logy of Malocclusion

task. A number of classifications of etiologi~

treatment of various malocclusions. factors of malocclusion have been put forward
The orthodontic
Etiology speciality is the
of malocclusion deals with
study of (refer to table 1).
its cause or causes. Malocclusion can occur due Graber has classified the etiological

to a number of possible causes. Broadly speaking factors as local and general factors. The local
malocclusions are caused by either genetic factors factors responsible for malocclusion produce a
or by environmental factors. Comprehensive localized effect confined to one or more adjacent

orthodontic management involves identification or opposing teeth. The general factors on the other
of the possible etiologic factors and an attempt hand are those that affect the body as a whole
to eliminate the same. Although it may not be and have a profound effect on the greater part of
possible to eliminate the cause in most cases of the dento-facial structures.

malocclusion, it nevertheless is of value in

HEREDITY
preventive and interceptive orthodontic
procedures where a possible malocclusion is
In everyday life, we come across quite a number
prevented or intercepted by timely removal of the
of families where the inmates have a lot of
cause.
resemblance,,"Jhus it is quite logical to assume
Development of normal dentition and
that offsprings inherit quite a few attributes from
occlusion depends on a number of interrelated
their parents. Heredity has for long been attributed
factors that include the dentoalveolar, skeletal
as one of the causes of malocclusion.
and the neuromuscular factors. Thus localization
The child is a product of parents who
of the possible etiology may be a very difficult
 Table 1

MOYER'S CLASSIFICATION
b. Tongue thrusting
c. Lip sucking and lip biting
1. Heredity d. Posture
a. Neuromuscular Systellt e. Nail biting
b. Bone f. Other habits
c. Teeth 6. Diseases
d. Soft Parts
a. Systemic diseases
2. Developmental defects of unknown origin b. Endocrine disorders
3. Trauma c. Local diseases
a. Prenatal trauma and birth injuries L Nasopharyngeal diseases and disturbed
b. Postnatal trauma
respiratory function
ii. Gingival and periodontal .
disease
4. Physical a.
agents
Premature extraction of primary teeth iiLTumors
b.Nature of food iV.Caries
5. Habits 7. Malnutrition
a. Thumb sucking and finger sucking

WHITE AND GARDINER'S CLASSIFICATION 4. Prolonged retention of deciduous

teeth

A. Dental base abnormalities 5. Large labial frenum

6. Traumatic injury
1. Antero-posterior malrelationship
C. Post-eruption abnormalities
2. Vertical malrelationship
1. Muscular
3. Lateral malrelationship
a. Active muscle force
4. Disproportion of size between teeth
and basal bone b. Rest position of
musculature
5. Congenital abnormalities
c. Sucking habits
B. Pre-eruption abnormalities
d. Abnormalities in path of
1. Abnormalities in position of
closure
developing tooth germ
2. Premature loss of deciduous teeth
2. Missing teeth
3. Extraction of permanent teeth
3. Supemumerary teeth and teeth
abnormal in form

GRABER'S CLASSIFICATION
g.Respiratory abnormalities [mouth
GENERAL FACTORS
breathing etc.,.]
h. Tonsils and adenoids
1. Heredity L Psychogenic tics and bruxism
2. Congenital 7. Posture
3. Environment 8. Trauma and accidents
a. Pre-natal [trauma, maternal diet, German
. measles, maternal metabolism etc.,.] LOCAL FACTORS
b. Post natal [birth injury, cerebral palsy, T.M.J. 1. Anomalies of number :
injury.] Supernumerary teeth,
4. Pre-disposing metabolic climate and disease Missing teeth [congenital
a. Endocrine imbalance absence or loss due to
b. Metabolic disturbances
accidents, caries, etc.]
c. Infectious diseases 2. Anomalies of tooth size
5. Dietary problems (nutritional deficiency) 3. Anomalies of tooth shape
6. Abnormal pressure habits and functional aberrations 4. Abnormal labial frenum : mucosal barriers
a. Abnormal sucking 5. Premature loss of deciduous teeth
b. Thumb and finger sucking 6. Prolonged retention of deciduous leeth
c. Tongue thrust and tongue sucking 7. Delayed eruption of permanent teeth
d.Up and nail biting 8. Abnormal eruptive path
e.Abnormal swallowing habits [improper 9. Ankylosis
deglutition] 10. Dental caries
f. Speech defects 11. Improper dental restoration
 ..""' ..ilt~~t~cili~~~! Etiology of Malocclusion

issimilar genetic material. Thus the child h. Frenum: The size, position and shape of the
inherit conflicting traits form both the parents frenum is said to be genetically influenced. Thus
'ng in abnormalities of the dentofacial region. malocclusion such as midline diastema that may
other reason attributed for genetically be due to abnormalities of the frenum are to a
rmined malocclusion is the racial, ethnic and large extent determined genetically.
regional inter-mixture which might have led to According to Harris and Johnson a
co-ordinatedinheritance of teeth and jaws. number of craniofacial parameters showed
According to Lundstrom there exists a significant genetic influence. These include the
umber of human traits that are influenced by following distances: sello - gnathion, sella - point
e genes that include: A, sella - gonion, nasion - anterior nasal spine,
articulare - pogonion, bizygomatic width, anterior
· Tooth size : The size of the dentition is to a facial height.
rge extent determined by genes. Abnormalities As so many traits show a strong genetic
of tooth size such as microdontia and macrodontia pattern a number of malocclusions can be partly
are attributed to heredity~ or solely attributed to genetic factors. These genetic
traits can be further influenced by existing pre-
· Arch dimensions : The dental arch length
and arch width are believed to be inherited. natal or post-natal environmental factors.

c. Crowding / Spacing: Crowd.ing and CONGENITAL DEFECTS

spacing of teeth are believed to be of genetic
origin. Most of these conditions are believed to Congenital defects or developmental defects are
be a result of uncoordinated inheritance of arch malformations seen at the time of birth. They may
ength and tooth material. be caused by a variety of factors including genetic,
radiologic, chemical, endocrine, infections and
· Abnormalities of tooth shape: Anomalies
mechanical factors.
oftooth shape such as the presence of peg shaped
The congenital abnormalities that cause
rals is another trait that shows high genetic
malocclusion can be broadly classified as general
predisposition.
and local congenital abnormalities.
e. Abnormalities of tooth number : Presence
of either more or less number of teeth can also be General congenital factors
erited. This includes condition such as
a. Abnormal state of mother during pregnancy
nodontia and oligodontia. b. Malnutrition

-. Overjet: The horizontal overlap of the upper c. Endocrinopathies

lower dentition referred to as the overjet is d. Infectious diseases

-eyed to be genetically influenced. e. Metabolic and nutritional disturbances

f. Accidents during 'pregnancy and child birth
Inter-arch variations: Discrepancies in
g. Intra-uterine pressure
nsverse, sagittal and vertical planes between
h. Accidental traumatization of the fetus by
pper and lower jaws can be inherited.
external forces
84 Orthodontics - The Art and Science

Local congenital factors Cleidocranial dysostosis

a. Abnormalities of jaw development due to This is a congenital condition characterized by

intra-uterine position . unilateral or bilateral, partial or complete absence
b. Clefts of the face and palate of the clavicle. The patient may exhibit the
c. Macro and microglossia following features:
d. Cleidocranial dysostosis a. Maxillary retrusion and possible mandibular
The following are some of the congenital protrusion
conditions frequently encountered by the b. Over retained deciduous teeth and retarded
orthodontist. eruption of permanent teeth
c. Presence of supernumerary teeth
Clefts of the lip and palate d. Presence of short and thin roots

Clefts involving the lip and palate are the most

Cerebral palsy
commonly seen developmental defects that occur
as a result of non- fusion between the various This is a condition where in the patient lacks
embryonic processes. Cleft patients may exhibit a muscular co-ordination. It usually occurs due to
number of dental problems including missing birth injuries.The uncontrolled and aberrant
teeth, mobile teeth, rotations, cross bite, etc., muscle activity upsets the muscle balance resulting
(discussed later as a separate chapter). in malocclusion.

Congenital syphilis ENVIRONMENT

Syphilis of congenital origin is transmitted from

Various pre-natal and post-natal environmental
the infected mother to the child. The child exhibits
factors can cause malocclusion.
one or more of the following features:
a. Hutchinson's incisors Prenatal factors
b. Mulberry molars
c. Enamel deficiencies The fetus is well protected against injuries and
nutritional deficiencies during pregnancy. But
d. Extensive dental decay
there are certain factors, the presence of which
e. The maxilla may be smaller in size relative to
the mandible can result in abnormal growth of the oro-facial

f. Anterior cross bite region thereby predisposing to malocclusion.

Abnormal fetal posture during gestation
Maternal rubella infections is said to interfere with symmetric development of
the face. Most of these deformities are temporary
Maternal rubella infections during pregnancy is
and usually disappear as age advances.
believed to cause widespread congenital
Hie other prenatal influences include
malformations in the child. The following are
some of the feature that can be seen. maternal fibroids, amniotic lesions, maternal diet
and metabolism.
0. Dental hypoplasia
Maternal infection such as German
b. Retarded eruption of teeth
measles and use of certain drugs during
c. Extensive caries
pregnancy such as Thalidomide can cause gross
congenintal deformities including clefts.
teeth are called supplemental teeth.
A frequently seen supernumerary tooth is
the mesiodens which occurs in the maxillary
midli.ne(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 spacing.
Supernumerary teeth can also occur in the Fig 2 (A) A 10 year old showing unerupted
premolar or third molar regions. supernumarary tooth in the upper central incisor
region. blocking the eruption of the central incisor
Supplemental teeth are most often seen
(B) Radiograph of the same patient.
in the premolar and lateral incisor region. It is
not uncommon to find an extra lower incisor. The
supernumerary and supplemental teeth cause c. Mandibular second premolars
non-eruption of adjacent teeth (fig 2)and can d. Mandibular incisols
deflect the erupting adjacent teeth into abnormal e. Maxillary second premolars
locations. In addition extra teeth occupy arch Absence of teeth can be unilateral or

length intended for normal complement of teeth. sometimes bilateral. They may occur along with
Thus they can result in crowding and rotations of other anomalies such as presence of extra teeth.
adjacent teeth. Unerupted supernumerary teeth Absence of one or more teeth predispose to
spacing in the dental arch. The adjacent teeth
pose a risk of cystic transformation) migrate and therefore cause abnormal location
Missing teeth and axial inclination of teeth (fig 5). Absence of

Congenitally missing teeth are by far more a permanent tooth quite often results in over-
retained deciduous teeth.
common than supernumerary teeth and can occur
in either of the jaws. The following are some of
ANOMALIES OF TOOTH SIZE
the commonly missing teeth in decreasing order
of frequency:
In order to have normal occlusion, there should
a. Third molars
be harmony between the tooth size and arch
b. Maxillary lateral incisors
length and also between the maxillary and
 A B

G H
~ 3 W & (B) Supplemental lateral incisor (C) & (D) Supernumerary tooth seen erupting palatally
Ej&1r.)Supplementallateral incisor (G) & (H) Macrodonticsupernumerary incisor in the midline
 _~ ~ __~ ~ __ ••_ • ._ •••• _u ••• ~"_"'_ ••• _ .n •• m ._. ._

88 Orthodontics • The Art and Science

c D

E F

H
Fig 4 (A) & (B) Missing lower incisor (C) & (D) Bilateral missing upper lateral incisors (E) & (F) Bilateral
missing lower second premolars (G) & (H) Bilateral missing upper lateral incisors.
 Fig 5 (A) and (B)
Upper left lateral
incisor congenitally
missing. Note the
resultant spacing of
the maxillary arch and
non coincident of
upper and lower
midlines. The
maxillary right lateral
is also microdontic.
(e) Radiograph of the
same patient.

mandibular tooth size. An increase in size of ANOMALIES OF TOOTH SHAPE

teeth results in crowding while, smaller sized teeth
predispose to spacing. A commonly seen anomaly Anomalies of tooth size and shape are very often
is the presence of smaller sized maxillary lateral interrelated. Abnormally shaped teeth predispose
incisors. Anomalies of size can also occur in the to malocclusion. The following are some of the
mandibular premolars. Fusion between two examples of frequently seen tooth shape
adjacent teeth or between a supernumerary tooth anomalies:
and a normal tooth may predispose to a. The presence of peg shaped maxillary lateral
malocclusion. Variations in size of tooth can occur
incisors is often ac~ompanied by spacing and
along with variations of shape. m ig ration of teeth (fig 6).
The size of teeth is to a large extent b. Another anomaly of tooth shape is the
determined genetically. Thus most of these presence of an abnormally large cingulum
conditions show a positive family history. on a maxillary incisor (fig 7). The presence

af an exaggerated cingulum prevents
establishmentaf narmal averbite and averjet.
The invalved taath is usually in labiaversian
due to' the farces af acclusian.
c. The mandibular secand premalars may rarely
have an additianal lingual cusp, thereby
increasing the mesia-distal dimensian af the
taath.
d. Cangenital syphilis is aften assaciated with
Fig 6 (A) And (B) Upper left lateral incisor
microdontic . Reduced tooth material results in
spacing of the dentition. (C) and (D) Macrodontic
maxillary right central incisor. E) Lower peg incisors.
•
presenceaf abnarmal taath farm. Pegshaped
laterals and mulberry malars are classical
findings in such patients.
e. Anamalies af shape can accur as a resulto'
develapmental defects like amelogenes·
imperfecta, hypoplasia of teeth, fusion on
gemination.
f. Dilaceration is described as a condition
characterized by an abnormal angulatio
between the crown and root of a tooth or
angulation within the root. It usually occurs
due to a blow to a deciduous tooth which .
transmittedto the underlying permanenttoO'
bud. Dilacerated teeth fail to erupt to normal
level and can thus cause malocclusion.
Fig 9 (A) and (8) Premature loss of deciduous second molar has resulted in mesial migration of the first permanent malo
Second premolar has erupted lingually due to inadequate space.

malocclusion. PROLONGED RETENTION OF

b. The earlier the deciduous teeth are extracted DECIDUOUS TEETH

before the successional teeth are ready to

This refers to a condition where there is undue
erupt, the greater is the possib!Jity of
malocclusion. retention of deciduous teeth beyond the usual

c. In a person having arch length deficiency or eruption age of their permanent successors. A

crowding the early loss of deciduous teeth deciduous tooth that fails to undergo resorption

may worsen the existing malocclusion. will prevent the normal eruption of its permanent
successor.
Prolonged retention of deciduous
anteriors usually results in lingual or palatal
eruption of their permanent successors.
Prolonged retention of buccal teeth results in
eruption of the permane~t teeth either bucally or
lingually or may remain impacted within the jaws.
Quite often certain parts of the deciduous
rootswhich are 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 deflect or block the
adjacent erupting teeth.
The following are some of the reasons
for prolonged retention of deciduous teeth:
a. Absence of underlying permanent teeth(fig
10, 11).
b. Endocrinal disturbances such as
hypothyroidism
c. Ankylosed deciduous teeth that fail to resorb
Fig ) 0 Over-retained lower deciduous central incisors
due to congenital absence of the permanent central incisors d. Non - vital deciduous teeth that do not resorb
 Etiology of Malocclusion 93

fig 11 Lower deciduous second molar over retained due to congenital absence of lower right second premolar

ELAYED ERUPTION OF PERMANENT retained root fragments, or formation of a bony

TEETH barrier.
The maxillary canines develop almost
'e are a number of\feasons that can delay the
near th.e floor of the orbit and travel down to their
'on of permanent teeth. The following are
final position in the oral cavity. Thus they are
eofthem:
most often found erupting in an abnormal
Congenital absence of the permanent tooth.
position (fig 12).
Presence of supernumerary tooth can block
e erupting permanent tooth.
Presence of a heavy mucosal barrier can
revent the permanent tooth from emerging
into the oral cavity. A surgical incision in
ost cases accelerates the eruption.
Premature loss of deciduous tooth can result
in delayed eruption of the underlying
permanent teeth due to formation of bone
overthe erupting permanent tooth.
Endocrinal disorders such as hypothyroidism
can cause a delay in eruption of the
permanent teeth.
::
'resence of deciduous root fragments that
are not resorbed can block the erupting
permanent teeth.

ORMAL ERUPTIVE PATH

the causes of malocclusion is an abnormal

eruption which could be due to arch length Fig 12 Impacted maxillary canines. The maxillary canines
de&:iency, presence of supernumerary teeth, are frequently impacted and erupt in ectopic position.
94 Orthodontics - ThfZ Art and ScifZncfZ

ANKYLOSIS DENTAL CARIES

Ankylosis is a condition wherein a part or whole Caries can lead to premature loss of deciduous
of the root surface is direply fused to the bone or permanent teeth thereby causing migration of
with the absence of the (rttervening periodontal contiguous teeth, abnormal axial inclination and
membrane. This mosfoften occurs as a result of supra-eruption of opposing teeth.
trauma to the tooth which-perforates the Proximal caries that has not been restored
periodontal membrane. Ankylosis can also be can cause migration of the adjacent teeth into
associated with certain infections, endocrinal the space leading to a reduction in arch length.
disorders and congenital disorder such as A substantial reduction in arch length can be
cleidocranial dysostosis. Clinically, these teeth expected if several adjacent teeth involved by
fail to erupt to the normal level and are therefore proximal caries are left unrestored.
called submerged teeth (fig 13). At times these
IMPROPER DENTAL RESTORATIONS
teeth are totally submerged within the jaw and
therefore cause migration of adjacent teeth into
Improper dental restorations may predispose to
the space.
malocclusion. Over-contoured occlusal
restorations cause premature contacts leading to
functional shift of the mandible during jaw closure.
Under-contoured occlusal restorations can permit
the opposing dentition to supra-erupt. Proximal
restorations that are under-contoured invariably
result in loss of arch length due to drifting of
adjacent teeth to occupy the space. Poor proximal
contact also causes food lodgement and
periodontal weakening olf the teeth.

PREDISPOSING METABOLIC
CLIMATE AND DISEASE

A number of endocrinal disorders, infectious

conditions and metabolic disturbances can
predispose to malocclusion.

Endocrine Imbalance

Certain endocrinal disorders may result in

malocclusion. The following are some of the
endocrinal disturbances that can cause
Fig 13. Maxillary left first permanent molar is ankylosed. malocclusion.
Note the tooth is submerged and is infraocclusion with
the rest of the dentition_ Hypothyroidism : Hypothyroidism is
characterized by the presence of one or more of

features:
'on in rate of calcium deposition in
and teeth.
ed delay in tooth bud formation and
'on of teeth
carpel and epiphyseal calcification
deciduous teeth are often over-retained
the permanent teeth are slow to erupt
rmal root resorption
gularities in tooth arrangement and
crowding of teeth can occur
erlhyroidism : This condition
acterized by increase in the rate of
maturotion, and an increase in metabolic rate.
patient exhibits premature eruption of
• I ous teeth, disturbed root resorption of
deciduous teeth and early eruption of permanent
. The patient may have osteo- porosis which
-indicates orthodontic treatment.
oporathyroidism : This endocrinal
er is associated with changes in calcium
bolism. It can cause delay in tooth eruption,
tooth morphology, delayed eruption of
- • ous and permanentteeth and hypoplastic
rparathyroidism : Hyperparathyroidism
uces increase in blood calcium. There is
ineralization of bone and disruption of
ecular pattern. In growing children,
interruption of tooth development occurs. The
may become mobile due to lossof cortical
and resorption of the alveolar process.
bollc dIsturbances
rile diseasesare believed to slow down
of growth and development. These
'005 may cause a disturbance in tooth
eruption and shedding thereby increasingthe risk
Etiology of Malocclusion 95
of malocclusion.
Diseasesaffecting the oro-facial muscles
can 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 are more common in the
developing countriesthan in the developed world.
Nutrition related disturbances such as ricketts,
is
scurvy and beriberi can produce severe
malocclusion and may upset the dental
developmental time table.
POSTURE
Poor postural habits are said to be a cause for
malocclusion. Although not substantiated, they
may be associated with abnormal pressure and
muscle imbalance thereby increasing the risk of
malocclusion.
Children who support their head by
resting the chin on their hand and those who
hang their head so that the chin restsagainst the
chestare observedt~ have mandibular deficiency.
Poorpostureas a causeof malocclusion although
not proved may neverthelessbe an accentuating
factor for other ma locclusions.
ACCIDENTS AND TRAUMA
Children are highly prone to injuries of the dento-
facial region during the early years of life when
they learn to crawh~walkor during play. Most of
these injuries go unnoticed and may be
responsible for non-vital teeth that do not resorb
and deflection of erupting permanent teeth into
abnormal positions.
98 Orthodontics - Th~ Art and Sci~nc~

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