable. The
drawbacks include difficulty in speech and risk of TMJ
problems.

Invisible retainers
They are retainers that fully cover the clinical crowns
and a part of the gingival tissue. They are made of ultra
thin transparent thermo-plastic sheets using a Biostar
machine. They are esthetic and often go
unnoticed.(Fig 4)
 Retention and Relapse

E F
-Ig 5 Retainers IA' Hcwle/s retaine' (BJ Lirigjal bonded retainer fror-. canine to canine (Cj Fixed Ingual re'ciner -'o' the •wo central incisors
tyo'cclty used to retain a midline diastema (D) U'ngua bar cod retainer (E) Kesling's tooth positioner (F) spring aligner
 hg 6 Sendee ccrhe to ccnhe retainer
Bonded lingual retainers
They are retainers that arc bonded on the lingual
aspect. Stainless steel or blue Elgiloy wire is adapted
lingua lly to follow the anterior curvature. The ends are
curved over the canines where it is bonded.
Various pre-fcbricated lingual retainers arc
available that can be bonded on to the teeth (tig 7). An
alternative to the use of wires's to use etched or
perforated meral cast bars that can be bonded on Ihe
lingual side of the *cetn. Recently some workers have
recommended the use of a spiral wire that can be
bonded individually to each loolh in a segment.
Fig 7 Bordcd canine to ccnhe retainer
Class II malocclusion generally are a result of
discrepancies in growth between Ihe maxilla and the
mandible. Relapse following the correction of Class II
malocclusion are due to continued differential growth
of maxilla relative to mandible. Minor relapse
tendencies may bea resull of tooth movement due ro
gingival and perioConral factors. Over correction of the
occlusal relationship is an important factor in
compensating for relapse following treatment.
However long term growth related chances are more
likely to pose a problem in retention. These growth
related changes depend

Band and spur retainer

This type of retainer is used in cases where a single
tooth has been orlhodonticaliy Treated for rotation
correction or labio-lingual displacement (fig 8). The
tooth that nas been moved is banded and spurs are
soldered on to -he bands so as to overlap Ihe adjacent
teeth. In case it is usee to retain a tooth that has been
blocked palotolly, the spurs arc mode or the labial
aspect so that the loolh does not once again get
displaced palatal ly. In deroxr ion cases one spur is
placed lab'ally (on the side the tooth lends lo rotate
palotolly) and the otner lingua lly to avoid relapse.
SPECIAL CONSIDERATIONS IN RETENTION
OF CERTAIN MALOCCLUSION

Class II malocclusion
Fig 8 Band end jpur retainer
Fig 9 Procedure of moking o lingual bondab'e retainer. (A) The wire "s ccapted on ihe lingtel surace of Ine teeth from canine to the opposite canine. (B> The retainer is
stabilized on the cost u$ing water-soluable adhasive (C) An impression is mode with a rubber besed heavy body nctericl to form a seating -emplate. I D; The seating
template (hot is used io position the retainer against the teet'n (E) lingual reta ncd bonded on both ends.

on o number of factors including age, sex, and maturity The use of headgears or functional appliances to
of the patient. This relapse tendency can be prevented maintain the Class II correction is indicated if the octive
by continued use of headgears to restrict maxillary treatment is completed at on early age ond continued
growth in conjunction with a retainer to maintain the growth is expected following the active phase of
dental alignment. Some authors prescribe the use of treatment.
functionol oppliances similar to activator or bionator
after the active phase of class II correction. The use of
these appliances maintains the corrected maxillo-
mandibular relation and prevents growth reloted
relapse tendencies.
 Class III malocclusion
Retaining a Class III malocclusion may be a difficult

472 r Orthodontics - The Art and Science

task due to the continued growth of the mandible. The
use of chin cap to restrict mandibular growth has been
recommended by some authors to counter the
continued growth tendency of mandible. However the
use of chin cap is believed to increase the vertical
growth of the mandible. Mild Class III cases are best
retained using Class III functional appliances such as a
reverse activator, FR 3 or Class III bionator. However
severe Class III coses that relapse following active
orthodontic therapy may require surgical correction
after growth ceases.

Deep bite
Deep over bites are best retained by removable upper
retainers made in such a way that the lower anteriors
contoct the base plate behind the moxillary anteriors.
This is similar to anterior bite plane; W the molars need
not be separated. This type of retainer helps in
maintaining the corrected deep bite.

Open bite
Relapse following correction of open bite is usually a
result of molar extrusion or insisor intrusion. Incisor
intrusion may occur due to continued indulgence in
habits such as thumb sucking or tongue thrusting.
Thus elimination of the associated etiologic factor
would help in long- term stability. Excessive vertical
growth tendencies and continued eruption of
posteriors may pose the risk of relapse. In these
patients open bites are best retained by high pull
headgears to upper molars or use of bite block
appliances such as posterior bite plane that stretches
the musculature ond produces an intrusive force on the
dentition.
References

1. Grobor TM : Orthodontics : Principles and practice. WB

Sounders,! 938
2. HoustonWJB : Orthodontic Diagnosis, Wright, Bris-ol, 1982
3. Profitl WR: Contemporary Orthodontics, St Louis,
CVMosby,1986.
4. Robert E Moyers : Hond book of Orthodontics, Yeor book
medical publishers, inc,1988.
5. Show Wc : Onhocontic ond Occlusal management, Wright,
1993
6. Thomas M Graoer, Robert L Vanorsdall : Orthodontics current
principles and techniques, Mosby year booklnc, 1994
SOLDERING

Soldering is defined as a process of joining metals by

the use of a filler metal which has a substantially lower
fusion temperature than that of the metals being
joined. If the fusion temperature of the filler metal used
exceeds 450f'C, then the procedure is termed brazing.
Soldering makes use of filler metals having fusion
temperatures less than 450°C. Thus the terms
soldering and brazing signify the same procedure, but
vary in the fusion temperatures of the intermediary
metals used.
Soldering involves the flow of the molten filler

Ha b Procedures
metal due to capillary attraction between the metallic

parts to be joined.

Dental solders
Dental solders are alloys that are used as intermediary
or a filler metal to join two or more metallic parts. They
should possess the following
ideal requisites;
i) The solder should exhibit excellent tamish and
corrosion resistance in the oral environment.
ii) The fusion temperature of the dental solder
should be lower than that of the parts being
joined. Ideally the fusion temperature of the solder
should be 50CC -100"C less than the parts being
joined.
iii} It should be free flowing and should adequately wet
the metal parts it unites so that good adhesion is
achieved.
iv) The strength of the solder should be similar to that
of the metals being joined.
v) The colour of the dental solder should match with
that of the parts to be soldered.
Most dental solders are composed o: gold,
silver, copper, zinc, tin and nickel. While copper gives
a yellow appearance to the solde*. its substitution by
nickel gives a more white colour to the solder.
474 Orthodontics - The Art and Science

Flux
Flux is a Latin word meoning flow. The success of a
good soldered joint depends on how well the dental
solder flows over the parts to be joined. Dental solders
do not adequately flow or wet metallic surfaces that
have an oxidized layer. The flux aids in removal of the
oxide coating so as to increaso the flow of the molten
solder. In addition, the flux also dissolves any surface
impurities, prevents oxidation of the metals and also
significantly reduces the melting point of the dental
solder.
The flux used commonly in dentistry has the
following composition : Borax glass -
55%
Boric acid - 35%
Silica - 10%

Fluoride fluxes containing boric acid and

potassium fluoride in a 1:1 ratio, also produce excellent
soldered joints.

Anti-flux
Anti-flux is a material that is used to confine the flow of
the molten solder over the metals being joined. The
commonly used onti-fluxes arc lead pencil markings,
graphite lines and iron rouge.

Types of soldering Fig 1 (A) soldering torcn (B) Soldering in progress

In dental practice, soldering can be carried out iri two Free hand so/dering ; Most of the soldering procedures
methods; carried out by an orthodontist fall under this category.
a. Investment soldering and The process involves soldering two metallic parts
b. Free hand soldering together after adequate stabilization, without the use of
/nvesfmenf soldering : Investment soldering is carried investment, to precisely hold the parts together.
out whenever the area of contact between the metallic
parts being joined is large and whenever precision is
Steps In soldering

needed in joining the metals. The procedure involves 1. Cleaning the surfaces to be joined.
the embedding of the metallic parts in an investment 2. Assembling the parts to be joined.
leaving a gap of about 0.13 mm between the metals. 3. Selecting the right solder and flux.
4. Selection of a proper joint.
 5. Application of flux. be maintained until the filler metal has flowed
6. Heating and introduction of solder. completely into the joint.
7. Quenching. Lab
Quenching : The Procedures
assembly 485
is immediately quenched in
water so as to limit the spread of heat.
C/eaning fhe surfaces to be ^oinea! ; The parts to be

Fig 2 Selec'ion of solder jointJAJ Point con lac" offers inadequate strength (B| Wrapping of wire a'ound "He o-Fer is the best type of joint (C)
Longer areos of join- he p increase the joint strength

joined should be adequately cleaned to remove dirt and

Practical considerations in soldering

other surface contaminants which invariably result in There are certain factors that should be considered.
poor solder flow and therefore failure of the procedure. 1) Use the reducing flame of the soldering torch.

Assembling the parts to be foined : The parts to be 2) Use wet cotton and asbestos to limit the spread of

joined are stabilized in the desired fashion using plaster heat.

or orthop'nosphate cement. While assembling the units 3) The soldered joint should not be polished as it

together an adequate gap should exist between the weakens the joint.

parts to be joined. A gap of about 0.5 mm is considered 4) Anti - flux should be used to prevent excessive

adequate. spread of solder.

Se/ecfron of the right solder ond f/ux : The appropriate

dental solder should be selected based on the metallic
parts being joined. The solder selected should be
compatible with the metals in aspects of strength and
colour. However they should exhibit a lower fusion
temperature. Similarly a good flux is also selected.

Se/ecrion of a proper joint ; A proper joint between the

metals being joined greatly enhances the strength of
the joint. Point contacts do not offeradequate strength.
When two wires are being joined together it would be
beneficial to wrap one of the wires around the other (fig
2).

Application of flux : The flux is applied in the gap

between the parts and also covers a portion of the
parts being joined. The flow of the solder can be limited
by using anti-flux.

Heating and introduction of solder : The area to be

joined is heated using a soldering torch (fig 1). As soon
as the flux begins to fuse, the solder is introduced. The
solder melts ond encases the joint. The flame should
 to join orthodontic components is colled spot welding.
The heat source is usually a high amperage electricity.

476 Orthodontics - The Art and Science

Orthodontic spot welders employ tne electrode
technique and ere used instead of soldering in cases
where the heating cycle must be very short, in order to
prevent changes in the physical properties of the
components being joined.

Principle of spot welding

Heat ond pressure are the two basic principles involved
in spot welding. Electric current (A/C) is made lo pass
through a step-down transformer to obtain a low
voltage and high ampercge current ihot is conducted
through two copper electrodes (fig 3) on either side of
the metals being joined. The resistance offered by
stainless steel to current of high amperage generates
very high temperature at the electrodes. Thus the area
of metal under the electrodes becomes plastic. The
copper electrodes simultaneously opply pressure on
the metals and therefore squeeze the melals into each
other.
The copper electrodes in a welding unit serve
the following purposes:
a. Transmitthe current to the metals to be joined so
as lo cause a rapid increase in temperature.
b. The two cleclrodes help in holding together the two
metals to be joined.

=
ig 3 (A; Spol wolder (B| Cooper dccrrcdes ot the
spor •//elder

Applications of soldering In
orthodontics
o. Soldering is used lo join parts of orthodontic
appliances.
b. Soldering con be used lo fasten attachments to
bands.
WELDING

Welding involves tne joining of two or more metal

pieces directly under pressure without the introduction
of an intermediary or filler material.
Cold welding is done by hammering or
pressure. An example of cold welding is the gold foil
filling. Hot welding uses heat of sufficient intensity to
melt the metals being joined. The type of welding used
c. The electrodes are designed to opply pressure on should be in total contact. If not, they should be filed
the metals being joined. As soon as Ihe until total contact is achieved.
temperature increases, the pressure exerted by Lab Procedures
The welder has o timer that477
is set to the
the electrodes helps in squeezing the metals into required reading. The metals to be joined are placed
between
the two

Fig 4 Orthodortic s'udy irodel (A) =,orl view {B) Bycca view

eoch other, d. The electrodes help in conducting electrodes and the switch is turned on. The elcctrode
ihe heat produced away from the area so as to pressure can be maintained for a few seconds to help
preserve the properties of stainless steel around obtain a good joint.
the weld spot.
Applications of welding in orthodontics
It is very important thot the passage of current
at the weld spot be of very short duration i.e. not more Welding finds a number of applications in orthodontics.
than 1 / 10 Ih of a second. In case the current is passed They include:
for a longer duration of time, it results in weld decay due a. Joining of metal strips during banding.
to precipitation of carbides from the metal. Thus most of b. Fixing attachments such as brackets and molar
the modern welders have an electronic timer that helps tubes onto bands.
in discharging current of very short duration.
Welding of stainless steel depends on the
proper use of each of the following three variables:
1. The current flowing through the circuit.
2. The time during which the current is allowed to
flow.
3. The mechanical pressure applied at the welding
heads.
Procedure of spot welding
Select the proper electrode for the thickness or shape
of the material to be welded. A broad electrode should
be used for thin material end a narrow one for thick
materiel. The electrodes of the welder are cleaned so
as to remove any carbide precipitates. The surface of
each electrode must be smooth, flat, ond perpendicular
to its long axis. When the electrodes are together, they
ORTHODONTIC STUDY MODELS In a well fabricated set of study models the
ratio of fhe anatomic portion to artistic portion should
Study models are accurate plaster reproductions of the
be 3:1. The steps involved in the construction of study
teeth and their surrounding soft tissues. They ore an
model include:
important diagnostic aid in orthodontics and make it
1. Impression making
possible to view the occlusion from all aspects (fig 4).
2. Disinfection of the impression
The importance of study models as an essential
3. Casting the impression
orthodontic diagnostic aid nas been discussed in
4. Basing and trimming of the cast
chapter 11. The aim of the present chapter is to
5. Finishing and polishing
describe a method of fabricating study models.

Ideal requisite of study models

Orthodontic, study models should fulfill the following
criteria :
The modeis should accurately reproduce the teeth
and their surrounding soft tissues without any
distortion.
The models are to be trimmed in such a manner
that they are symmetrical ond pleasing to the eye.
This enables instant identification of asymmetries
Fig 5 Qnho- dontic
in the arch form. impress on trays. (A)
The models are to be trimmed in such a way that and l&j Metal ic
porfcrctec trays. !Q
when placed on their backs, they accurately end (D) Perforated
reoroduce the occlusion. plastic trays with
nigh flanges for
iv} The study models should have a clean, sulcus reproduction.
smooth and nodule free surface, v) The study
models should not only depict the teeth but should also
reproduce as much of the alveolar process os possible.

Parts of a study model

Orthodontic sludy models consist of Iwo parts :
1. Anotomic portion and
2. Artistic portion.
The anatomic portion is that part of the study
model which is the actual impression of the dental arch
ond its surrounding structures. This portion is usually
made of stone plaster. The artistic portion of the study
model consists of a plaster base that supports fhe
anatomic portion. This portion of the study model helps
in depicting the actual orientation and occlusion of the
study models and also gives a pleasing and symmetri-
cal appearance to the models.

/mpress/on making
Obtaining a good impression of the nard and soft
tissues of t'ne dento-alveolar region is on important
factor in the proper fabrication of orthodontic study
casts. The impressions should extend to the limits of
the buccal sulcus and into the lingual sulcus of the
lower arcn. The maxillary impression should cover the
hard palate but should not extend on to the soft palate.
The den'ist should be relaxed and not be
nervous. The patient should be asked to rinse the
mouth to eliminate food particles etc.,.
It is recommended to use high flange
orthodontic trays that extend deep into the buccal and
lingual sulcii (fig 5). This is an important consideration
as orthodontic study models should reproduce as much
of the supporting structures os possible. The trays
selected should include the last erupted molars and a
clearance of around 3 mm should exist between the
teeth and the troy. Use of trays that are too wide or too
narrow invariably cause soft tissue distortion and
therefore results in inaccurate study models.
Irreversible hydrocolloids (alginate) are
widely used for impression moking. During the
procedure, the patient is seated in a vertical position to
avoid entry of the imaression material into the pharynx.
Disinfecting the Impression
Lab Procedures 479
The impressions are rinsed thoroughly in water and are
disinfected to free them of microorganisms, plaque and
other oral secretions Ihot may be present on them.
Disinfection con be done by soaking the impression in a
disinfectant solution such as Biocide. The duration of
immersion should be ascertained from the
manufacturers. After disinfection, the impressions are
once again rinsed in water to clear them of any residual
disinfectant.
Fig 6 (A| Rubber bnse forr.ers (6) Impression i rive-ted irro the bose
forrrcr
Casting the Impression
The impressions obtained arc casted using orthodontic
stone or model stone. It is beneficial to use some form
of vibrator to eliminate incorporation of air bubbles.
Basing' and trimming of the cast
Once the anatomic area of the study models is poured,
the artistic portion of the study cast is built to from a
base over the anatomic portion. To help in making the
base, rubber base formers are available (fig 6.a). Once
the anatomic portion of the model is poured, the
impression tray is turned upside down and pushed into
the plaster filled into the base former (fig 6.b).
T'ne plaster base is allowed to set for 30- 60
minutes. The trimming of the bese is a meticulous task
that contributes to the beauty of the
 48fl Orthodontics - The Art and Science

Fig 7 The trimming of Ihe orthodontic model (A) Stop I (B)

Step II (CI Stop III ID} Step IV <E ) Step V (F) StcpVI 'G; Step
VII (H! StepVlll (IJ Step IX (J) Step X
models (fig 7). The Trimming of the orthodontic model
is done on an electric plaster trimming machine having
a medium-grit carborundum wheel.
Step I: The base of the mandibular cast should be pare
lie! to the occlusal plane. The lower model is inverted
over a 'T' shaped aiece of rubber and a marking is
circumscribed all around the base of the model using a
marker mounted on a vertical stand. Once the marking
is made, the base of the cast is trimmed upto the
marking. Step /I: The back of the mandibular model is
trimmed peroendicularto the midline. The back of the
model should also be 90° to the base of the model.
While trimming the back care should be taken to leave
5 mm of the plas'e'' base distal to the most posterior
teeth. Step /}(: Occlude the upper and lower models
together and trim the maxillary backs surface, so that
the maxillary back is in flush with the mandibular back.
Step IV: The upper and lower models are occluded
together and are placed on their backs on the model
trimmer. The base of the maxillary cast is trimmed so
that it is parallel to the base of the lower model. At t'ne
end of this step, the bases of the maxillary and the
mandibular casts are parallel to each other and to the
occlusal plane and the backs of both the upper and
lower casts are at right angles to the bases. Step V:
The buccal cuts are made on the mandibular cost 5-6
mm away from the buccal surface of Ihe posterior
teeth. The buccal cuts are to be made 60' to the back of
the model. Sfep VI: The anterior segment of the lower
arch is trimmed into a curve that follows the curvature
of the lower anterior teeth. The anterior curve should
be 5-6 mm away from the labial surface of the anterior
teeth.
Step V/J: The posterior cuts of Ihe mandibular
F g 8 Study rrodel slcrage
model are trimmed at approximately 115" to the back
of the mode . The linear measurement of the posterior
cuts should be 13-15 mm. Step Vfll: The buccal cuts
are made on the maxillary cast 5 mm away from he
buccal surface o: the most posterior teeth. The buccal
cuts snou'd be 65r to the bcck of the maxillary cast.
Step .'X: The anterior cuts are mode on the maxillary
cast. The cuts on eilhe-" side shou'd be of eoual length
and snould lie 5-6 mm ahead of the labial surface of
the anterior teeth. The anterior cuts or either side
should meet at Ihe midline o£ the cast and should
extend till the midline of the canire. Tne anterior cjts
are made 30° to the bcck of the cast.
Step X: The posterior cuts of the maxillary cast ce
mode n such a way tha* they are in flush with the
posterior cuts of the mandibular cas'. This is done by
occluding tne models and trimming the maxillary
posterior cuts till they ore in line with the mandibular
posterior cuts.
Finishing and polishing
The artistic portion of the dental cast is polished using
fine grained sand paper. Care should be taken not to
round off the edges of the models. The final polishing
of the casts is done by placing them in soap solution
for ore hour. The ccs^ are

Fig 9 Ac p I ccrion o: cold mould sea'
removed from the soco batn ond are rinsed under
warm water. The casts are then allowed to dry and are
buffed so that they acquire a smooth and sniny
appeorance. The finished study models are stored in
boxes for future reference. Model storage boxes
usually store 2-4 sets of models.
Acryllzatlon
An important component of most removable and
functional orthodontic applionces is rhe ccrylic base
plate. The bose plate sen/es to join all the components
together into o single functional unit, besides helping in
retention of the appliance and anchorage. The base
plate used in an orthodontic appliance is fabricated
using methyl methacry- late resins. Botn neat cure as
well as self cure acrylic resins are used for the
purpose.
Use of heat cure acrylic resins
Heat cure acrylic resins are not routinely used for
fabrication of an orthodontic base plate as the
procedure involved is time consuming and tedious.
Nevertheless heat euro resins give a product that is
more stable with minimal porosity.
The heal cure acrylization is carried out in
Fig 10 S'lclcy wcx fo stabilize wire components
the following steps:
a. The wire components of the appliance are
stabilized using sticky wax or plaster.
b. The cast is then dipped in water for 10-15 minutes
and the surface wetness is allowed to dry.
c. A single sheet of pink wax is softened over a flame
and is pressed over the model. Excess pressure is
to be avoided as it can result in thinning of the
wax. In creas where extra thickness is needed, an
additional sheet of wax can be applied.
d. Excess wax present over the teeth is trimmed off
using a wax knife or a Lecron's carver.
e. The edge of the wax around ihe leeth is flamed
and pressed firmly into position.
f. The closps and other areas of the metallic
components that are to be kept free from acrylic
should be covered with plaster.
g. The appliance is flasked, dewaxed and acrylized
similar to a prosthetic appliance.
h. The applionce is deflasked, trimmed and polished.
Use of self cure acry//c resins
The self cure or cold cure acrylic resins are most
frequently used for the fabrication of orthodontic base
plates. The use of self cure resins does not take up as
much time and effort as the use of
 C D
Fig 11 Salt and pepper method of ccrylizotion |A] and (B) Application o; polymer followed by monomer (Q Removal ot excess acrylic using o le
Cron's carver before it hardens (D) Completion of ocrylizot'or

heat cure resins. Acrylizotion asing cold cure resins is Application of co/d mould sea/: The area that is to be
carried out in the following steps. acrylized is coated with a uniform layer of a seoarating

Pre-freofment of fhe cast: The cast is inspected for medium using a camel hair brush (fig 9).

plaster nodules or air bubbles. These nodules must be
trimmed using a sharp knife ond any pores present on
the surface of the cast should be filled with plaster. The
cast to be acrylized is soaked in water for 10 -15
minutes. This procedure prevents the liquid monomer
from being absorbed into the dry plaster.
Stobif/zari'on of the wire components: The wire
components of the appliance are stabilized in their
ideal position using sticky wax or plaster mix (fig 1OJ.
Acryiization: Acrylization using cold cure resins can be
carried out in two ways. They are the salt ond pepper
method and the single mix method.
Salt and pepper method : This method of acrylization
involves adding of the powder and
 Orthodontics ■ The Art and Science
monomer alternatively to build up the appliance (fig
11). Acn/lizotion is done gradually by dividing tne
working crea into small parts. The maxillary cast can
be divided into four segments that are acrylized
individually.
The cast is oriented in such o manner thct
the segment to be acrylized is parallel to the floor and a
layer of acrylic powder is poured over the cast. The
liquid monomer is applied to the powder until it gets
saturated. The procedure is reaeated in the
othersegmentsofthecastto complete the acrylizafon.
The disadvantages of the salt and pepper teennique
include :
a. Difficulty in obtaining a uniform thickness of base
plate
b. It is time consuming
c. Poses high risk of porosity
Single mix method : In this teennique adequate amount
of poiymer is placed over a gloss slab or a porcelain
cup. Monomer is added and is mixed well using a wax
knife or cement spotula. When the material reaches a
stringy consistency, it is transferred over the cast and
is adopted uniformly over it using finger moistened with
monomer. The excess is removed using a Lecron's
car/er.
Curing in rhe pressure pot: The acrylized appiiance is
immediately placed ir. c pressure pot which is filled witn
compressed air so as to prevent air bubbles from
developing in the appliance. The appliance should be
left within the pressure pot for not less than 10 minutes.
An alternative to -he use of pressure pot is to cure the
acrylic in a bowl of hot water for about 20 minutes after
acrylization.
Trimming and pof/sfWng: After allowing the acrylic to
cure, the appliance is gently removed from the cost
using a wax knife wedged between the base plate and
the cast. Gross trimming can be done using a stone
mounted on a lathe (fig 4.ai. Finner trimming is carried
out using appropriate acryic trimming burs. Care
should betaken to avoid generation of excess heat
during the trimming procedure as it can distort the
appliance. The appliance should be frequently
immersed in water during the trimming procedure. The
appliance is smoothened using a fine gritsond papor.
Finally it is polished using french chalk and pumice on
a rag wheel (fig 4.b).
Acrylization using thermoplastic sheets
Bose plates can be fabricated using thermoplastic
acrylic sheets. These sheets are available in various
thicknesses and colours. Tneyare warmed on a
Biostar machine (fig 5) to a temperature of 220" C for a
specified period of time and adapted over the cast by
meons of vaccuurn pressure.
The advantage of using this technique is
that uniform thickness of the base plate can be
obtained with need for minimum polishing.
References
1. Craig : Dervul Motcriols: Mosby 1998
2. Grcber ~M, Swain 6F : Orthodontics : Current princip cs ord
Techniques, St Louis, CV Mosby, 1985
3- Kenneth J Anuscvice : Pniltips science of Dental Mo- leriais
:Saunders. 1 996.
4. Prof it WR: Contemporary Orthcdon-ics, St Louis. CV
Mosby, 1986.
5. Solzrnai JA : Practice of Orthodontias. JB lippinco't company,
1966
6. Thomas iVI Grabc, Robert I Vanarsdotl : O'tnodon tics current
principles and teenniques, Mosby yea- book he . 199<:
7. White TC, Gardiner Jl I, Leiglvon 8C ; Orhocontics for dental
students, Mac mi I cn,1985
Y
ou may have had a very illustrious greot - great made his far reaching discoveries by carefully
grandfather, but by the laws of chance you analyzing Ihe results of his experiments
have received only abou'one
- sixteenth of your genes from him. You received just
as many genes from the horse - thieves, river
- gamblers and other undesirables who may have been
in that generation of your family tree.
- A. M. Winchester
Between these lines of sheer sarcasm lies the same
uncertainty with which we crowd around a new born

jjjenetic Factor in
iQrthodontics
baby trying to establish whom he resembles putting
into scrutiny eoch and every part of his body.
Genetics is the science concerned with the
structure & function of all genes in different orgonisms.
Genetics is a rapidly developing science that has
reached on advanced level of genetic selection &
cloning.
Studies of genetic interest can be traced
back lo 6000 B.C. in certain stone carvings of Babylon.
Genetic theories and concepts were influenced by the
hypothesis of various prominent philosoohers. Among
them the forerunners were Pythagoras, Empedocles,
Aristotle, Harvey, Adams, Darwin etc.,. In 1814 Joseph
Adams proposed many of the basic principles of
medical genetics. He is even termed by some authors
as the founder of human genetics.

Fig 1 Gregor Mendel

- Father of Modern
Generics

The studies regarding genetics hod a break

through when an Austrian monk, Gregor Mendel (fig 1}
 Orthodontics - The Art and Science
on cross breeding garden pea (Pisum sativum). Mendal
adopted the most simple methods and studied a single
m
Fig 2 Wcrson and Cr'ck proposed ihe structure of DNA mc lac u la
characteristic through many generations. He is aptly
named the Father of Modern Genetics' for his
outstanding contribution in the field ot genetics. Mendel
put forward the Law of Segregation according to which
every individual possesses two factors
determine a specific characteristic. Among these two,
one pair is transmitted from each parent. This is called
iViendel s 1 st Law or the Law of Segregation.
After Mendel's studies and discoveries, ihere
was a renewed awareness in the field of genetics. In
1903, Sulton and Boveri proposed the 'Chromosome
Theon/ of Inheritance'.
Thomas Hunt Morgan et cl in 1935, were
awarded the Nobel prize, for their extensive studies on
the arrangement of genes along the chromosomes.
Watson and Crick in 1953, demonstrated the structure
of the DNA molecule. The complexity of the
chromosome structure was further unveiled when the
'Solenoid model' of chromosome structure was
proposed by Finch and Klung.
Genetics In Orthodontics 487
MOLECULAR BASIS OF INHERITANCE
The cell
The cell is the basic unit of any living body. It is made
up of different organelles, i.e. the cell wall, cytoplasm,
endoplasmic reticulum, ribosomes, mitochondria,
nucleus, etc.,.
The c/jrorooso/ne
Within the nucleus of each cell are thread like
structures of different lengths and shapes called
chromosomes. The number of chromosomes present
in every cell of an organism is constant but it changes
from one species to another.
The D.N.A.
Chromosomes are made up of long chains of
Deoxyribonucleic acid (DNA) molecules, twisted and
twined in a specific manner. Eoch long strond of a DNA
which molecule is a chain of nucleotides. The basic
nucleotide unit comprises of a deoxyribose sugar, a
phosphate molecule and one protein either purine or
pyrimidine. The nucleotides form a pair by a weak
hydrogen bond between the proteins. At the same time,
the sugar molecules on both sides get attached to an
adjacent pair by means of phosphate bonds. The
structure hence resembles a step ladder.
The complex structure of a chromosome can
more clearly be exploined by the 'Solenoid Model of
Chromosome Structure' as proposed by Finch and
Klung. The ladder like structure of DNA according to
them undergoes coiling of the DNA duplex itself,
secondary coiling of these twisted duplex around
sphericol protein beads col led histones, to form
nucleosomes, tertiary coiling of nucleosomes to form
chromatin fibres and quaternary coiling to form the
chromatic loops. These loops are then tightly wound to
form
 Repetitive
It is characterized by recurrence of a dento-facial
deviation within the immediate family and its
progenitors.

Dfscont/nuous
It is characterized by the recurrence of a malocclusion
troit that reappears within the family background over
several generations but not continuously.

Variable
It is characterized by the occurrence of different but
related types of malocclusion within several
generations of the same family.

GENE MUTATIONS

Protein synthesis for the process of replication is

Fig 3 Structure of a chromosome the
chromosome.
The gene
The gene forms the basic unit of inheritance by
determining the make up and structure of a particular
characteristic in an organism. A gene consists of a
portion of the double stranded DNA molecule with 300
to 1000 nucleotide pairs. Each chromosome consists of
hundreds of thousands of nucleotide pairs, which can
be considered as a sequence of genes.
Transcription
Transcription is the process by which information is
transmitted from DNA to the messenger RNA at Ihe
initial stage of replication.
Translation
Translation is the process in which the gene* c
information is actually converted into prote;n synthesis.
PATTERNS OF GENETIC TRANSMISSION
The pattern of genetic transmission within the
dento-focial complex can generally be of 3 types:
controlled by genes. A change induced by certain
agents in the composition of the base pair of the DNA
molecule may lead to the synthesis of an altered
protein. This may result in a gross reduction or even a
complete loss of the biological activity resulting in an
altered expression of certain specific characteristics of
the individual.
Gene mutation can be of different types like,
visible mutations, detrimental mutation, lethal mutafion
etc.,.
Mutagens are agents that induce genetic
mutations. They ore of different types
1. Ionizing radiation
2. Certain drags, chemicals and food additives
3. Cerai n viruses
4. High temperature
Altnough genetic mutations are usuolly
associcted with a specific mutagen, sometimes
spontaneous mutations lake place. Although we do not
have any supporting evidence, some researches
ottribute it on the bcsis of Darwinian evolution ond
adaptive mutation to the environment.
CHROMOSOMES IN MAN
In 1956, Tjio ond Levan, and independently Ford and
Homerron demonstrated that the number of
chromosomes in man is 46 i.e. 23 pairs. Among these,
44 (22 pairs) are autosomes and a pair of sex
chromosomes. The autosomes in the male & femole
colls are identical while the sex chromosomes are
different. Males, out of 2 sex chromosomes, hove one
X and one Y chromosome while femoles have 2 X
chromosomes. This forms the basis of
determination in the offspring. Normal human cells
hove 46 chromosomes while the gametes have only 23
chromosomes i.e. haploid cell. During fertilization, the
union of 2 haploid cells from each parent results in an
offspring with 46 chromosomes.
GENETIC DISORDERS
GEWET7CS - IN AN ORTHODONTIC
PERSPECTIVE
Genetics In Orthodontics 489
The significance of genetic studies in the field of
medicine and related branches cannot be over-
sex
emphasized. Hereditary predisposition of certain
diseases like Hemophilia, the importance of Rh factor
in pregnancy and childbirth, congenital abnormalities
like Downs syndrome etc., are a few examples that
highlight the importance of genetic studies and genetic
counseling.
• Like any other discipline in medicine, the

Genetic disorders in a general aspect can be

considered to be of two types i.e. numerical disorders
and structural disorders.

Numerical disorders
Numerical disorders are those in which there is a
change in the number of chromosomes within the cell.
The following are some examples of numericol
disorders :
1. Polyploidy : A condition where there is. an
additional full set of chromosomes.
2. Monosomy : A condition where one autosome is
missing.
3. Trisomy : A condition when there is an addition of
a single chromosome only.
4. Klinefelter's Syndrome : It is a sex chromosome
abnormality in males where there are additional X
chromosomes.
5. Turner's Syndrome : A sex chromosome
abnormality in femoles with one X chromosome
missing.

Structural disorders
Structural disorders are those in which there is a
change in the basic composition and structure of the
chromosome. Structural disorders can be of the
following types:
1. Translocation : An exchange of segments
between non-homologous chromosomes.
2. Deletions : Loss of a segment of the chromosome.
3. Ring chromosomes : Deletion at both the ends of
the chromosome. Later the deleted ends stick
togetner to form a ring.
importance of genetic influence within the dento- BUTLER'S FIELD THEORY
alveolar complex and related structures were
According to this tnaory, mammalian dentition cor be
recognized ouite early. In 1836 Frederick G. Kussel
divided into several developmental fields. The
after extensive study reported that malocclusion, both
developmental fields include the molar/ premolar field,
ske'etal and dental can be transmitted from one
the canine and the incisor fields. Among the fields,
generation to another. Later many investigators
dentol variability manifests itself strongly in the dis'al
followed his path and came up with their observations
than in the mesial direction. For example the lateral
which attributed malocclusion more to an inherited
incisor is more prone to variation tnan the central
trend than the result of any environmental influences.
incisor.
Dento-focial disturbances of genetic origin
can briefly be listed as follows : METHODS OF STUDYING
1. Micrognathia ROLE OF GENES
2. Mocrognathia
3. Cleft lip and palote
Twin studies
4. Downs syndrome (Trisomy 21)
5. Gardners syndrome The genetic influence of inheritance has always been a
6. Marfan s syndrome ccuse of controversy. Some of the pioneers in the
7. Cherubism medical field proposed the possibility of some genetic
8. Cleido - cranial dysplasia components which helped in transmission of certain
9. Mandibulofacial dysostosis troits. However, others believed thot the make of an
10. Osteogenesis i m oerfecta individual is entirely due to environmental influences.
11. Bimoxillary protrusion Twinning of human embryo seems to be nature's
12. Bimaxillary atresia answer to this healed controversy. Human twins can
13. Retarded eruption of teeth be of 2 types:
14. Hypodontia, anodontia, oligodontia, etc., 1. Monozygotic twins
15. Abnormal overjet and overbite 2. Dizygotic twins
16. Open bite
/Monozygotic Twins : They are two individuals
17. High arched oolate
developed from a single fertilized ovum, which
18. Abnormal number and arrangement of teeth
Research into the genetic influence of the
dento-facial complex have thrown light on new vistas
of thoughts and at the same time disproved some of
the misconceptions within the subject. For example,
previously, racial crossing among humans was
considered to be one of the factors of malocclusion.
Later this was disproved by studies stating that human
racial crossing presented little or negligible risk to
dental occlusion.
Similarly another study on relapse of treated
cases showed that relapse con be ccused by
hereditary tendencies that come into ploy and upset
the results after treatment has been completed.
Occlusal mannerisms, jaw positioning and abnormal
aressure hebits which induce untoward forces that
tend to move Ihe orthodontically treated teeth back into
malocclusion con also be of genetic origin.
490 Orthodontics - The Art and Sciencc
divides into hvo ot an early stage of development. communities where practices like polygamy and
Monozygotic twins thus have a genetic mako-up 'marriages within the family13 still exist.
identical to each other. Relapse is not an uncommon phenomena in

Dizygotic hvins : They are two individuals developed Orthodontics. While treating a patient ortnodontically,

from two separate ova, ovulated and fertilized at the we do change the genetic expression of the patient.

same time. The two ova are fertilized by two different Once the treatment is completed, and the appliance is

sperms. They are not genetically identical as they removed, there is always a chance that the genetic

develop from two different embryos. They are expression of the potient re-establishes. Ruling out all

analogous to siblings except that they have an almost other possibilities like misdiagnosis, defective

similar developmental environment including the intra - appliance therapy and improper potient care, a great

uterino life. variety of relapse can possibly be attributed to these

Twin studies are done by analyzing genetic factors. Let us hope that the over- innovative

monozygotic and dizygotic twins in a specific manner. field of genetics finds the right answers to many of the

In case of monozygotic Wins, they have a similar still unanswered questions in this field.

genetic make-up, but post notally some of them have References

different environmental conditions. This helps us to
study the expression of the genetic factors and at the
same time, the environmental influences on this
genetic expression. Similarly in the case of dizygotic
twins who have a similar environmental condition, the
influence of genetic as well as the environmental
factors in the expression and development of an
individual can be studied.
Although twin studies have several limitations
like identification or different types of twins as well as
their developmental environment,the work of many
researches has thrown light into the understanding of
genetic contribution in the growth and development of
an individual.

Pedigree studies
Pedigree studies are the most common among genetic
studies. Here o definite trait of an individual is studied
along his 'family tree' so as to find any hereditary
influence. Many of the family traits like bimaxillary
protrusion, missing teeth, high arched palate etc., can
readily be attributed to hereditary inheritance. While
doing these studies one should be aware of the
dominant and recessive traits and their expressions.

inbreeding
The mode of transmission of certain traits can be
studied and their dominant and recessive
characteristics determined by analyzing
49
certain
13 Horris and Johnson : Heritability of malocclusions. Am J
Orthod 1991 ; 258-268
 >•7 w 'f - ;:v.

T Computers in
.
•• v..; ■•.*: ','•'^v v- '' •■-.>•'■
' • .' • ■ • v A ••••' .■ : 'f •

greater capability for accuracy and rapidity. Their

processing forte is management of large amour's of
disconnected pieces of data, with retrieval,
illllHIIi^MW^HHB
rearrangement and relocation in storage areas.
Orthodontics

he worldwide RC. revolution has today succeeded to

the point wherein there is hardly a person left whose life
has not been affected, directly or indirectly by
computerisation. Dentistry, being that branch of
medicine which relies heavily on technology and which
embraces new techniques with great gusto, was quick
to hitch onto the RC. bandwogon and employ
computers to enhance not only record keeping, but
practice management, patient education and
motivation. Let us briefly go over each aspect of usage
of computers in dentistry. A computer can be described
as an automatic electronic device capable of accepting
information (data}, perform operations and calculations
occording to the instructions given and supply the
results of the operations.
Humons live in the realm of information Machines
operate in the realm of dato. Data are raw facts while
information can be said to be data that is placed into a
meaningful context for use by humans. Humans
narrate information better than data, while computers
handle data better than information.
Virtually everything that we do in dentistry
that involves research, teaching, administration or
patient care is based on generation, storage and
manipulation of information. Computers are capable of
handling large amount of data. They accomplish
mundane, repetitive tasks consistently well where as
human performance is likely to decline overtime.
Computers can perform routine communications with
greater s peed and accuracy than is humanly possible.
They are capable of massive computation and
calculations more rapidly than humans. They have a

CHARACTERISTICS OF A COMPUTER
Speed
Computers ore capab.'e of making calculations at a
very fast rate that is not possible by the average human
brain. The presently available medium sized computers
can execute over a million instructions per second .To
exemplify this it would not be an exaggeration to say
that a computer can perform calculations in one minute
that an individual would require his entire lifetime.
Accuracy and reliability
Computers are designed in such a way that they exhibit
a nigh level of endurance capacity so that they can
work without tiring. Computers work on Ihe principal of
electric impulse transmission which makes it very
reliable and mistake proof. They are capable of
repeating the same job over and over again without any
decline in their efficiency.
Memory
Computers ore capable of storing large omount of data
and information in their inbuilt and auxiliary memory
systems. Information that is stored in the computer
memory can be retrieved at an astonishing speed
whenever reauired. Modem day computers can retrieve
data from its memory in a few nanoseconds (1
nanosecond= 0.000000001 second)
integrity
It is Ihe ability to take in and store a sequence of
instructions to be obeyed. Such a sequence of
instructions given to the computer is called a program
and it must be written in a language that the computer
can understand. The computer performs calculations or
manipulates the data that has been fed to it using the
instructions that has been given to it and furnishes the
desired results.
Versatility
Computers possess the ability lo communicate with
other systems and adopt several modes of
presentation such as audio, visual, animation, etc.,.
COMPONENTS OF A COMPUTER SYSTEM
A computer system comprises of two bosic
components. They are the hardware component and
the software component (fig 1).
The hardware component includes all the
mechanical devices in the system, the rnachinary and
the electronic components that perform physical
functions. The software is an organized set of
reody-made or specially written instructions that makes
the equipment work. In simple words whatever we can
see and touch in a computer can be said to be the
hardware while, the unseen instructions that make the
machine run is the software.
A typical computer system consists of a
central processing unit (CPU), input devices, storage
devices, and output devices.
The central processing unit can be said to be
the brain of the computer. The functions of the CPU
include storage of data and instructions, carrying out
the data processing as per the instructions given,
controlling the sequence of operations as per the
stored instructions, issuing commands to all pads of the
computer system and sending the results to the output
device. The CPU consists of an arithmetic logic unit,
registers, control section, and internal bus. The
arithmetic logic unit carries out arithmetic and logical
operations. The registers store data and keep track of
operations. The control unit regulates and controls
various operations. The internal bus connects the units
of the CPU with each other and with external
components of the system.
 HARDCD-ROM
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MSFFIM,

mm
MONITOR
KEYBOARD
LIGHT PEN

Control Section

MOUSE
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SCANNER
Fig 1. Coirponenis of o corrputer sys'em
434 Orthodontics - The Art and Science

AN titCI R ONI C DE NT Al PAT t r M U CCR D CAN

STORE TIIF = OLLOMNGDATA

Patient information such as name, age, sex,

Patient address and telephone number.
Chief complaint
Medical and Dental history
Data from the clinical examination
Diagnostic tests and their results
Storage of patient photographs,
Storage of patient radiographs

Storage of patient study models

Diagnosis and treatment plan
Patient progress
Medical and dental laboratory prescriptions.

Fig 2. Applications of uii electronic rscorc storage sys^en.

The input devices ore components of a An orthodontic establishment can use computers for a
computer that are meant to present the information to number of purposes. These can be broadly
the computer. A computer system can have one or classified as:
more types of input devices. For most computers, ihe 1) Administrative Applications
principal input device is a keyboard. 2) Clinical Applications and
The storage devices comprise of the internal 3) Other applications.
memory and the external memory. The internal Administrative applications of a computer
memory of a computer are the RAM (Random Access are aimed at smooth running of the dental clinic. They
Memory) and the ROM (Read Only Memory). The include:
external memory comprise of the floppy disk drive, CD- a) Patient appointments and recalls
Rorn, hard disk drive and magnetic tapes. b) Billing
Output devices display the results of the c) Accounting
computations. The output devices include the visual d) Correspondence
display unit or the monitor and various types of e) Inventory controls and supply orders fj Dental
printers. insurance claims
g) Document preparation and word processing h}
USES OF COMPUTERS IN ORTHODONTICS
Referral information i} Missed appointments follow up
 Clinical applications of computers are those
that help the dentist in his or her professional practice.
They include:
1) Patient records storage and retrieval
2) Patient evaluation, examination and treatment
planning
 nMi.,Wn,u*m-nnM irrii h m ra

Miili^»

Fig 3. Medico I arc Denta mJtirrcd c softwares end encydoped'cs thai make learn'ng a jov.

3) Potient motivation Several of the companies producing Dental office

4) Aap'iiance designing using CAD, CAM management softwares today offer computerized
5) Computerized imaging scheduling modules. With these programs, it is no
6) Computerized cephalometrics longer necessary to maintain o paper appointment
7) Computerized growth prediction book. The scheduler ollows the receptionist to find
8} Clinical diagnosis and treatment planning available times Lor patient appointments and log them
Computers have a number of other applications on the computer.
besides the clinical and administrative uses
COMPUTERIZED DENTAL PATIENT
mentioned above. They include :
1) Creating a data base of survey information 2}
RECORD

Continuing medical education

One of the applications OT computers in Dental practice
3) Reviewing of literature
is the electronic storage of diagnostic information.
4) Research
Electronic dental patient record (E.D.RR.) is slowly
5) Case presentations and other conference
and steadily replacing bulky paper records. Electronic
presentation
dental patient records
6) Entertainment and family use
COMPUTERIZED SCHEDULING
 F>>; • pj; • kvhw: «r; «•«M ; .««k»; .-t*^

Clinical application of tfie Universal oppliance ■BOBjfigp.

worn cucu on uas.. «.ids. WP. G.-V

DURING IV fccrufcve yesrs cfc<r syecialty, orthodontia were

products of-
ia'^xzied their will a fashico Ct^hodceiti3l£ toiay have ' sr. rigidly .«ir
beiistited grcr.l; e<kw!t:on and
Curi'jsity have Ifwfend, they «rc las» likely m iclies' a given given cose By
dicbrn. fcatier, thsj new "iiagrostic takng adjutage c J reoonl using
biologic aod yxvrth studies, they ar. tro;hnertof an inhTiiujJ principles ir.
case. the
Ir, reviewing many vnnec crh^i^tic techrjcues. it is fascmatii^
Jo cbiervs the the use of light forces ml ecuur.u;us mcvemart the yexs. A:
«ams to be the cctrmoo goal of. appl: aice thsi was designed pre3etfc
for light wires sirl Kb b=en uied «ccccdogiy is know 1 •racket
lint design
3?ercer ;:
©incoming
One
lb? ruerte of tte ifrjliar/j; wo; derived from « versatility »4 frcra this 1 ts great
the fact thai Aikinsoo'- irtrodiced Eur Jppliar.cc to 'he flexibility I
profession about 30 years age m Sooth technique is s-ant,1-1 ontic
mi most of its advocates tre loastod on the West Co» :t of thi. practice.
aid tjty, though rot generally JoKwn vbroigboi U* orthodeolic I net inleoded
wcrid, hnvij |
H is my irterfccn to it Certain dim afftkohens cf -his appliancy
in fci o'' Rither. tn«icjilvii».ic.i and demohsfcoitti of this unique
aypli»cc will be atteirptec j jeafcii'SSiUpnil
Clpa] |e ease of
THE UNIVERSAL APPLIANCE
W gingival
In its sppHcacion, the Universal 49'iiir/?: can oc deser.bcd a; opetung,
arailtibEciied one, atackmnts The «wadset itself (Tig 3) := !p<nuigar>JUpt
designed to procuse tooth mc^csmnt m t) manipulation This o
hss two c^eiings— the jic-.xiI or ccwlus Jj, 'which lies p; ytiich is at
ngfX angles to £ii s axis. lbs bracket will receive nbLon arches Hf. 14. P-(i\«9 <h0 8NJMT-.J W»UM
as Urge 1

ijlw'y.ww • ■ v' Vn?

Fig 4. A number cf rred'ccl and c

Wouldn't it be wonderful to be able to store study
help in storing pafient information in a digital format models in the form of holograms that would allow
which can be retrieved, duplicated, cataloged, viewing from all
journals arc available on C.D-Rcms.
transmitted and archived os needed. The applications
of such a computerized system of dental pafient record points of advantage? Such technology, though not
are listed in fig.2. commonly available, does exist today.
Record storage problem increases as the
practice ages. Study models are bulky and heavy, PRACTICE MANAGEMENT
presenting considerable problems for organization and
Dentistry, after all is a profession like any other ond
storage as they continue to accumulate.
today, living in a consumerist society practitioners
Current technology is available for in- officc
have to professionally manage their hospitals and
use of computers combined with video cameras lo copy
clinics in such a way that, there is palienl satisfaction
radiographs, study models, photographs, and
and job satisfaction. To cater to this need of
handwritten records for storage in compact digital form.
professional management, some of the dental
administrative softwares go one step beyond potient
administration and work on the dara thai is fed in,
creating reports that analyze the nature of the work
being done over a period of time, the cost
effectiveness of time spent on the various procedures,
the productivity of the
 •r iixtlnitr.n; »811J
F»» C* 'w f*i crft« To* Het
f»y(S g)

MIc «nj
fnldt» piOejoir

PiCCnCiJ osaa»i] C5CD C50T KO>»

C0H OI5 14

0t(9t*wvffifffWw'!':- cr.cvrt i KCW.

22
05CC3 ceo:c
D1» o:9

l-SCOXB? C5CCOCC3

Fig 5. Di g holly onoiureri and slorcd images for later viewing, il s possible to store uho'ogrophs and radiographs o^ the oa*iert ct
various stages of fie treatment

dentist over a period of time and so on, thus providing
valuable management information reports which
analyze the practice within the shortest time.
PATIENT EDUCATION
There has always been a need in all branches of
medicine to educate patients about
prevention and cure. Most dentists regard this aspect
very highly and spend o lot of their time informing the
patients about the various dental problems, health
guidelines, etc.,. However, computers can save this
valuable time of the dentist by using the latest
multimedia technology. Multimedia simply means
using multiple media like text, pictures, graphics,
movies and sound to make a presentation (fig 3).
Internationally, various multimedia patient education
presentations are available, which can be purchased
and played on the computer system for the benefit of
the patients, just like a video cassette is played.
CASE" PRESENTATIONS
Most of us dentists consider ourselves as lifelong
students and researchers ond our profession is not
diseases, limited to practice alone. Maintaining research data
and creating presentations is one of the greatest
boons o^ comouterization. Most advertising agencies
use internationally marketed oresentation softwares
like Microsoft Office, Power Point to push their
products. This same tool can be used by dentists to
make slide presentations, wherein one can use text,
colour, pictures and actual photographs. These tools
are extremely user friendly and they not only make
presentation classy and informative, but olso save
valuable time, money and effort that was formerly
spent on the same.
498 Orthodontics - The Art and Science

vyy igj » ■ ». a n I 'ira Ww: v: c 1 n

❖ I USA' r.-rt."IfTTl «"«

; jvjv'.Ofirti; «"V
H»^
WcJtonie lu
*iunjhlriUi>ut}i.i:<
«ilUnin^iS Uit«l4l(ivr J lid
c1
candiciaiic. 11m
Animalia

HfirJ! '.yy/

'JwwmV.Vi
tr^liUTr.
root

com

Fig 6 . Irre'net is a r'cb source of information. A numner of denial sites are ovoilao e or -hc not

Dental imaging the image on the monitor, click and the image can be
saved as a part of a picture album for each patient in
This is a tool that is a God sent gift for most dentists.
the computer itself. These images can be viewed,
Since dentistry, now deals with changing the look of a
edited, transformed into slides, and printed, Not only is
person's face, record keeping naturally involves a lot of
it the most effective record keeping tool, but it is also
photographs that document the treatment. But manual
the most effective morketing tool. There is hardly any
photography is time consuming, laborious and
patient who is unimpressed by the photo recording of
expensive over a period of time and it has its limitations
his/her treatment and it also creates awareness among
with intraoral pictures. Moreover, it creates more
patients about the need of dentistry and its effects.
paperwork. Denial imaging is a solution wherein, a
Digital cameras are available that can be
small intraoral camera is inrerfaced lo the computer, so
used to capture intraoral ond extraoral pictures which
that the user has to just focus the camera to capture
are later stored in a computer for lulure viewing. These
digital com era s do not use the conventional
photographic films. They record images on memory
cards which are later transferred to a computer for
storage end revewing (fig 5).
CONTINUING MEDICAL EDUCATION AND Computerized cephalometry provides, in
RESEARCH REFERENCES addition to reliability, the advontoge of speed. It can be

Continuing medical education is essential for the

Computers In Orthodontics 499
performed in 10% of the time of a normal manual
registration and calculation.The advantages of this
orofessional exoerlise and growth of every doctor. With
system include :
limitations of time, long distances and traffic difficulties
1. Easy storoge and retrieval of cephalometric
it becomes increasingly difficult for tne dental surgeon
tracings and values.
to attend workshops or other continuing education
2. Integration of cephalometric registrations within
programs. Access to medicol and dental Journals, and
an office-management computerized system.
occess to large volume of medical reference materiol is
3. Combination of the cephalometric data with other
easily available on the Internet and also on C D-ROM s
patient records.
(fig 4). Numerous dental web sites or. the internet offer
The following are some of the popularly
offer vast amount of information related to
used computerized cephalometric systems.
dentistry.Communication and consultatior with
colleagues in all parts oc the world is possible using RMO's Jiffy Orthodontic Evaluation
Email and Internet.
Multimedia medical ond dental publications
ore now widely marketed. Multimedia publications not
only include text and pictures, but also video clips and
sound recordings. Virtual reality presentations and
animated simulations also form an important part
o:multimed'a. Currency several hundred medical and
dental books ore available as CD- ROM's
Anybody who is involved in research knows
that a very large part of research work is tedious
tabulations, data analysis and painstaking statistical
analysis. All this can be greatly facilitated using a
computer leaving valuable time for the researcher to
spend on actual scientific working.

COMMUNICATIONS & ENTERTAINMENT

Besides all these uses, computers hove revolutionized

our concepts of communications too. A computer in our
clinics can function as an answering machine and a
fax. It can link you to the Internet and con be used -or
international communications via Ihe Email. It can also
be used as o tool for entertainment, not only for playing
fascinoting games, but con be used to watcn television
programs, as a CD player and CD movie olayer.

COMPUTERIZED CEPHALOMETIC
SYSTEMS

Prior to the introduction of computerized cephclometry,

oil angular and linear measurements were calculated
manually. Besides being time consuming, it involves
the possibility o; human error.
 RMO(Rocky Mountain Orthodontics) was the first lo clinician to perform noninvasive and non-radiographic
cephalometric ana lysis. Cephalometric landmarks are
500 Orthodontics - The Art and Science
digitized by lightly touching the sonic digitizing probe to
provide the denial profession with a computer oided
a point on the patient's skin corresponding to it. This
cephalometric diagnosis in the 1960's. A recently
emits a sound, which is then recorded by the
designed softwore package the JOE, generates
microphone and monitored as X, Y and Z co-ordinates.
tracings of lateral or fronto! cephalograms using
Ricketts, Jarabak, Steiner, Sassouni and Grummons •

analyses. It can also provide a visual representation of The system allows cephalometric evaluation

normal for comparison to the patient's tracings, ond treatment progress as often as necessary without

generate c collection of cephalometric values tested in radiation exposure. The Digi Graph work station's

c logical order along with the norms and amo'. of hardware and software enable the performance of

deviation from normc! and pul together c V of cephalometric analyses, tracings, superimposition and

orthodontic problem analysis. visual treatment objectives. The program is capable of

14 analyses. Measurements for any selected onalysis
con be displayed on the monitor and the observed
PorD/os (Purpose on Request Digitizer Input
Output system) values are shown along with the patient norm adjusted
forage, sex, race and head size including standard
A product of the Institute of Orthodontic Computer
deviations. The Digi Graph allows all patients'
Sciences, Denmark it is a cephalometric system aimed
radiographs tracings, cephalograms, photos and
at providing dentists with a user - friendly program.
models to be stored on the computer hard disk,
This program can be eosily changed to satisfy
thereby reducing storage requirements. Furthermore it
individual needs ond preferences.
is a valuable tool for improving communication among
Por Dios works with a digitizer in the
clinician, patient and staff. Optional components
standard way and also enaoles Ihe use of a video/
include:
scanner as means ot digitization of X-rays. It uses
1. A consultation unit: It transports information into
popular analyses including Bjork, Bursfone, Co ben,
the ooeratory, doctor's office / consultation orea,
Downs, McNamara, Ricketts and Stein e r. Por Dios
thus allowing viewing and comparison of
has built-in functions to calculate discrepancies
information and the development of visual
between the actual and its deviation from the norms.
treatment objectives.
The norms for each variable can be changed for
2. A high - resolution video camera with a telephoto
different ethnic groups. It is multilingual and the user
lens for taking intra-orol views by freeze framing
can choose from English, French, German, Italian,
the video image.
Dutch, Spanish, Danish and Greek.
3. A light box for X-rays and a study model holder for
The system facilitates double digitization
video imaging that will be included in the floppy
minimizing error and ensuring the validity of the whole
disk.
registration procedure. The drawings can be printed
4. Camera and video printer for producing copies of
eitneron a matrix printer, laser printer or a color plotter.
video monitor infonnation.
An import • export facility makes it possible to make
calculations on all stored patients. It can produce a
COMPUTER-AIDED DIAGNOSIS
database file containing the results of Ihe digitization.
Reseorch is currently in progress attempting to create
Dlgl Graph
a computer system that would, in effect.
Product of Dolphin Imaging Systems USA. The Digi
Graph is a synthesis of video imaging, computer
technology and sonic digitizing. The Digi Graph work
station equipment measures 5' x 3 x 7'. It enables the

c—
 Computers In Orthodontics 501

simulate the diagnostic abilities ol the practicing through bone, thus disclosing previously hidden parts
physician. Several programs have been designed to of the body, such os the sainal cord. NMR can also
aid the physician to make multiple and complex differentiate omong blood, liver, and muscle, and in the
diagnoses. Experience with these programs, however, future the sensitivity may help distinguisn between
confirms the belief that medical diagnosis is a complex benign end malignant tissues.
process. The computer is able to construct a N1V1R works by expos:ng the patient to a
differential diagnosis after being presented the 'arge magnetic field and low-level radiofrequency
necessary historical items, symptoms, physical signs, pulses. Electrical charges generated by the nuclei of
and laboratory abnormalities associated with a specific atoms composing the molecules of tne body produce c
medical disorder. However, the program cannot submicroscopic magnetic field, allowing them to be
recognize subcomponents of illness, such os specific ottracted to an external magnetic field provided by rhe
organ system involvement or the degree of severity of NMR scanner. After the nuclei have been aligned by
the pathologic orocesses. The computer is still limited NMR, they are bombarded with rod i o waves. The
in its ability to reason and is unable to simulate the radio waves are then turned off, and the nuclei are
thought processes and problem-solving methods allowed to relax, re-emitting the radio signals that ore
employed by the human mind. Thus, the practice of converted by the NMR scanner's computer into images
medicine remains an 'art' rather than an exact science, of the body. These images ore superior to those
ond the computer currently remains only a tool to aid, obtained with all previous technology.
rather than replace, the physician.
Conclusion
MEDICAL IMAGING Thus in conclusion Ihe computer will provide the
Doctor and his staff with immediate access to more
The advent of computers hos allowed rapid
information than ever before. Communications is
technologic advances in the field of diagnostic imaging,
improved dramcticallyasare other forms of marketing.
including X-rays, ultrasound, and nuclear imaging
With detailed patient histories, diagnostic information
systems. Clinical applications of ultrosound diagnosis
and treatment plans stored in the computer, research
have broadened considerably. Such technology is now
and practice analysis con be done with ease. These
used to detect disorders ins'olving the liver and biliary
advantages are more important to a good clinician than
system, kidney and in obstetrics and gynecology. They
any initial inconveniences that he may face while
are also used to diagnose cranio-facial pathologies by
computerising his clinic.
the dental surgeon.
The medical profession is very familiar with
the use of the CAT scanner as an instrument to provide
non-invasive information regarding the size, shape and
health of major body organs. However, a new more
versatile, and safer method of providing
three-dimensional views of the inner body has
emerged in recent years. This technique, called
N1V1R (Nuclear Magnetic Resonance}, has several
advantages over CAT. Of greatest significance is its
safety. It is entirely non-invosive and does not require
tne use of dye injections or the exposure of the patient
to ionizing radiation. The N.MR scanner is also
superior to the CAT scanner in that it can image
502 Orthodontics - The Art and Science

All this is possible today at a reasonable

cost which recovers itself in a short period of time.
Competitive forces have further driven the
prices of computer hardware/software lower ond
lower, each year, thus bringing down the patients and
Doctor's cost to benefit ratio. The computer can truly
be called a "Dream Machine".

References
t. Abelscn : Introduction to computerization cf 'he orthodontic
practice. Am J Orthod 1992 ; 366-372
2. Abelson : Practice anc com m jnicat'or.s systems. Am J
Orthod 1992; 471-474
3. Arthur Fcfman, DDS : Corrptterizec Appointment Reminder. J
elm Orhod 1966; 687-687
4. Bajmrnd : Cornajrc-aided nead film onalvsis. Am J Orthod
1980; 41-65
5. Side Melsen, DDS, DO. Giorgio Fiore li, DDS : 8'omechonics:
Corrputc-Based Mochanotneraay. J clin Ortnod 1994 ;
136-141
6. Dennis M. Killiany, DDS. MSD : Analytical Orthodon-ic
Comajter Programs. J clin Orhod 1985 ; 445-448
7. Ecoromidcs : "he in-house computer :or the orthocort c o^ice.
Am J Orthcdl983 ; 115-124
3. Homer W. Pill'ps: Enhanced Office Automation.J clin Orthod
1992; 539-550
9. Richard G. Alexander, DDS, MS; John C. Gorman, DMD, MS;
Doone C. Grummo : The DigiGraph Work Stat on. J clin
Orthod 1990 ;402-407 1C. Rober G Keirr, DDS, Moderotor;
Jomes K. Economidcs, DDS, MSD; Paul Hoffman Jr., D D :
JCO Rojndtapic: Computers in Orihocontics. J clin Orhoa
1987; 591-597
11. Robert R Schclz, DDS : Update or. Orthodontic Computer
Sys-ems. J din Orthod 1937; 735-739
12. Robert P. Schol?, DDS: Indefinite S'orcge of Orthodontic
Rccords. J din Ortnod 1988; 734-735
13. Ryden : Toolh position measurement using holographic
images. Am J Orthod '982 ; 310-313
14. Sokuda, Tome, Yosh'da, houe, Oimae, Tsuchiya,
Adachi, Nakagawa, anc Inoue : Compjter network
system in orthodontics. Am J Ortnod 1992 ; 210-220

I
n the last few years there has been considerable showed an increase in the percentage of patients over
interest in orthodontic treotmentforthe adult 21 years of age from a fraction more than 4% ten
patient. A recent sun/ey conducted by the AAO
 years ago to almost 7% today. Nearly 11% is expected
after another decade.
There is no definite age when the male or
the female reaches physical maturity and it is
therefore impractical to try to determine exactly when
adulthood begins. Since an adult is defined as one
who is fully grown, most males of 18 or 19 and most
females of 16 can be considered as adults.
According to Ackerman, "adult orthodontics
is concerned with striking a balance between
achieving optimal proximal and occlusal contoct of the
teeth, acceptable dentofaciol esthetics, normal
function ond reasonable stability."
REASONS FOR INCREASE IN
ADULT PATIENTS
504 Orthodontics - The Art and Science
The percentage of adult patients who hove received
orthodontic treatment hos increased significantly in the
last decade. From 1970 to 1990 an 800% increase in
adult patients was observed.
An increase in the number of adult patients
in the past few years has undoubtedly been due to
decreased numbers of child patients with the recent
explosion of activity in the field of preventive dontistry.
Harvey G. Barrer observed that the child population is
decreasing and that the number of orthodontists is
increasing. At the same time, we find an increase in
the number of adult consultations. The reservoir of
adult orthodontics is large because of many who could
not avail themselves of treatment two or three decades
ago.
 Tne increasing number of adults requiring or for adjunctis'o orthodontic treatment to moke control of
requesling orthodontic treatment can also be escribed dental disease and restoration of missing teeth easier
to : and more effective.
1. Innovations in appliances, especially the advent of
direct bonding, ceromic brockets ond
tooth-colored wires have ccught the attention of
many adults who would not otherwise seek
orthodontic treatment.
2. Improved appliance placement techniques. The
latest development is lingual orthodontics or
invisible orthodontics, which may shortly be a
proven technique.
3. Increased experience with adult orthodontic
treatment and the achievement of good results.
4. Increased public oworeness of the possibilities of
adult treatment.
5. Increased desire of patients and restorative
dentists for treatment of dental mutilation
problems, using loolh movement and fixed
restorations ratherthan removable prostheses.
6. More sophisticated and successful management
of the symptoms associated with joint dysfunction.
7. More effective manogement of skeletal jaw
dysplasias, using advanced orthognathic surgical
techniques.
With the ever-changing times, the adult has
awakened to the benefits of orthodontics. His
increased social and business activity has made him
aware of visible esthetic short commings, growing
personal affluence and access to third party
participation have put him in reach of treatment
previously difficult to obtain but now readily available.
With this, the orthodontist has a new responsibility of
developing esoteric procedures for treating adult
patients.
The increased demand for adult
orthodontics today can also be ascribed to the
following factors:
J . Medro - Numerous articles in magazines and
newspopers, as well as advertising by dentists
increase public awareness.
2. insurance - Third party payment for patients of
other phases of dental care can make funds
available for adult orthodontics which is only
occasionally covered by insurance.
3. Attluence ■ Totol dental treatment is more
occeptable in today's adults because Ihey can
afford it.
4. Family dentist awareness - The family dentist is
more aware of the problems of occlusion and the
role of proper tooth alignment in enhancing
restorative dentistry. Paralleling abutment teeth
simplifies tooth preparation for crowns, bridges,
portiaI dentures, resin bonded retainers and other
restorations.
5. fsfbetics ; Today there is greater awareness of
health and appearance. To achieve better facial
esthetics, the teeth must be properly aligned, with
oil missing teeth replaced.

Orthodontic treatment for adults has been

the fastest growing orea in orthodontics in recent
yeors.There appear to be two reasons for this, and
therefore two groups of adult patients :
The first group, comprising of young adults
who desired but did not receive comprehensive
orthodontic treatment as youths, now seek it as they
become financially independent, and are more aware
of the benefits of orthodontic treatment.
The second group consisting of adults (often
older than those in the first group) who have other
dental problems are being recognized as candidates
 Factor
Basic No growth potential, Tcoft movement possible in
tf'iference only iocih movement addifon lo growth modricaticn

Appearance ot Often of great cono:-'~

Usually not of any concern m tolerate
appliance Appl-sncs Take, more time lo adjust.
Appliances must be well most appliances readily
toierance ' made and care'uKy
adjusted

Will adjust Ojictdy

Adjustment more dififciH

May be a comp-'icat rig

Parodontal disease Usually none or not
faaor and nust be severe
eliminated befo'6
starting orthodontic
treatment
Usually not 3 co-icern
General health Must consider mo'e
care'ully prior lo

Patients are usually weli Ranges from poor to

motivated and co-operation exceilem
is not a problem
treatment
Cooperation Net very appreciative

Treatment appreciation Usually very

appreciative

DIFFERENCE BETWEEN ADULT AND have one less {and often unpredictable) factor with
ADOLESCENT PATIENTS which to contend.
The need for orthodontic treatment in the
What are the differences between adult and child
odult is often symptom related which can be detected
orthodontics? The basic difference is that in children
by the patient, while that in children is based more
we must concern ourselves with tooth movement plus
often by signs detected by the parents or the
growth, whereas in adults we are dealing strictly with
practitioner. There are, however, several other
tooth movement. We cannot count upon growth to help
differences between adult and child orthodontics
us (or hinder us) in ochieving our treatment objectives.
(refertable I).
In a way, then, adult orthodontics is simpler, for we

49
INDICATIONS FOR ADULT ORTHODONTIC
TREATMENT

Ravins clearly outlined the reasons for orthodontic

therapy: ,
1. To improve tooth-periodontal tissue relationship.

49
2. To establish an improved plane of occlusion in
order to distribute forces through the broadest areo
Orthodontics - The Art and Science
possible.
3. To balance the existing space between teeth for
belter prosthetic replacement.
4. To improve spaces to provide normal tooth-
to-tooth contact.
5. To improve occlusion and co-ordination with the
masticatory muscles and the TMJ.
6. To satisfy the aesthetic desires of the patient.
CONTRAINDICATIONS FOR ADULT
produced by a force is equal to the force times the
distance from the point of force application to the
centre of resistance.
Orthodontic forces must be applied to the
crown of a tooth, and the further rhe point of forcc
application is from the cenrre of resistance, the greater
will be the tipping moment produced by any given
force and consequently a larger countervailing couple
(m) would be necessary to effect bodily movement.
Mechanics and treatment
Adult treatment mechanics need not differ from the

ORTHODONTICS standard techniques; they are modified only to meet

specific treatment requirements. Simplicity with
Barrer discussed several contra-indicotions relating to maximum control is the byword. All dental movements
adult orthodontic therapy. They ore : are considered to be possible. Of these intrusion is
1. Severe skeletal discrepancies difficult, root resorption is a frequent penalty. Extrusion
2. Advanced local or systemic disease is the least difficult. Tipping is not difficult, but septal
3. Excessive alveolar bone loss crest bone loss may be a serious hazard. Rotation is
4. Inability to obtoin a result that the patient or doctor simple and rapid but has tne highest relapse factor.
will perceive as satisfactory With well designed appliances, controlled
5. Poor stability prognosis dental movement and availability of basic
6. Lack of patient motivation requirements, treatment can be no more eventful for
the adult than for the child, perhaps less so.
BIOMECHANICAL CONSIDERATIONS
Age related changes In the
Since adult patients who need orthodontic treatment periodontal ligament
often hove periodontal problems, the amount of bone
The primary tissue to be influenced by mechanical
support of each tooth is an important consideration.
forces applied to the teeth is the periodontal ligament.
When bono has been lost, the periodontal ligament
Collagen is produced by the fibroblasts, which are the
(PDL) area decreases, and the same force agoinst the
most frequently occurring cells of the periodontal
crown produces greater pressure in the PDL of a
ligament. The osteoclasts occurring within a few hours
periodonlally compromised tooth than a normally
after orthodontic
supported one. The absolute mognitude of force used
to move teeth must be reduced when periodontal
support has been lost, to prevent damage to the PDL,
bone, cementum, ana' root.
The greater the loss of attachment, the
smaller the area of supported root and the further
opicol the centre of resistance wi 11 become. The
centre of resistance of a single rooted tooth lies
approximately six-tenths of the distance between the
apex of tne tooth and crest of the supporting alveolar
bone. Loss of alveolar bone height or periodontal
attachment leads to apical relocation of the centre of
resistance. The magnitude of the lipping moment
•

m
111 M
Adult Orthodontics 507

stimulus are most likely derived from the local Together, these hard and soft tissue
monocytes and / or macrophages. After the initial changes dictate a conservative approach to
wave, a second population of resorbing cells appear mechanics. The biologic background for orthodontic
thot are blood borne. Some of these cells migrate from tooth movement in adults indicates that:
the vascular network at the centre towards the bony 1. The forces used in adults should be at a lower level
surface, serving as progenitor cells for osteoblasts. than those used in children.

A mechanical stimulus, such as a force 2. The initial forces should further be kept low

applied to a tooth, will result in an increased because the immediate pool of cells available for

proliferation of the cells in the periodontal ligament. It bone resorption is low.

has been proposed that the insufficient source of 3. The moment lo force ratio for a particular tooth

preosteoblasts might account for the delayed response movement should be increased according to the
periodontal status of the individual teeth.
to mechonical stimulus.
4. With increasing marginal bone loss, light
Norton suggested that the decreasing blood
continuous intrusive forces should be maintained
flow and vascularity that occurs with increasing age
during tooth disolacement.
may provide an explanation for the insufficient source
of progenitors cells that characterizes the aging DIAGNOSIS AND ADULT ORTHODONTICS
patient. The age relcted changes in vascularization
may explain the delayed reaction to orthodontic forces Orthodontic diagnosis deals with recognition of the
described in odults. various characteristics of the malocclusion. It involves
collection of pertinent data in a systematic manner to
Age related bone changes help in identifying the nature and cause of the problem.
Orthodontic tooth movement as a result of bone Diagnosis involves development of a comprehensive
modeling and remodeling also depends greatly on oge data base of pertinent information. The data is derived
related changes of the skeleton. Cortical bone from case history, clinical examination and other
becomes more dense while the spongeous bone diagnostic aids such as study casts, radiographs and
reduces with age and the structure changes from that photographs. The standard diagnostic aids are
of a honeycomb to o network. mandatory. Because of a greater possibility for
dormant pathosis, buried roots, impactions,
Local age changes
periodontal breakdown, and atrophic changes,
The apical displacement of the marginal bone level is a periapical, occlusal and TMJ films should be obtained
local factor that influences the biological background routinely in addition to the panarogram and
for tooth movement in adults. The marginal bone loss is cephalogram. A systematic approach to the
age related but is also the result of progressive examination is essential to ensure that nothing is
periodontol disease. With marginal bone loss the
overlooked. The problem oriented diagnostic
centre of resistance of the tooth is displaced apically.
Another factor of importance is occlusal
function. This is highly related to both the quality and
quantity of the lamina dura and surrounding bone.
Teeth that hove lost occlusal contacts becouse of
extraction develop disuse atrophy in their supporting
bone.
procedure as described by Profit! and Ackerman is 1. General dentist
recommended to ensure that no aspect of the patient 2. Orthodontist
need is ignored. 3. Restorative dentist
Adulf patients come to us after years of using 4. Prosthodontist
and abusing their dentitions. Their teeth hove : 5. Oral and maxillofacial surgeon
More wear facets 6. Plastic surgeon.
Shorter cusps
Sha I lower fossae TREATMENT ASPECTS IN ADULT
Many have had extensive dental work : amalgams, ORTHODONTICS
crowns or inlays
Profitt has classified adult orthodontic procedures into
Bridges and partial dentures
the following three areas :
For the adult, the clinical examination takes
1. Comprehensive orthodontic treatment
on special significance in isolating existing or potential
2. Adjunctive orthodontic treatment
pathosis and the etiological factors of trauma,
3. Surgical orthodontic treatment
mandibular shifts, wear facets, occlusal disharmonies,
and faulty dental restoration. Additional diagnostic Adjunctive orthodontic treatment
procedures that we should consider in adult patients
Adjunctive orthodontic treatment is, by definition, tooth
are:
movement carried out to facilitate other dental
1. A full TMJ series of X-rays
procedures necessary to control disease and restore
2. Muscle Examination
function. Although malocclusion as classically
3. Stress Evaluation
described is not necessarily on unhealthy condition,
4. Diet Evaluation
some tooth positions are not conducive to long-term
Periodontal considerations In oral health. The goals of adjunctive treatment should
diagnosis be to:
Most adult potients who seek orthodontic treatment 1. Facilitate restorative treatment by positioning the
have some form of periodontal breakdown. teeth so that more ideal ond conservative
Orthodontic treatment in the presenco of periodontal techniques can be used.
disease results in more septal bone loss, more tooth 2. Improve the periodontal health by eliminating
mobility during treatment and more residual mobility plaque harboring areas, improving the alveolar
post-treatment. Pre treatment consultation with the ridge contour adjacent to the teeth.
periodontist should be routine and orthodontic 3. Establish favorable crown-to-root rotios and
objectives should be altered if required on his advice. position the teeth so that occlusal forces are
Re-evaluation and constant periodontal transmitted along the long axes of the teeth.
therapy during orthodontic treatment will further ensure Adjunctive treatment implies limited
a more positive prognosis. They require specific orthodontic goals, improving a particularaspect
post-treatment periodontal care and long- term
retention procedures, often of a fixed design.
Multldlsclpllnary approach
Most adult patients require a multidisciplinary team for
their comprehensive rehabilitation. The team may
include
of the occlusion rather than comprehensively altering colored brackets and lingual orthodontics can be
it. Typically, appliances are required in only a portion of considered for adult patients.

the dental arch and for only a short time. 6. Comfort requirements : Adults are usually less
The adjunctive treatment procedures adaptable to the appliance thon young patients. Thus
include: simple comfortable appliances are preferred in adults.
1. U prig h ting of teeth
7. Biomechanj'co/ considerations : Adults exhibit
2. Forced eruption
greater bone loss and loss of attachment, leading to
3. Alignment of teeth
apical shift of the centre of resistance. Thus greater will

Comprehens/ve treatment for adufts be the tipping moment produced fora given force.
Adult treatment mechanics need not differ
Comprehensive orthodontic treatment according to
from the standard techniques; they are modified only to
Profitt, implies orthodontic treatment which would take
meet specific treotment requirements. Simplicity with
more than six months duration. Comprehensive
maximum control is the byword. Adults are turned off
treatment in adults is similar to that in adolescents.
by :
However the following considerations should be kept in
1. Unaesthetic appliances
mind while treating adults.
2. Feor of pain
J. Keep in mrnd the biological limitations: Adults
3. Extended treatment time
exhibit decreasing blood flow and vascularity and
4. Personal inconvenience
insufficient source of progenitors cells at the site of
5. Cost
tooth movement. In addition the cortical bone becomes
The appliances used in adult orthodontics
more dense while the spongeous bone reduces with
should fulfill the following requirements :
age. These biological limitations dictate a conservative
1. Should be simple in order to maximize cooperation.
approach to mechanics in adult orthodontic Ireotment.
2. They should respond to light force for best
2. Lower force /eve/s ; The forces used in adults physiologic response.
should be at a lower level than those used in children. 3. They should be fixed to maintain treotment control.
The initial force? should further be kept low because 4. They should be long acting to decrease the
the immediate pool of cells available for bone
resorption is low.

3. Periodontal considerations : Adults are more

likely to be periodontally compromised. Periodontal
care should be undertaken as frequently as needed
during the orthodontic treatment to keep a check on
periodontal inflammation.
4. >V1u/tidiscip/inary approach : Most adult patients
require a multidisciplinary team for their
comprehensive rehabilitation. The team may include
Orthodontist, Restorative dentist, Prosthodontist and
Oral surgeon.
5. fstfiefic requirements : Adults are usually more
concerned of esthetics. They are likely to be put off by
appliances thot are not esthetic. Use of esthetic tooth
 Orthodontics - The Art and Science
number of appointments 5. They should require
the shortest over-all treatment period while affording us
the highest potential for o stable correction with
minimum retention requirements.
Surg/ca/ orthodontic treatment
As adults do no grow any longer, dentofacial
orthognathic surgeries are major surgical procedures
carried out along with orthodontic therapy to correct
dento-facial deformities or severe
disproportions involving the maxilla, the mandible or
both in combination. Orthognathic surgery basically
involves planned fracturing of the facial skeletal parts
and repositioning them as desired.lt requires a team
approach with the oral surgeon and the onhodonlist
being important members of the team.
Orthognathic surgeries can be performed in
the maxilla as well as the mandible to correct jaw
discrepancies in all the three planes of space.
adults -.A.J.O 1993 ; 455-470. 5. Concept and Commentary:
Adult Orthodontics :
J.ctinical onhod 1972 ; 45B-472. 6 Golietlo : Adult anterior
open bite : A.J.O 1 990 ; 522-526.
Glassman, Nchigian, Mad way, and Aronowitz : Conservative
surgical orthodontic adull rapid- pclarcl expansion : A.J.O
1984 ; 207-213.
Harvey L. Levitt : Adult Orthodontics : J.clinicol ortnod 1971 ;
130-155.
Manuel H.Marks, HerrnanCorri, : Alias o- Adult Orthodontics :
Lea ond Feoiger, 1989
Reynders : Review article : A.J.O 1 990 ; 463-471.
Special Considerations for Adult Orthodontics : J.c.inical
orthod 1976 ; 535-545.
Tayer : Aduts attituoes tov/ord orthodcmic therapy : A.J.O
oro-facial
1981 ,-305-315.
Thomas W\. Graber ond Robert L Vanarsdall: Mosby , 1995
Varela end Gorcio-Cam'oa: irr.pcct of orthodontics on ccult
patients : A.J.O 1995 ; 142-148.
Warren Hamula : Orthodontic Office Design Designing Adult
Areos : J.clinical orlliud 1 992 ; 355 360.

RETENTION IN ADULT ORTHODONTICS

Retention mechanics should be part of the original

treotment plan. It may include removable retainers,
operative procedures, and/or fixed retention. When the
patient has abnormal lip, tongue or cheek muscle
activities, it is incumbent on the orthodontist to prepare
the patient for long term use of fixed retainers.
Retention is a critical and challenging aspcct of adult
orthodontics. The general principles of retention hold
good for adult patients.
In many cases of adult orthodontics the need
for post orthodontic stabilization will coincide with the
need for both restoration of mutilated dentition and
cross- arch stabilization.
References

1. Aoull Orthodontics :J.clinicol orthod 1932 ; 606-618.

2. Birte Mat sen : Current coniroveroes in Orthcdornics ;
Quintessence, 1991
3. Bine Mel S en on Acult Orthodoxies: JCO Interviews 1988;
630-64 1.
Ccssidy, Herbosa, Rotskoff, and Johnston : Comparison of
surgery and orthodontics in 'borderline'
 activator) Andrews six keys, 59-62
Angle E.H., 5 Anglo's c1 ossification
Basis, 69-70 Classification, 69
Disadvantages, 75-76 Modifications,
76-77 Angle
" A-B Plane, 151
A.N.B., 154
Convexity, 151

ndex Facial, 151

Frankfort mandibular incisor, 158
Fnnnkfort mandibular plane, 158
lncisor mandibular plane, 158 Incisor
occksal plane, 151 Inter incisal, 151
Lower incisor to N-B, 1.37
Mandibular plane, 154 Occlusal
plcne, 154 S.N A, 154 S.N.B, 154
A point, 147 Upper ircisor to N - A, 157 Y-axis, 151
Abnormal eruptive path, 93 Abnormal lobiol Ankyloclossia, 52, 127 Ankylosis, 94 Anodontia,
frenum, 91,386 Abnormcl path cf closure, 85-86 Anterior bite plane, 437 Anterior crossbite,
129 Abutment, 225 Acid etch, 307 75, 407, 423, 428-429, Anterior nasal spire, 148
Ackerman - Praifit clossrication, 79 Anterior open bite
Acrylic, 482 Classification, 415
Activator Dental, 416-417 Etiology,
Advantages, 339 415-416 Features, 417-418
Construclion Bite, 339 Skeletal, 417-418
Treatment, 418-420
Contraindications, 338
Anthropoid space, 41 Apical
Disadvantages, 339
base, 462 Apoliances
Fabrication, 341
Active, 27A
Indications, 339 Mono Fixed, 301 -328
gement, 341 Mods of Functional, 329
action, 339 Modification,
344 Trimming, 342
Active components
Fixed appliances, 309 Removob! e
appliances, 286-295 Adam's clasp
Advantages, 280
Construction, 281-282
Modifications, 280-283 Parts, 280
Synonyms, 280 Adenoid facies,
104 Age factors, 211-214 Aims of
orthodontics, 2-3 Alizarin, 12
Anchor bends, 437-438 Anchorage
Baker's, 207 Cervical,
206 Classifica'ion, 205
Cranial, 204 Definition,
203 Extra-Oral, 206
Facial, 204
Inter-Maxillory, 207
Intra-Moxil ary, 207
Intra-Oral, 206 Maximum, 210
Minimum, 210 Moderate, 210
Multiple, 208 Muscular, 207
Occipital, 204 P'onning, 209
Recioroccl, 205 Rein;on:ed, 208
Simple, 205 Sirgle, 208
Sources, 203-204 Stationary,
205 Andreser app lio nee (see
 .'v'-v■•.vv-v vv-
jp»!!

Orthodontics - The Art and Science

Myofunctional, 329 Advantages, 307

Ortnopaedic, 365-376 Passive, Disadvantages, 309
274 Removable, 277-300 Arch Procedure, 309
perimeter analysis, 175 Arch Bone
wires Deposition, 14, 190-192
Basic requirements, 314 Beta Formation, 15-16
titanium, 315 Classification, 314 Resorption, 14, 192
El g i loy, 315 Gold, 314 Gold Remodeling, 14, 190
olloys, 314 Multi-stranded, 314 Bows
Nitinol, 315 Rectangular, 314
Short, 286
Round,314 Square, 314 Stairless
Long, 287
steel, 315 Arrowhead clasp (see
Split, 287
Adam's clasp) Asymmetry, 121
Reverse,
Attachments, fixed appliance Ball
287 Fitted,
end hook, 312 Brackets, 310-311
Button, 312 Cleat, 312 Eyelet, 289 Mills,
312 288
Lingual attachments, 312 Robert's,
287-288
iViolartubes, 311
High, 289
B Brackets
Begg, 310 Bondable,
B point, 147 310 Ceramic, 311
Baker's anchorage, 207 Classification, 310
Backward path of closure, 129 Edgewise, 310
Balancing extractions, 268 Metallic, 311 Plastic,
Ball end clasp, 285 311 Ribbon Arch,
Band and bar space maintained 225 310 We Ida b le, 310
Band ond loop space maintained 223 Branchial arches, 27
Band and spur retainer, 470 Breathing
Banding Oral, 129 Nasal,
Indications, 303 129 Oro-Nosal, 129
Procedure, 303-305 Bands, Bruxism, 106
309-310 Basal metabolic rale, Buccinator mechonism, 52-53
116 Base formers, 479 Base Butler's field theory, 489
Buttress, 53-54
of model, 478 Base plate,
295, 298-299 Basion, 147
Basion-nasion plane, I 49 Begg
Appliance, 322 Retainer,
466-467 Belchier, 12
Bennett's classification, 78 Benninahoff,
53 Beta hypothesis, 101
Bimoxillory protrusion, 70
Biomechanics, 181-194 Bionator
Bite registration, 357 Class III
appliance, 356 Indications, 357
Open biteoppliance, 356 Stcna'ard
cppliance, 356 Types, 355 Bite
plane
Anterior, 299, 473 Posterior,
299, 418 Bite registration, 332
Bjork, 143
Bolton's analysis, 178-179 Bolton's p
lone, 149 Bonded herbst appliance, 359
Bonding
 c Management, 444-448 Passive
obturator, 445 Pre-surgical
Comouflage, 402 orthopaedics. 445 Problems
Conine associated, 443 Surgical lip
Indications for extraction, 264 closure, 446 Surgical palate
Irr pactions, 264 Retraction, 327 closure, 446 Clinical examination,
Redactors, 292-294 Cantilever 120-128 Clip on retainer, 467
spring Single, 290 Double, 291 Coffin springs, 256, 430 Coil
Corey's analysis, 175 Carpel index, springs
161 -1 74 Case C., 5
Cast (see study models) Closed, 318 Open, 318
Ca'lan's appliance Cold cure acrylic, 482-488
Indications, 429 Compensating extractions, 268
Disadvantages, 429 Centre Complex tongue thrust, 103
of Composite resin, 307-309
Resistance, 196 Computers, 491-502 Concave
Rototion, 197-198 profile, 122 Condyle, 36
Centric Condylion, 148 Congenital
Con'acts, 58 Holding cusps, 56 deformities, 83-84 Construction
Occlusion, 57 Relation, 57 Cephalo - bite, 332 Convex profile, 122
caudal growth gradient, 10-11 Coronoid process, 36 Cortical
Cephalometric analysis Downs, 151-153 drift, 15 Corticotomy, 454
Steiner, 153-157 Tweed, 158 Wits, 158 Cosmetic surgery, 460
Cep'nalometrics
Equipment, 144 Landmarks,
145-148 Lines or planes, 148-150
Uses, 144 Ceramic bracket, 311
Cervical head gear, 368 Chief
complaint, 116 Chin cap/cup
Indications, 375 Types,
375 Chronologic oge, 211
Circumferential clasp, 279
Circumfe'entiol 5uprccrestal
fibrotomy, 454 Clasps
Adam's, 280-283
Ball- end, 285
Circumferential, 279
Crozat, 286
Jackson's, 280 Mode
of action, 278
Requirements, 279
Schwarz, 286
Southend, 283
Triangular, 285 Class
I, 70
Class II, division 1 Biology,
379 Features, 371,397
Role of extraction 402
Skeletal features, 399
Treatment, 300-405
Class II, division 2
Features, 72, 405
Treotment, 405-406
Class III
Diagrosis, 409 Etiology, 409
Feotures, 407-409 Skeletal featums,
409 Treatment, 413-414
Classification of etiology of
malocclusion Gmber's, 82 Mayers,
82
White and Gardiner, 82
Classification of
malocclusion Ackerrranand
Pro^h, 78-80 Angles, 69-77
Bennett, 78 Lischer, 77
Simon, 78 Cleft lip& palate
Classification, 441-443
Embr^logicol backgrojnd, 438
Etiology, 440 Incidence, 431
 mm
Orthodontics - The Art and Science
Couple, 196 Cranial Disto-occlusion, 71 Downs
base Flexure, 24 analysis, Drift, 15
Postnatal development, 29-31
Prenatal development, 21-24 Crib (see E
hobit breaker) Crossbite
Ectopic eruption, 93
Anterior, 423
Edge wise, 321
Classification, 423
Elastic chain, 317
Dental, 425 Functional,
Elastic thread, 317
425 Posterior, 423
Elastics, 315
Skeletal, 424 Treatment,
Elcstomeric separators, 319
428-432 Cross section
Electromyoaraphs , 133 Elgiloy,
wires, 314 Crowding
315 Embryo, 21 Enamel
Diognosis, 393 Etiology, 392
Decalcification, 309
"Treatment, 393-394 Crown and bar
Endochonc'rial ossification, 15
space rraintainer, 225 Curve of
Endocrine, 94-95 Enlow's
Monson, 57
Counterpart principle, 19 V principle,
Spee, 56
19 Ennudeotion of premolar, 231
Wilson, 57
Environmental, 84-85 Epidemiology of
D
malocclusion, 1 09-1 14 Epigenetic, 19
Epiphysis [see
Data
Derived, 12 hond-wristX-Rays) Eruption
Direct, 12 Indirect, 12 Dates, 45-46
Decay Theories of, 182 Etiology
Proximo', 94 General factors, 82
Occiusol, 94 Local factors, 82
Decompensanon, 456 Excessive force, 185
Deep bi'e Expansion
Definition, 433 Incomolele,
433 Complete, 433 Classircation,
433 Skeletal, 434 Dental, 434
Diagnosis, 435 Treatmen-,
437-438 Delaire face mask, 374
Delayed eruption, 93 Delayed
resorption, 92 Dental age, 213
Dental casr(see study models)
Dental lamina, 37 Dentition
Deciduous, 41-42 Mixed,
42-48 Permonent, 48 Dentofacial
orthopaedics
Extra-oral cpp'iances, 366-376
Functional appliances, 329-365
Denotation, 395-396 Development, 8
Development of
Cranial base, 21-23,29-31 Dentition,
37-39 Mandible, 27-29,33-36 Maxilla,
24-27,31-33 Palate, 26-27 Dewel's method
of serial extraction, 231 Dewey, 77
Diagnosis, 115-142 Diagnostic aids,
115-116, 138-142 Diagnostic set up,
130-131 Diastema, 385-390 Dilacerotion,
90 Disking (See proximal stripping)
Displacement

Primary, 15 Secondary, 15
Distal shoe space maintained 224
Distalization
Intra-oral methods, 243
Extra-oral methods, 243
 Arch, 247-258 Dental, 256 Rapid, Removable, 101 Fixed,
247-256 Screws, 254 Skeletal, 247 Slow, 101 Habits, 97-108 Ho
256 Experi me nta I o p proaches, 12 Extra nd-wrist
- oral anchorage Cervical, 368 Occipital, Anatomy, 162 Radiograph,
369 Cranicl, 369 Facial, 371 Extraction 162-171 Howley's appliance, 466
Canire, 264 First molar, 266 First
Head cop, 366
premolars, 265 Incisors, 262 Need
for, 260 Second mo lor, 267 Second
premolars, 265 Serial. 228-233
Therapeutic, 260 Third molar, 268
Extrusion, 199

Face bow
Inner bow, 366 Outer bow, 366
Junction, 366 Face mask
Sio-rrechanicol considerations, 372
Delaire, 374
Hickham, 374
Indications,371
Parts of, 372
Petit, 375
Site of anchorage, 372 Tubinger, 374
Facial
Angle, 150 Divergence, 123 Form,
121 Plane, 149 Profile, 121 Symmetry, 122
Factors affecting growth, 8-9 Fetal
moulding, 84 Finger spring, 291 Finger
sucking, 97 Fixed
Appliance, 301-328 Retainers,
468-470 Fluoride, 240 Foetal period, 21
Forces
Continuous, 201
Intermittent, 201
Interrupted, 202 Frankfort
horizontal plane, 148 Fronkel appliance
Construction bite, 354 Indications,
349 Mode of action, 349 Philosophy, 348
Types, 349 Free-way space, 128
Frenectomy, 254 Frenum
Labial, 127 Lingual, 127
Frontal resorption, 1 83
Functional appliance
Activator, 338-348
8iorotor, 355-357 Cation's,
428
Function Reaulctor, 348-355 Herbs',
358-361 Jasper juniper, 361 -364 Up
bumper, 337 Sved, 208
Twin block, 357-358 Vestibular
screen, 335-337 Functional
Examination, 128-130 Matrix theory,
18-19 Fusion of
Processes, 24-26 Teeth,
89

G
Genetic transmission, 487
Genetics, 485-490 Gnathion, 148
Gonion, 148 Growth Definition, 7
Differential, 10 Factors offecing, 8-9
Modification, 401-402, 413 Spurt, 9-10
Guidance of eruption, 228-233 Gum pad,
40

Habit breaker
516 Orthodontics - The Art and Science
Heed gears
Cervical, 361 Combination,
361 Occipitcl, 361 Helical canine
retractor, 293 Herbs" appliarce
Incicctions, 359 Advartages, 359
Disadvantages, 361 Horded. 359
Banded, 359 Descriorion, 359
Treatment effects, 359 Heredity,
81-83 High oull heed cears, 361
History
Of Orthodontics, 4-6
Recording, 116 Horizontal
plcnes
Basion-Nosion, I'19 F-H
alane,' 48 Mandibular,
148 Occlusal plone. 1 48
Palatal, 148 S-N plone,
148 Hvolinization, 183
Hyrox, 252
Mccrocontia, 89 Mclformed teeth
Dilaceration, 90 Fusion, 89
Mulberry molars, 90 Peg shaped
laterals, 90 Mclocclus'on
Classification. 63-80
Epidemiology, 109-114 Etiology,
81-96 Indices, 110-114 Mandible
Postnatal development, 33-36 Prenatal
development, 27-29 Mandibular
Plane, 148 Process, 27 Mostication,
49-50 Moture swa I lowing, 50-51 Moxilla
Expansion of, 247-258 Postnatal
development, 31-34 Prcnala! development,
24-27 Maximum anchorage, 210 Mechanics,
195-202

Ideal occlusion (See Andrews six keys)

Impactions, 450-453
Implants, 13
Ircisal liability, 44
Irclined plcnes
Lower anterior, 208 Irdices of
malocclusion, i 10-1 14 Infantile
swallowing, 50, 102 Inner bow, 366
Inter-maxillary fixation, 460
Inter-rraxi.lary onchorage, 20/ Irlerceplive
orthod or tics Definition, 227 Procedures,
227-238 Intermittent forces, 201
Interrupted force, 201 Intra - maxi I lory a
n c h orag e, 20 7 Inlra-orol periapical
films, 134 Intrusion, 199

Jackson's clasp, 280 Jackson's mad, 3

K

Kesiing's set uo, 130-132 King s ley, 4

KorkhaLS o nal ys is, 178

Lab al bows (see bows} Labial trenurn,

127 Landmarks, 145-148 Lateral palh ot
closure, 129 Late rol sulcus, 40 Latex
elas-'cs, 3" 5 Leeway space, 44 Ligation,
312-313 Ligoture wire, 312 Lines,
cephclcmetric, 148-150 Lingual frenum,
127 Lingual non-occlusion, 424 Lip
Bumper. 207
Compctenca, 125 lischer's
classification, 77 Local factors, 82
Longi'udinai studies, 11 Loops, 327

M
Meckel's cartilcge, 27-28 Med'cal history, Orhodontic loolh movement, 183-194
116 Memo I is, 126' Mento-lobial suicus, Orthodontics
126 Menton, 148 Mesial Definition, 1
Displacement, 15,31 Need for treatment, 1 -3 Services
Migration, 182 Step, 43 offered, 3-4 Orthognathic surgery, 449-460
Tipping, 66 M.esioocclusion,
Orthopaedic aoplionces, 365-376
75 Methods of
Osteoblasts, 190 Osteoclasts, 192
Gaining spoce, 239-246
Gathering growth dota, 11 Studying Osteogenesis, 15-16 Overbite, 127
bone growth, 12 Microdontia, 89 Mid Overset, 127
pa'atal suture, 248 Midline diastema
Diagnosis, 386 Etiology, 385-386
Retention, 386 Treotment, 388-390
Milwaukee brcce, 85 Minimum
anchorage, 210 Mixed dentition,
40-48 Mixed dentition analylis, 1 79
Model analysis, 175-180 Model
surgery, 460 Models, 130, 478
Moderate anchorage, 210
Mocifica*ion of growth, 401-402
Moment, 197 Monobloc, 338 Moss, 17
Mouth breathing, 104-107
Multistranded wires, 314
Muscle exercises, 236-237
Musculo r anchorage, 207
Musculature school, 462
Mutation, 487

Myofunctional appliance, 329-364 N

Nance holding arch, 224
Nance method of serial extraction, 231
Nasal pits, plocode, 26
N aso I respiro'ion, 129
Nasol septum, 1 7
Nasal spine
Anterior, 148 Posterior,
148 Nasion, 147
Nasion-basion line, 149
Nasolabial anglo, 126 Natal
teeth, 41 Natural morkers, 1
4 Neck strap, 366
Neonatal teeth, 41 Neurotropism, 20
Nickel titanium wire, 315 Nitinol, 315 Non
vital teeth, 93 Norma' occlusion, 55-62
Norwegian appliance (see activator)

O
Observation, 12 Occip'.'al
nead gears, 369 Occlusal
olane, 148 Occlusal school,
462 Occlusion, 55 Open
bite. 415-422 Opinion, 1 1
Opr'mum orhodontic force, 185-186 Oral
habits
Bruxism, 106-107 □ossification, 98
Lip biting, 107 Mouth breathing, 105-107
Noil biting, 107 Thumb sucking, 97-102
Tongue trusting, 102-103 Oral hygiene,
270-274 Oral respira'ion, 129 Oral screen,
335-337 Orbitale, 147 Ort'no-donlic
appliance Active, 274 Classification, 271
Definition, 271 Extra-ora', 365-376 Fixed,
301-328 Functional, 329-364 Passive, 274
Removable, 277-300 Requirements,
2/4-276 Orthodontic bonds, 309
Palate, 26-27, 127 148 Reinforced anchorage, 208
Panoramic radiograph 136 Relapse
Parial denture space Causes, 462-463 Definition, 461
rnaimainer 221 Removable appliance Advantages, 272.
Passive applionce, 274 Components, 278 Definition, 271
Path of closure Disadvantages, 222 Removable space
Forward, 129 Lateral, maintainors, 220-222 Reproximation,
129 Posterior, 129 Peg shaped 239-241 Resins
loterals, 90 Periapical radiographs, Cold cure, 482
134 Pericsion, 454 Periodontal Heat cure, 482
Ligament, 186 Periosteum, 332 Resorption of
Permanent dentition, 48 Phosphoric Bone, 192
acid, 379 Photographs, 132-133 Restorations
Piezoelectric theory, 189 Planes, Occlusal, 94 Proximal, 94
cephalometric, 148-150 Planning Retained infantile swallow, 50
treatment, 377-384 Pogonion, 148 Retainers
Pont's analysis, 1 77 Porion, 147 Begg, 466
Positioner, Kesling's, 468 Post-surgical Clip-on, 467
onhodontics, 460 Definition, 466
Posterior
Crossbite ,429 Nasal spine,
148 Open bite, 420 Pre-surgicol
orthodontics, 456 Preformed
bands, 309 Premature loss of teeth,
91-92 Prenatal development
Cranial base, 21-24 Mandible,
27-28 Maxilla , 24-27 Palote, 25
Pressure-tension theory, 188
Preventive orthodontics Definition,
215 Procedures, 215-226 Primary
dentition, 41-42 Primate space, 41
Profile, facial
Concave, 122
Convex, 122 Straight,
122 Prolonged
retention, 466
Prostaglandins, 192
Proximal cories, 94
Pseudo Class III, 75
Psychological
considerations, 101
Pubertal, 9
Q

Quad helix, 257-258 Quantitative

measurements, 12

Radiographs,
Bitewing, 135 Intro-oral, 134-136
Extra-oral, 136-138 ' '
Cepholometric, 137, 143-160
Hand-Wrist, 137, 161-172
Occlusal, 135 Panoramic, 136
Peri-apical, 134 Ranking, 12
Ropid maxillary expansion j
Appliances used, 251 -252
Applied anatomy, 248
Diagnosis, 249 Effects,
249-250 Indications, 248-249
Screw, 254 Rating, 1 2
Reciprocal anchorage, 205
Rectongulcr wire, 314 Regaining
space, 234-236 Registration point,
 Pi 519
Index
•
^'ff^'v: ' -" ' • ■ •
• Fixed, 468-470 Hawley's, 466 Ideal Supplemental teeth, 85-86
requirements, 466 Invisible, 468 Wrap Supraeruplicn, 434 Surgical
around, 468 Retention, 461 Reverse orthodontics Definition, 449 Major
curve of Spee, 438 Reverse head gear procedures, 454-460 Minor
(see face mask) Ribbon arch hrcckets, procedures, 449-454 Sufural
310 Rotation ■ growth, 31 Sved appliance, 208
Retention, 396 Sv/a I lowing
Treatment, 394 Round Infantile, 50
wire, 314 Mature, 50
Symmetry, 121
Symmetry of face,
121 Symphysis, 35
Scissors bite, 424 Scott's Synchondrosis
hypothesis, 16-17 Screws Intra-sphenoid, 31
Pilch, 254 Intra-occipitol, 31
Structure, 254 Secular Spheno-ethmoid, 31
trends, 8 Sella, 147 Spheno-occipital, 30
Sella nasion plane, 148 Semi Ion
g itu d no I studies, 11 Separators
Brass, 319 Dumbell, 319
Elas'omeric ring, 319 Teratogens, 440
Kessling's, 320 Sequence of Theories of growth
eru ption ,48 Serial extraction Cartilaginous, 16-17
Advantages, 229 Functional matrix, 18
Basis, 228 Genetic, 16
Contra Indications, 228 Diagnosis,
.229 Disadvantages, 229 Indications,
228 Methods of, 231-233 Shape
memory, 315 Shaoe variations of teeth,
89-90 Sicher's theory, 16 Simian space,
41 Simon's classification, 77-78 Simple
anchorage, 205 Simple tongue thrust,
103 Single tooth crossbite, 423 Six keys
to normal occlusion, 59-62 Size
variations of teeth, 86-89 SNA, 154
SNB. 154 Space maintainors Definition.
219 Fixed, 222-225
Functional, 220 Removable,
220-222 Types, 220 Spacing
Diagnosis, 391 etiology, 391
Treatment, 391-392 Speech, 130
Springs
Cantilever, 290-292
Classification, 290 Coffin,
292 Finger, 290
Ideal requirements, 289 T
Spring, 292 Torqueing, 318 Z
Spring, 291 Stabi'ity, 377 Stainless
steel wires, 314 Stationary
anchorage, 205 Steiner analysis,
153-157 Study models, 130,478
Submerged teeth, 94 Subspinale,
148 Suckling, 50
Supernumerary teeth, 85-86
Supplemental diagnostic aids, 116
 Sutural, 16 Van Method of serial extraction,
Limborgh, 18 Therapeutic 231 Twin studies, 489-490 Types of
Body, 120-121 Head, 121
Orthodontics - The Art and Science
extractions, 242, 259-269 Wrist ossificction (see hand wrist
t
Three prong pliers, 258 Through the bite
elastics, 317 Thumb sucking, 97-102 X-Raysi
Tipping, 193 Tongue
Blade, 428 Thrusting, 102-103 Tie, X
127 Tooth
Bud, 37
X- Rays {see radiographs)
Movement, 181-194 Torque, 321
Torquing aLxillory, 318 Trajectories of
Y
force, 53-54 Transpalctal arch, 224
Transverse relationship, 67 Treatment
Y axis, 1 5 1
planning, 377-384 Triad of factors, 99
Trimming of appliances, 299-484
Z
Tweed's
Analysis, 158
Z spring, 291

Ugly duckling stage, 48 Undermining Venn diagram, 79 Vertical

resorption, 185 Unfovourcble sequelae of malocclusion, 67 Vestibular
Malocclusion Unilateral screen, 335-337 Visual treatment
Clefts, 441-442 objective, 335 Vital staining, 12-13
Crossbite, 423-424 U p M*
righting springs, 317 .U-J ^JSSll £
Useful habits, 98
jLJi'i wL
1 ,<r
^ S j "'' j >J^I nl Vi JLSIMI Jji

Wax bite (see bite registration)

Wilkinson's extraction, 267
Wires {see arch wires)

-2
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3. Surgical correction

Growth modification
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