CLASSIFICATION OF MALOCCLUSION

INTRODUCTION
To understand a group of identities it is advisable to divide them into groups
and subgroups based on certain similarities. Classification of malocclusion is the
description of dento-facial deviations according to a common characteristic, or norm.
Various classifications are proposed by different researchers based on their
experiences and depending upon what they found to be clinically relevant.
Depending upon which part of the oral and maxillofacial unit is at fault, mal
occlusions can be broadly divided into three types:
• Individual tooth malposition.
• Mal-relation of the dental arches or dento-alveolar segments.
• Skeletal mal-relationships.

These three can exist individually in a patient or in combination involving each

other, depending upon where the fault lies-in the individual dental arch or the dento-
alveolar segments or the underlying skeletal structure.

INDIVIDUAL TOOTH MAL POSITIONS

These are malposition of individual teeth in respect to adjacent teeth within the
same dental arch. Hence, they are also called intra-arch malocclusions.
These can be of the following types:

MESIAL INCLINATION OR TIPPING

The tooth is tilted mesially, i.e. the crown is mesial to the root
DISTAl INCLINATION OR TIPPING
The tooth is tilted distally, Le. The crown is distal to the root
LINGUAL INCLINATION OR TIPPING
The tooth is abnormally tilted towards the tongue (or the palate in the maxillary arch)
LABIAUBUCCAL INCLINATION OR TIPPING
The tooth is abnormally inclined towards the lips cheeks.
INFRA-OCCLUSION
The tooth is below the occlusal plane as compared to other teeth in the arch.
SUPRAOCCLUSION
The tooth is above the occlusal plane as compared to other teeth in the arch.
ROTATIONS
This term refers to tooth movements around the long axis of the tooth. Rotations are
of the following two types:

Transposition
This term is used in case where two teeth exchange places, e.g. a canine in place
of the lateral incisor.

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SKELETAL MALOCCLUSIONS
These malocclusions are caused due to the defect in the underlying skeletal
structure itself. The defect can be in size, position or relationship between the jaw
bones.

MALRELATION OF DENTAL ARCHES

These malocclusions are characterized by an abnormal relationship between
teeth or groups of teeth of one dental arch to that of the other arch. These inter-arch
alterations can occur in all the three planes of space, namely-sagittal, vertical or
transverse.

SAGITIAL PLANE MALOCCLUSIONS

They can be of two types:

Pre-normal Occlusion
Where the mandibular dental arch is placed more anteriorly when the teeth meet
in centric occlusion.

Post-normal Occlusion
Where the mandibular dental arch is placed more posteriorly when the teeth
meet in centric occlusion.

VERTICAL PLANE MALOCCLUSIONS

The mandibular arch is located more posteriorly as compared to normal. They
can be of two types depending on the vertical overlap of the teeth between the two
jaws.

Deep Bite
Here the vertical overlap between the maxillary and mandibular teeth is in
excess of the normal.

Open Bite
Here there is no overlap or a gap exists between the maxillary and mandibular
teeth when the patient bites in centric occlusion. An open bite can exist in the anterior
or the posterior region.

TRANSVERSE PLANE MALOCCLUSIONS

These include the various types of cross bites. Generally the maxillary teeth are
placed labial/buccal to the mandibular teeth. But sometimes due to the constriction of
the dental arches or some other reason this relationship is disturbed, i.e. one or more
maxillary teeth are placed palatal/lingual to the mandibular teeth These differ in
intensity, position and the number of teeth that may be involved.

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ANGLE'S CLASSIFICATION OF MALOCCLUSION
In 1899, Edward Angle classified malocclusion based on the mesial-distal
relation of the teeth, dental arches and jaws. He considered the maxillary first
permanent molar as a fixed anatomical point in the jaws and the key to occlusion. He
based his classification on the relationship of this tooth to other teeth in the
mandibular jaw. More than 100 years have passed since Angle proposed his system of
classification yet, it remains the most frequently used classification system. It is
simple, easy to use and conveys precisely what it was conceived for, i.e. the
relationship of the Angle classified malocclusion into three broad categories. It is
presented in a form that is most accepted in the present times. The three categories are
designated as "Classes" and are represented by Roman numerals-I, II and III.

CLASS I-MALOCCLUSION
The mandibular dental arch is in normal mesiodistal relation to the maxillary
arch, with the mesiobuccal cusp of the maxillary first molar occluding in the buccal
groove of the mandibular first permanent molar and the mesiolingual cusp of the
maxillary first permanent molar occludes with the occlusal fossa of the mandibular
first permanent molar when the jaws are at rest and the teeth approximated in centric
occlusion.

Angle’s classification:
Angle based his classification on the assumption that the maxillary first
permanent molar was nearly unchanging in its position. He did recognize some
variation among individuals. Angle called the upper first permanent molars the keys
to occlusion. He described three major classes of occlusion:
Class I, Class II and Class III

Class I (figure 1) : If the molars are in their proper position, and if the dental
arches close in a smooth arch to occlusal position, the mesiobuccal cusps of the
maxillary first permanent molar will be in normal mesiodistal relation to the
mesiobuccal groove of the mandibular first permanent molar. The teeth anterior to the
molars may be in a variety of relationships.

Figure 1; class 1 molar relationship

Class II (figure 2, 3 and 4) : In class II, provided the molars are in their correct
position, the lower dental arch occludes distal to the upper arch in centric occlusion.
The mesiobuccal cusp of the maxillary first permanent molar being at least one half

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size cusp width toward the embrasure between the mandibular 2nd premolar and
1st molar. Angle described two divisions :

Class II Div 1 (figure 2): exhibits protruded maxillary incisor.

Figure 2; class II, division 1 with protruded upper anteriors

Class II Div 2 (figure 3 and 4): has incisor retruded

Figure 4; watch the overlapping of upper laterals

Each of these divisions has subdivisions, in which the molar relationship is

correct in one side, but incorrect on the other.

Class III (figure 5): Provided the molars are in their correct position in the
individual arches, then in the individual arches in centric occlusion, the lower dental
arch is mesial to the upper dental arch. This is exemplified by the maxillary first
permanent molar being at least one-half cusp toward the disto-buccal developmental
groove of the lower first molar.

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 Figure 5; Class III malocclusion

The dental arches must close in a smooth arch to occlusal position without
cuspal interference during closing or deviation of the mandible forwardly or laterally.

Lischer’s Contribution to Classifications:

Lischer suggested using the term neutro-occlusion as a more descriptive

term for angle Class 1. Disto-occlusion to describe Angle Class II and mesio-
occlusion to describe Angle Class III. He further suggests the suffix - version to
describe nine wrong positions of individual teeth.

1- Linguo version - towards the tongue

2- Labio or bucco version-toward the lip or cheek
3- Mesioversion - mesial of normal of normal
4- Distoversion - distal of normal
5- Infraversion - high on in the maxilla or lower in the mandible
6- Supraversion – over eruption
7- Torsoversion – rotation on the long axis
8- Perversion – impacted teeth
9- Transversion – swapping of tooth positions

Angle’s Class 1 Classification:

The term “Class 1 Malocclusion” embraces all occlusal abnormalities with the
exception of those which have an abnormal antero-posterior arch relationship.
Angle’s Class 1 Malocclusion has five types of modification “according to DEWEY-
ANDERSON modification”.

1- Class 1, type 1 (figure 6) malocclusion has the usual antero-posterior dental

arch relationship; the incisor may be crowded and or rotated. The canine often does
not have enough room to attain their proper position.

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 Figure 6; Crowding in anterior region ( Class 1, type 1)

2- Class 1, Type 2 (figure 7) has the usual posterior relationship, but the
maxillary incisors are procumbent and spaced, there is often a history of thumb
sucking.

Figure 7; spacing in anterior spacing ( Class 1 type 2)

3- Class 1, Type 3 (figure 8) malocclusion with one or more lingually locked

maxillary incisors. It is necessary in this case to ask the patient to close in centric
occlusion and to observe the premature contact points and the position of the
mandible. This type is also referred to as (pseudo-class 3 malocclusion).

Figure 8; single anterior cross-bite ( class 1 type 3)

4- Class 1, Type 4 (figure 9) has posterior crossbite. This usually involves the
molars or premolars.

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 Figure 9; unilateral single posterior cross-bite ( class 1, type 4)

5- Class 1, Type 5 (figure 10) may look like class 1, Type 1 but the local
etiology is different. There is crowding in the posterior due to lack of space and due to
early loss of deciduous teeth and drifting of the permanent molar forward.

Figure 10; crowding in the premolar area ( class 1, type 5)

Dental Base Relationship in Angle’s Class I Malocclusion :

Sagittal: Skeletal pattern is usually Class 1 but may be associated with very
mild skeletal II and III

Vertical and Transverse:

Soft Tissues: the soft tissue form and activity are within the normal range.

CLASS II-MALOCCLUSION

Mandibular dental arch and body are in distal relation to the maxillary arch. The
mesio-buccal cusp of the maxillary first permanent molar occludes in the space
between the mesio-buccal cusp of the mandibular first permanent molar and the distal
aspect of the mandibular second pre-molar. Also, the mesio-lingual cusp of the
maxillary first permanent molar occludes mesial to the mesio-lingual cusp of the
mandibular first permanent molar.
Angle divided the Class-II malocclusions into two divisions based on the labio-
lingual angulation of the maxillary incisors as:

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 Class II-Division 1

Along with the molar relation which is typical of class II malocclusions the
maxillary incisor teeth are in labio-version.
Deficient mandible.
High arched palatal vault-tendency for vertical growth
Incompetent lips may exist

Class II-Division 2
Along with the typical Class II molar relationship, the maxillary incisors are
near normal antero-posteriorly or slightly in lingo-version whereas the maxillary
lateral incisors are tipped labially and/or mesially. -Normal mandible.-broad and
shallow palatal vault- horizontal growth pattern- normal lip activity and behavior

Class II-Subdivision
When the Class II molar relationship occurs on one side of the dental arch only,
the malocclusion is referred to as a subdivision of its division

CLASS II DIVISION 1 MALOCCLUSION

 Proclined upper incisors
 Increased overjet
 Short upper lip may be present
 Narrow and v shaped upper arch
 Deficient mandible may exist
 Under developed chin may be present

Occlusal Features: According to Angle’s classification, the lower arch should

at least one-half cusp width post-normal to the upper and there is an increases in over
jet.

Labial Segments: The upper incises are usually proclined but may be of
average inclination. The lower incisor adage lie posterior to the cingulum plateau of
the upper incisors or there is an increases in over jet; overbite is deep, either complete
or incomplete. Sometimes the overbite is incomplete due to thumb sucking habits
primary a typical swallowing.

Dental Base Relationship:

Sagittal: Usually there is Class II skeletal patterns in many cases. This is the
primary etiological factor responsible for Class II arch relationship. Sometimes due to
soft tissue pattern, the inclination of the lower teeth will compensate for skeletal
pattern by proclination of lower incisor and decrease the over jet.

Vertical : Frankfort mandibular plane Angle is average or high. A high angle is

regarded as unfavorable picture. Partly because the lips are more likely to be
incompetent and partly because the lower incisor may be retroclined .

Transverse : No characteristics transverse feature .

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 Mandibular Position and path of Closer:
In few cases the mandible is habitually postured forward to facilitate the
production of a lip seal, in these cases an upward and backwards deviation of the
mandible on closer will be observed. It will be maintained but usually there is a
tongue to lower lip seal with the lower lip lying behind the upper incisors.

CLASS II DIVISION 2 MALOCCLUSION

 Lingually inclined upper incisors overlapped by proclined laterals

 Broad upper arch
 Deep incisor overbite
 Super eruption of the lower anteriors
 Upper lip of normal; length
 Mandible of good size

Occlusal Features: The lower arch should be at least one half cusp width post-
normal to the upper and the upper central incisor are retroclined .

Labial Segment: The amount of retro-clination of the upper central incisors is

closely related to the degree of post-normally of the lower arch and the severity of
skeletal mal-relationship. The upper lateral incisors are often proclined, mesially
inclined and mesio-labially rotated.

The lower labial segment is often slightly crowded and the lower incisors is
slightly retroclined, a feature which increase the inter incisor angle and so has adverse
effect on the depth of overbite. Over jet is slightly increased, in marked Class 2
skeletal patterns over jet may be increased, overbites is deep and complete. The
overbite depth depending on the severity of the skeletal mal-relationship and the size
of the incisal angle usually the lower incisors occlude on the palatal mucosa and the
upper incisors on the gingivae labial to the incisors.

Buccal segment may be crowded if there is early loss of deciduous molar

teeth and forward drift to fist molar.

Dental Base Relationship:

Sagittal: It is usually Class 1 or Mid Class 2, the profile is frequently well
balanced but usually with a prominent chin button.

Vertical: The lower facial height is reduced or average.

The Frankfort mandibular plane angle is often low. The low anterior facial height may
contribute to the depth of overbite.
Mandibular Position and path of Closure:
Usually the path of closer into occlusion is simple hinge movement, in some
severe cases; the mandible is habitually postured downward and forward.

True posterior displacements are sometimes found in class II division 2

Soft Tissue: The lips are competent, the lip line is often high, and the lower lip
is covering more than the occlusal half of the upper incisors.

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 Oral Habit: It is usually good, in cases with severe overbite the lower incisors
occlude with the palatal mucosa and the upper incisors with the gingivae labial to the
lower incisors. Direct trauma to the gingiva may develop.

CLASS III-MALOCCLUSION

The mandibular dental arch and body is in mesial relationship to the maxillary
arch; with the mesiobuccal cusp of the maxillary first molar occluding in the
interdental space between the distal aspect of the distal cusps of the mandibular first
molar and the mesial aspect of the mesial cusps of the mandibular second molar.

Pseudo Class III-Malocclusion

This is not a true Class III malocclusion but the presentation is similar. Here the
mandible shifts anteriorly in the glenoid fossa due to a premature contact of the teeth
or some other reason when the jaws are brought together in centric occlusion.
Class III-Subdivision
It is said to exist when the malocclusion exists unilaterally. Angle's
classification was the first comprehensive classification of malocclusion. It is still the
most widely accepted classification and is used routinely for day to day
communication between clinicians. With its simplicity, it also had its inherent
drawbacks
Angle’s Class III Malocclusion

Accord to Angle the lower arch should be at least one-half cusp width too
far forward relative to the upper arch .

Labial Segment:
The upper incisors are often crowded and proclined the lower incisors are
slightly crowded but often spaced. The inclination of incisor compensates the Sagittal
arch mal-relationship. The lower incisors edged lie anterior to the cingulum plateau of
the upper incisors, usually there is a reverse over jet. Frequently the anterior inter-
maxillary height is increases and there is anterior open bite, occasionally there is
reverse over jet and the anterior inter-maxillary height is low, the over jet is deep or
the anterior teeth meet edge to edge .

Buccal Segment:
Frequently, the upper arch is short so that the buccal segments are crowded,
the canines may be mesially inclined and the first permanent molars are distally
involved. There is sometimes cross-bite in the buccal segments, may be unilateral or
bilateral. A unilateral Crossbite is usually associated with lateral displacement of the
mandible to obtain maximal interception.

Dental Base relationship:

Probably the jaw form is inherited. The Hapsburg family in Germany has
always been quoted as classic example. True Class III malocclusions occur with
skeletal relationship associated with a mandibular protrusion or in some cases a
degree of maxillary retrusion. Class III has been classified into three groups:

Group 1 : Small maxilla, decreased anterior facial height, the mandible is

normal and high Frankfort mandibular plane angle usually there is openbite .

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 Group 2: larger mandible, True mandibular and normal to
low Frankfort mandibular plane.
Group 3: The pseudo Class III, with mild skeletal pattern, usually loss of
deciduous teeth in the buccal segments at a critical stage of development and an initial
contact has some slight forward movement and over closure with the upper central
erupting lingual to their counterparts. In pseudo Class 3, the patient can bite edge to
edge incisor position and there is a good prognosis for establishing an incisor
overbite. Skeletal 3 patterns tend to become more marked at teen due to later stages of
growth.

Soft Tissue:
The lips are competent at rest; the upper lip may be short and lower lip
everted and rather flabby as in the classic Hapsburg profile. The length of the lip
tends to reflect the size of the underlying skeletal structures of either jaws, and
therefore, class III cases maybe having large tongue.
Path of Closure of the Mandible:
In true Class 3 malocclusion the path of closure from rest position to occlusion
is simple hinge movement. The displacement of the mandible with over closure may
occur. Loss of posterior teeth and initial contact on the deciduous canine prior to
eruption of the permanent incisor may facilitate over closure.

Drawback of Angle's classification

1. Angle presumed the first permanent molars as fixed points within the jaws, which
definitely is not so.
2. Angle depended exclusively on the first molars. Hence, the classification is not
possible if the first molars are missing or if applied in the deciduous dentition.
3. Malocclusions are considered only in the antero-posterior plane. Malocclusions in
the transverse and vertical planes are not considered.
4. Individual tooth malocclusions have not been considered.
5. There is no differentiation between skeletal and dental malocclusions.
6. Etiology of the malocclusions has not been elaborated upon.

MODIFICATIONS OF ANGLE CLASSIFICATION

DEWEY'S MODIFICATION OF ANGLE'S CLASSIFICATION OF

MALOCCLUSION
Dewey in 1915 modified Angle's Class I and Class III by segregating
malposition of anterior and posterior segments as:
Type 1: Angles Class I with crowded maxillary anterior teeth
Type 2: Angles Class I with maxillary incisors in labio-version (proclined)
Type 3: Angle's Class I with maxillary incisor teeth in linguoversion to
mandibular incisor teeth (anterior in cross bite)
Type 4: Molars and/ or premolars are in buccal or linguoversion, but incisors
and canines are in normal alignment (posteriors in cross bite)
Type 5: Molars are in mesio-version due to early loss of teeth mesial to them
(early loss of deciduous molars or second premolar)

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 DEWEY'S MODIFICATION OF ANGLE'S CLASS III
Type 1
Individual arches when viewed individually are in normal alignment, but when
in occlusion the anteriors are in edge to edge bite
Type 2
The mandibular incisors are crowded and lingual to the maxillary incisors
Type 3
Maxillary arch is underdeveloped, in cross bite with maxillary incisors crowded
and the mandibular arch is well developed and well aligned

L1SCHER'S MODIFICATION OF THE ANGLE'S CLASSIFICATION

OF MALOCCLUSION
Lischer in 1933 further modified Angle's classification by giving substitute
names for Angle's Class I, II and III malocclusions. He also proposed terms to
designate individual tooth malocclusions.

NEUTRO-OCCLUSION
Neutro-occlusion is the term synonymous the Angle's Class I malocclusion.
DISTO-OCCLUSION
Disto-occlusion is synonymous with Angle's Class II malocclusion.
MESIO·OCCLUSION
Mesio-occlusion is synonymous with Angle's Class III malocclusion. Lischers
nomenclature for individual tooth mal positions involved adding the suffix "version"
to a word to indicate the deviation from the normal position.
1. Mesioversion-mesial to the normal position
2. Distoversion-distal to the normal position
3. Linguovcrsion-lingual to the normal position
4. Labioversion-labial to the normal position
5. Infraversion-inferior or away from the line of occlusion
6. Supraversion-superior or extended past the line of occlusion
7. Axiversion-the axial inclination is wrong; tipped
8. Torsiversion-rotated on its long axis
9. Transversion-transposed or changes in the sequence of position

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 SIMON'S CLASSIFICATION OF MALOCCLUSION
Simon in 1930 was the first to relate the dental arches to the face and cranium in
the three planes of space, i.e.
• Frankfort horizontal (vertically)
• Orbital plane (antero-posteriorly)
• Raphe or median sagittal plane (transverse).

FRANKFORT HORIZONTAL (VERTICALLY)

Frankfort horizontal plane (F-H Plane) or the eye-ear plane is determined by

drawing a straight line through the margins of the bony orbit directly under the pupil
of the eye to the upper margins of the external auditory meatus (the notch above the
tragus of the ear).
Th.is plane is used to classify malocclusions in the vertical plane. Vertical
deviations with respect to the plane are:
1. Attractions when the dental arch or part of it is closer to the Frankfort horizontal
plane it is referred to as attraction.
2. Abstractions when a dental arch or a part of it is further away from the Frankfort
horizontal plane, it is referred to as abstraction.

ORBITAL PLANE (ANTERO-POSTERIORLY)

This plane is perpendicular to the eye-ear plane (Frankfort horizontal plane) at
the margin of the bony orbit directly under the pupil of the eye
Here it is pertinent to mention the law of the canine. According to Simon in
normal arm relationship, the orbital plane passes through the distal axial aspect of the
maxillary canine.
Malocclusions described as anterior-posterior deviations based on their distance
from the orbital plane are:-
1. Protraction the teeth, one or both, dental arches, and/ or jaws are too far forward,
i.e. placed forward or anterior to the plane as compared to the normal where the
plane passes through the distal incline of the canine.
2. Retraction The teeth one or both dental arches and /or jaws are too far backward,
i.e. placed posterior to the plane than normal or anterior to the plane as compared
to the normal; where the plane passes through the distal incline of the canine.

RAPHE OR MEDIAN SAGITTAL PLANE (TRANSVERSE)

The raphe or median sagittal plane is determined by points approximately 1.5

cm apart on the median raphe of the palate. The raphe median plane passes through
these two points at right angles to the Frankfort horizontal plane
Malocclusions classified according to transverse deviations from the median
sagittal plane are:
1. Contraction a part or the entire dental arch is contracted towards the median
sagittal plane.
2. Distraction A part or the entire dental arch is wider or placed at a distance which
is more than normal.

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 ACKERMAN-PROFITT CLASSIFICATION

Ackerman and Profitt proposed a very comprehensive system of classification which

divided malocclusions in all the three planes of space and tended to give an indication
towards the severity of the malocclusion present. The system proposed by Ackerman-
Profitt is based on the set theory, where a set is defined on the basis Of morphologic
deviations from the ideal. The classification was illustrated using the Venn symbolic
logic diagram the classification considered five characteristics, and their
interrelationships were assessed. The five characteristics are as follows:

CHARACTERISTIC 1-ALIGNMENT:
Intra arch alignment and symmetry are assessed as when seen in the occlusal
view. A dental arch is classified as ideal crowded/ spaced.
CHARACTERISTIC 2-PROFILE:
The profile can be convex/straight/concave. This also includes the assessment of
facial divergence, i.e. anterior or posterior divergence.
CHARACTERISTIC 3- TRANSVERSE RELATIONSHIPS:
These include the transverse skeletal and dental relationships. buccal and palatal
cross bites are noted.
These are further sub classified as unilateral or bilateral. Distinction is made
between skeletal and dental cross bites.
CHARACTERISTIC 4-CLASS:
Here the sagittal relationship of the teeth is assessed using the Angle
classification as Class I/Class II/Class III. A distinction is made between skeletal
and dental malocclusions.
CHARACTERISTIC 5-OVERBITE:
Malocclusions are assessed in the vertical plane. They are described as anterior
open bite/posterior open bite/anterior deep bite/posterior collapsed bite. Here again
a distinction is made as to whether the malocclusion is skeletal or dental.
The first characteristic is represented as a square which contains a larger circle
representing the profile or characteristic 2. This contains three smaller circles
overlapping each other partially, representing the transverse, sagittal and vertical
deviations respectively.The confluence of these sets form nine groups, each a
combination of certain characteristics. The ninth group represents the most complex
malocclusion with all possible features.

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 Cross Bite
CONTENTS
1. Definition
2. Etiology
3. Classification
4. Clinical Features
5. Diagnosis
6. Management

DEFINITION:

According to Graber:
Cross bite is a condition where one or more teeth may be abnormally
malposed buccal or lingually or labially with reference to opposing teeth.

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 Etiology of cross bite
Etiology of Anterior cross bite Etiology of posterior cross bite
[I] Dental Causes
1. Traumatic injury to primary 1. Prolonged retention of primary
dentition that causes a lingual tooth.
displacement of permanent tooth 2. Ectopic eruption of the permanent
bud. first molar.
 Persistence of a deciduous tooth 3. Prolonged thumb or finger sucking.
 Palatal deflection of its erupting 4. Cleft palate cases.
successor
 Single tooth anterior cross bite
2. Super numerary tooth.
3. A habit of biting the upper lip
4. Cleft lip repair cases
5. Arch length inadequacy
 Causing lingual deflection of
permanent tooth during eruption.

Etiology of Anterior cross bite Etiology of posterior cross bite

[II] Skeletal Causes
1. Genetic. 1. Genetic.
2. Due to deficient anterior growth of 2. Due to deficient lateral growth of
maxilla. maxilla.

3. Excessive abnormal mandibular
growth in anteriorly.
4. Combination of both 2. & 3.
Eg.
 In cleft palate cases
 se Stimulation in mid palatal
suture
 se Lateral maxillary growth
3. Excessive abnormal mandibular
growth laterally.
4. Combination of both 2. & 3.

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 Etiology of Anterior cross bite Etiology of Posterior cross bite

[III] Functional Cross bite

1. Pseudo class III 1. Unilateral posterior cross bite

2. Habitual forward positioning of 
the mandible to obtain Due to occlusal interferences
maximum interception may 
lead to an anterior cross bite. Deviation of mandible during jaw
closure

CLASSIFICATION

[I] Based on Location

Cross bite

ANTERIOR POSTERIOR
CROSS BITE CROSS BITE

a. According to a. According to
b. According to a. According to
no. of teeth no. of teeth
side involved extent
involved involved

Single tooth Single tooth Single posture

Unilateral
cross bite cross bite cross bite

Segmental Segmental Buccal non-

Bilateral
cross bite cross bite occlusion

Lingual non-
occlusion

[II] Based on Etiologic Factor

Cross bite

SKELETAL CROSS BITE DENTAL CROSS BITE FUNCTIONAL CROSS BITE

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Clinical Features

Anterior cross bite

An abnormal labiolingual relationship (reverse overjet) between one
or more maxilary and mandibular anterior teeth.

Posterior cross bite

An abnormal buccolingnal relationship of teeth in the maxilla and
mandible when the 2 dental arches are brought into Centric Occlusion.

Single tooth crossbite

Involve only single tooth

Segmental crossbite
Involve a segment of arch

Unilateral cross bite

Involving and side of arch

Bilateral cross bite

Involving both side of arch

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Simple posterior crossbite
- Seen most frequently in clinical practice
- Buccalcusp of one or more maxillary posterior teeth occludelingual
to the buccal cusps of the mandibular teeth.

Buccal Non-occlusion (Scissors bite)

- Maxillary posterior teeth occlude entirely on the buccal aspect of
the mandibular posteriors.

Palatal/Lingual Non-occlusion
- Maxillary posterior occlude entirely on the lingual aspect of the
mandibular posterior.

Skeletal cross bite

Discrepancy in the size of maxilla & mandible.

Causes :-
1. Inherited
2. Defective embryological development.

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Anterior crossbite due to maxillary retrognathism.

Anterior crossbite due to mandibular prognathism.

Anterior crossbite due to maxillary retrognathism and mandibular

prognathism.

Causes of anterior dental cross bite

1. Lingual eruption path of maxillary anterior teeth.
2. Trauma to deciduous dentition in which there is displacement of
tooth buds

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 3. Retained deciduous causing lingual eruption of permanent teeth.
4. Supernumerary teeth.

Functional Cross bite:

- Habitual forward positioning of mandible (pseudo class III)

DIAGNOSIS
1. History
2. Clinical Examination
3. Study Models
4. Radiograph
1. Lateral cephalogram (for anterior cross bite)
2. PA view of cephalogram (for posterior cross bite)

[A] MANAGEMENT OF ANTERIOR CROSSBITE

- In 4 stages
1) In primary dentition
2) In mixed dentition
3) In permanent dentition
4) In post permanent dentition

[I] IN PRIMARY DENTITION:

(Preventive orthodontic)

Elimination of the factors that may lead to the anterior cross bite
Eg
- Removal of occlusal prematurities
- Extraction of supernumerary tooth before they cause
displacement of other tooth.
- Habit breaking appliance.

[II] IN MIXED DENTITION:

Interceptive orthodontics(In pre-adolescent age group)

- Anterior cross bite should be treated at an early stage.
Because
- If a cross bite present in the deciduous dentition, it may manifest in the
mixed & permanent dentition as well.
- If a simple anterior cross bite is not treated in early stage
- It may progress into skeletal malocclusion that later need
complicated orthodontic treatment or surgical treatment.

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(1) Use of tongue blade

Indications
- Used when a cross bite is seen at the time the permanent teeth
are making an appearance in the oral cavity.
- It is placed inside the mouth contacting the palatal aspect of the
maxillary teeth.
- Upon slight closure of jaw the opposing side of the stick comes in
contact with the labial aspect of the opposing mandibular tooth acts as a
fulcrum.
- This is continued for 1-2 hours for about 2 weeks.

Drawbacks of using tongue blade

- Only effective till the clinical crown not completely erupted in
the oral cavity.
- Used only if sufficient space is available for the correction.
- Patients cooperation is required.

(2) lower anterior inclined plane

Indications
- Used only in those cases where the cross bite is due to a
palataly placed max incisors.
(Constructed at 45 degree angulations on the lower anterior teeth by
acrylic or cast metal).

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Disadvantages of lower inclined plane

1) Difficulty in speech & chewing

2) Patient cooperation required
3) Require frequent re-cementation
4)
- Prevent the posterior teeth from coming into contact
If prolonged use
- Supra eruption of posterior teeth
- Anterior open bite
5) Cannot be given if
- Mandibular incisors are malaligned
- Mandibular incisors are periodontally compromised

[3] Double cantilever spring / z-spring

Indication
- Used when anterior cross bite involving 1 or 2 max. anterior
teeth.
-
Disadvantage
- Effective only when there is enough space for aligning the
teeth.

[4] Screw appliance

(i) Micro screw
- Used on individual tooth
- Multiple micro screw can be used to correct individual tooth in
segmental cross bite

(ii) Mini screw

- Capable of moving up to 2 teeth

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(iii) Medium screw
- Used to correct segmental cross bite

(iv) 3-D screw (3-dimensional screw)

- Capable of correcting posterior as well as anterior cross bite

[5] Face mask (or face mask along with RME)

Indications
- Used to correct skeletal anterior cross bite (Anterior cross bite
due to actual skeletal deficiency of the maxilla
- Protraction face mask or Reverse head gear

- If maxilla is narrow
RME screw also used for transverse expansion.

[6] Frankel III appliance

- Used to correct skeletal class III Malocclusion.

[7] Chin cap appliance

- Used to correct or prevent the anterior cross bite due to a
prominent mandible.
- Chin cap appliance rotate mandible backward and downward.

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[III] IN PERMANENT DENTITION (In Adolescent & Adult)

(1) Screw appliance

- Mini screw May be used to correct single

- Medium screw tooth or segmental cross bite.

- Adequate space is required to correct the anterior cross bite

- Otherwise results will be compromised

(2) Fixed Appliance

- Used to correct single tooth or multiple teeth

[IV] IN POST PERMANENT DENTITION

- Surgical orthodontist
(After the active growth is complete)
[B] MANAGEMENT OF POSTERIOR CROSS BITE
[1] CROSS BITE ELASTICS

Indication
- Single tooth cross bite involving molars can be treated by
elastics
- Elastics are stretched b/w the max palatal surfaces and
mandibular buccal surface.
- [Worn day & night & treatment should not be continued for
more than a weeks because elastics can extrude the teeth].

[2] COFFIN SPRING

- Omega shaped wire appliance is capable of correcting cross
bite in the young developing dentition.
- Expansion produced is slow & bilaterally symmetrical.

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[3] QUAD HELIX APPLIANCE
- A spring that consists of 4 helices
- Being soldered to the molar bands that are commented
generally on the first permanent max. molars.
- Capable of dento-alveolar expansion of the molar as well as
premolar region (slow expansion).
- It can be reactivated by 3 prong wires without having to be
removed.

(4) R.M.E.(rapid maxillary expansion)

- Hyrax screw

5) NiTi expanders
- Nickel titanium wire shapes
- Welded to molar bands that are cemented to the maxillary
permanent molars

NiTi expander place in a cleft case

6) Fixed orthodontic Appliance

- Used for correction of posterior cross bite

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 ANTERIOR OPEN-BITE
Anterior open-bite is said to exist when there is no incisor contact and
vertical overlap of lower incisors by the uppers. Incomplete overbite is a
minor variant of anterior open-bite and is present where there is no lower
incisor contact with either upper incisor or palate but the incisal overlap still
exists.

Etiology and Clinical Features

The cause of anterior open-bite is generally multi- factorial and can be
attributed to a number of facts. Clinically, anterior open-bite is grouped into
two main categories: the dental or acquired open-bites, which do not show
any distinguishing craniofacial malformations; and the skeletal open-bite
with superimposed craniofacial dysplasia. Both the dental and skeletal open-
bites may be classified as simple and complex, respectively, based on the
difficulty in their diagnoses and management

1.Dental open-bite (Habits)

This open-bite is caused by obstruction of eruption of the anterior teeth.

2. Skeletal open-bite (Hereditary)

This group shows some craniofacial malforma- tion which often varies
with maturity
3. Abnormal tongue function
4. Neurological disturbances
5. Iatrogenic open-bite
This open-bite is produced by active orthodon- tic treatment obviously
represents examples of poor treatment technique or inappropriate treat- ment
planning. More common mistakes in this category include the use of
anterior bite plane in already reduced overbite and the extrusion of upper
molars in high angle cases.

6. Pathological open-bite Pathological conditions may also present as

anterior open-bite, such as in cleft palate, acromegaly or in bilateral
condylar fracture cases. Le Fort II and III fracture cases often present with
gagging occlusion, hence anterior open-bite
Diagnosis and Treatment
-Simple orthodontic treatment :The treatment of non-skeletal open-bite
in which the child indulges in some form of non-nutritive sucking should
include adequate effort to dissuade him from this habit, although most
clinicians tend to agree that intervention is not usually indicated until about
the age of 5 years when the permanent dentition starts to erupt.
-Complex orthodontic treatment

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 Removable maxillary intrusion splints which carry posterior bite blocks
are very useful in closing anterior open-bite. Functional appliance with bite
blocks, such as Clark's twin block (CTB)
-Orthognathic surgery
-Retention and Prognosis: Many studies have indicated that if open-bite
correc- tion is not stable, it was because the tongue contin- ues to be
postured anteriorly which causes the bite to reopen

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 DEEP BITE
Deep bite is one of the most common malocclusion seen in children as well
as adults and is most difficult to treat successfully.Unfavorable sequel of
this malocclusion predisposes a patient to periodontal involvement,
abnormal function, improper mastication, excessive stresses, trauma,
functional problems,bruxism, clenching and temporomandibular joint
disturbance

Classification

Deep bite can be classified as dentoalveolar deep bite and skeletal deep bite,
true deep bite and pseudo deep bite or incomplete deep bite and complete
deep bite

Etiology of deep bite

1) Inherent factors like Tooth morphology, Skeletal pattern and

malocclusion, Condylar growth pattern.

2) Acquired factors like Muscular habit, Changes in tooth position, the loss
of posterior supporting teeth, Lateral tongue thrust habit

Diagnosis of deep bite

A deep bite anteriorly could be caused by supra-eruption of upper and/or

lower incisors or infra-eruption of posterior teeth . Toevaluate whether infra-
eruption or supra-eruption is present, the orthodontist must use linear
measurements from the base of the alveolar process. This can be established
by Cephalometric analysis.

Treatment modalities of deep bite

1) Extrusion of posterior teeth.

2) Intrusion of anterior teeth.

3) Combination of both.

4) Proclination of incisors.

5) Surgical.

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Biomechanics of intrusion

Optimal intrusive force for anterior intrusion 15-20 g for each upper
incisor

Correction of deep bite with begg’s technique

Correction of deep bite with magnets

Correction of deep bite with mini screw

anchorage system

Correction of deep bite with lingual orthodontic

Correction of deep bite with orthodontics and

surgery

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