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Authors:

Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> Fr ont of B ook > Author s

Authors
Laura Mitchell MDS, BDS, FDSRCPS (G las), D. O rth RCS (Eng), M. O rth RCS
(Eng)
Consul tant O rthodonti st, St. Luke's Hospi tal , Bradf ord, Honorary Cl i ni cal
Lecturer, Leeds Dental Insti tute, Leeds

With Contributions From


Nigel E. Carter MSc, BDS, FDSRCS (Eng), D. O rth RCS (Eng), M. O rth RCS
(Eng)
Wi th contri buti ons f rom, Consul tant O rthodonti st, Newcastl e Dental Hospi tal and
School , Newcastl e

Bridget Doubleday PhD, M. Med. Sci. , BDS, FDSRCPS (G las), M. O rth


Wi th contri buti ons f rom, Consul tant O rthodonti st, Leeds Dental Insti tute, Leeds
Authors: Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> Fr ont of B ook > D is c laim er

Disclaimer

O xf ord Universit y Press makes no represent at ion, express or implied, t hat t he


drug dosages in t his book are correct . Readers must t heref ore alw ays check t he
product inf ormat ion and clinical procedures w it h t he most up t o dat e published
product inf ormat ion and dat a sheet s provided by t he manuf act urers and t he most
recent codes of conduct and saf et y regulat ions. The aut hors and t he publishers
do not accept responsibilit y or legal liabilit y f or any errors in t he t ext or f or t he
misuse or misapplicat ion of mat erial in t his w ork.
Authors: Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> Fr ont of B ook > P r efac e for S ec ond E dition

Preface for Second Edition

I must admit I w as delight ed t o be asked t o produce a second edit ion of An


Introducti on to O rthodonti cs. Clinical pract ice changes so f ast it is sat isf ying t o
have t he chance t o updat e t his book f or t he 21st cent ury.
Being an aut hor is a very exposed posit ion and t heref ore I w ould like t o express
my grat it ude t o all t hose w ho have made posit ive comment s about t he f irst
edit ion of t his book. I n addit ion, I w ould like t o t hank my co-aut hors f or kindly
agreeing t o revise some of t he chapt ers and t o t he st aff t hat have pat ient ly
w orked w it h me t o produce some of t he clinical result s seen in t he illust rat ions.
I am great ly indebt ed t o my husband, w ho not only has helped me w it h Chapt ers
20 and 21, but has also been very underst anding w hen t he t he book has t aken
priorit y over ot her areas of our lif e.
Authors: Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> Fr ont of B ook > Ac know ledgem ents

Acknowledgements

First ly I w ould like t o t hank my co-aut hor Nigel Cart er not only f or relieving me of
t he burden of t w o chapt ers, but also f or his t hought f ul help in set t ing t he right
level f or t he remainder of t he book. Nigel's command of t he English language is
f ar in advance of mine and his pat ience in correct ing my poor grammar w as much
appreciat ed. I should also ment ion Evelyn May w ho generously provided some of
t he illust rat ions t hat eluded me. Permission t o use t he I ndex of O rt hodont ic
Treat ment Need w as kindly grant ed by VUMAN Limit ed (Skelt on House,
Manchest er Science Park, Manchest er, M15 6SH). I w ould like t o t hank t he st aff
of O xf ord Universit y Press, w ho have been helpf ul and support ive t hroughout .
Finally, I must pay t ribut e t o t he help provided by my long-suff ering husband,
David Mit chell, w it hout w hose f orbearance and assist ance t his book w ould not
have reached complet ion.
Authors: Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> Table of C ontents > 1 - The r ationale for or thodontic tr eatm ent

1
The rationale for orthodontic treatment

1.1. DEFINITION
O rt hodont ics is t hat branch of dent ist ry concerned w it h f acial grow t h, w it h
development of t he dent it ion and occlusion, and w it h t he diagnosis, int ercept ion,
and t reat ment of occlusal anomalies.

1.2. PREVALENCE OF M ALOCCLUSION


Numerous surveys have been conduct ed t o invest igat e t he prevalence of
malocclusion. I t should be remembered t hat t he f igures f or a part icular occlusal
f eat ure or dent al anomaly w ill depend upon t he size and composit ion of t he
group st udied (f or example age and racial charact erist ics), t he crit eria used f or
assessment , and t he met hods used by t he examiners (f or example w het her
radiographs w ere employed).

Table 1. 1 UK Child Dental Health Survey 1993

In the 12-year-old age band:

Crowding sufficient to impede/prevent eruption 18%

Overjet >5 mm 27%

At least one instanding incisor 8%

I t has been est imat ed t hat approximat ely 66 per cent of 12-year-olds in t he UK
require some f orm of ort hodont ic int ervent ion, and around 33 per cent need
complex t reat ment . I n addit ion, now t hat a great er proport ion of t he populat ion
are keeping t heir t eet h f or longer, ort hodont ic t reat ment has an increasing
adjunct ive role prior t o rest orat ive w ork.

1.3. NEED FOR TREATM ENT


I t is perhaps pert inent t o begin t his sect ion by reminding t he reader t hat
malocclusion is one end of t he spect rum of normal variat ion and is not a disease.
Et hically, no t reat ment should be embarked upon unless a demonst rable benef it
t o t he pat ient is f easible. I n addit ion, t he pot ent ial advant ages should be view ed
in t he light of possible risks and side-eff ect s, including f ailure t o achieve t he
aims of t reat ment . Appraisal of t hese f act ors is called risk b enef it analysis

and, as in all branches of medicine and dent ist ry, needs t o be considered bef ore
t reat ment is embarked upon f or an individual pat ient . I n parallel, f inancial
const raint s coupled w it h t he increasing cost s of healt h care have led t o an an
increased f ocus upon t he cost b enef it rat io of t reat ment . O bviously t he t hreshold
f or t reat ment and t he amount of ort hodont ic int ervent ion w ill diff er bet w een a
syst em t hat is primarily f unded by t he st at e and one t hat is privat e or based on
insurance schemes.
The decision t o embark upon a course of t reat ment w ill be inf luenced by t he
perceived benef it s t o t he pat ient in t erms of improved f unct ion and aest het ics,
balanced against t he risks of appliance t herapy and t he prognosis f or achieving
t he aims of t reat ment successf ully. I n t his chapt er w e consider each of t hese
areas in t urn, st art ing w it h t he result s of research int o t he possible benef it s of
ort hodont ic t reat ment upon dent al healt h and psychological w ell-being.

1.3.1. Dental health


Caries
Research has f ailed t o demonst rat e a signif icant associat ion bet w een
malocclusion and caries, w hereas diet and t he use of f luoride t oot hpast e are
correlat ed w it h caries experience. How ever, clinical experience suggest s t hat in
suscept ible children w it h a poor diet , malalignment may reduce t he pot ent ial f or
nat ural t oot h-cleansing and increase t he risk of decay.

Periodontal disease
The associat ion bet w een malocclusion and periodont al disease is w eak, as
research has show n t hat individual mot ivat ion has more impact t han t oot h
alignment upon eff ect ive t oot h brushing. Cert ainly, in t he part ially edent ulous
mout h t he last remaining t eet h are usually t he low er incisors an area w hich is
commonly associat ed w it h crow ding. Nevert heless, cert ain occlusal anomalies
may prejudice periodont al support .
Crow ding may lead t o one or more t eet h being squeezed buccally or lingually out
of t heir invest ing bone, result ing in a reduct ion of periodont al support . This may
also occur in a Class I I I malocclusion w here t he low er incisors in cross-bit e are
pushed labially, leading t o gingival recession. Traumat ic overbit es can also lead
t o increased loss of periodont al suppport and t heref ore are anot her indicat ion
f or ort hodont ic int ervent ion.
Finally, an increased dent al aw areness has been not ed in pat ient s f ollow ing
ort hodont ic t reat ment , and t his may be of long-t erm benef it t o oral healt h.

Trauma to the anterior teeth


The risk of t rauma t o t he upper incisors increases w it h t he size of t he overjet .
The 1983 Child Dent al Healt h Survey f ound t hat children w it h overjet s in excess
of 9 mm w ere t w ice as likely t o experience t rauma. Boys and pat ient s w it h
incompet ent lips appear t o be more at risk; how ever, t he prevalence of t rauma
reduces w it h age, w it h t he peak incidence occurring around 10 years.

M asticatory function
Pat ient s w it h ant erior open bit es and t hose w it h markedly increased or reverse
overjet s of t en complain of diff icult y w it h eat ing, part icularly w hen incising f ood.

Speech
The sof t t issues show remarkable adapt at ion t o t he changes t hat occur during
t he t ransit ion bet w een t he primary and mixed dent it ions, and w hen t he incisors
have been lost ow ing t o t rauma or disease. I n t he main, speech is lit t le aff ect ed
by malocclusion, and correct ion of an occlusal anomaly has lit t le eff ect upon
abnormal speech. How ever, if a pat ient cannot at t ain cont act bet w een t he
incisors ant eriorally, t his may cont ribut e t o t he product ion of a lisp (int erdent al
sigmat ism).

Tooth impaction
Unerupt ed t eet h may rarely cause pat hology. Unerupt ed impact ed t eet h, f or
example maxillary canines, may cause resorpt ion of t he root s of adjacent t eet h.
Dent igerous cyst f ormat ion can occur around unerupt ed t hird molars or canine
t eet h. Supernumerary t eet h may also give rise t o problems, most import ant ly
w here t heir presence prevent s normal erupt ion of an associat ed permanent t oot h
or t eet h.

Temporomandibular joint dysfunction syndrome


This t opic is considered in more det ail in Sect ion 1. 7, w here t he eff ect s of bot h
malocclusion and ort hodont ic t reat ment upon t he t emporomandibular joint and
associat ed musculat ure are considered.
I n summary, t here are a number of dent al t rait s w hich do appear t o have an
adverse eff ect upon t he longevit y of t he dent it ion, indicat ing t hat t heir correct ion
w ould benef it long-t erm dent al healt h. These include t he f ollow ing:

I ncreased overjet
I ncreased t raumat ic overbit es
Ant erior crossbit es (causing a decrease in labial periodont al support of
aff ect ed low er incisors)
Unerupt ed impact ed t eet h (w here t here is a danger of pat hology).
Crossbit es associat ed w it h mandibular displacement .

1.3.2. Psychosocial well-being


While it is accept ed t hat dent of acial anomalies and severe malocclusion do have
a negat ive eff ect on t he pyschological w ell-being and self -est eem of t he
individual, t he impact of more minor occlusal problems is more variable and is
modif ied by social and cult ural f act ors. Research has show n t hat an unat t ract ive
dent of acial appearance does have a negat ive eff ect on t he expect at ions of
t eachers and employers. How ever, in t his respect , background f acial appearance
w ould appear t o have more impact t han dent al appearance.
A pat ient 's percept ions of t he impact of dent al variat ion upon his or her self -
image is subject t o enormous diversit y and is modif ied by cult ural and racial
inf luences. This result s in some individuals being unaw are of marked
malocclusions, w hilst ot hers complain bit t erly about very minor irregularit ies.
The dent al healt h component of t he I ndex of O rt hodont ic Treat ment Need w as
developed t o t ry and quant if y t he impact of a part icular malocclusion upon long-
t erm dent al healt h. The index also comprises an aest het ic element w hich is an
at t empt t o quant if y t he aest het ic handicap t hat a part icular arrangement of t he
t eet h poses f or a pat ient . Bot h aspect s of t his index are discussed in more det ail
in Chapt er 2.

1.4. DEM AND FOR TREATM ENT


Af t er w orking w it h t he general public f or a short period of t ime, it can readily be
appreciat ed t hat demand f or t reat ment does not necessarily ref lect need f or
t reat ment . Some pat ient s w ill complain bit t erly about mild rot at ions of t he upper
incisors, w hilst ot hers are blit hely unaw are of markedly increased overjet s. I t
has been demonst at ed t hat aw areness of t oot h alignment and malocclusion, and
w illingness t o undergo ort hodont ic t reat ment , are great er in t he f ollow ing groups.

f emales
higher socio-economic f amilies/ groups
in areas w hich have a smaller populat ion t o ort hodont ist rat io, presumably
because appliances become more accept ed.

O ne int erest ing example of t he lat t er has been observed in count ries w here
provision of ort hodont ic t reat ment is mainly privat ely f unded, f or example, t he
USA, as ort hodont ic appliances are now perceived as a s t at us symbol .
Wit h t he increasing dent al aw areness show n by t he public and t he increased
accept abilit y of appliances, t he demand f or t reat ment is increasing rapidly,
part icularly among t he adult populat ion w ho may not have had ready access t o
ort hodont ic t reat ment as children. I n addit ion, increased dent al aw areness also
means t hat pat ient s are seeking a higher st andard of t reat ment result . These
combined pressures place considerable st rain upon t he limit ed resources of
st at e-f unded syst ems of care. As it appears likely t hat t he demand f or t reat ment
w ill cont ine t o escalat e, some f orm of rat ioning of st at e-f unded t reat ment is
inevit able and is already operat ing in some count ries. I n Sw eden f or example,
t he cont ribut ion made by t he st at e t ow ards t he cost of t reat ment is based upon
need f or t reat ment as det ermined by t he Sw edish Healt h Board's I ndex.

1.5. THE DISADVANTAGES AND POTENTIAL RISKS OF


ORTHODONTIC TREATM ENT
Like any ot her branch of medicine or dent ist ry, ort hodont ic t reat ment is not
w it hout pot ent ial risks (see Table 1. 2).

Table 1. 2 Potential risks of orthodontic treatment

Problem Avoidance/Management of risk

Dietary advice, improve oral hygiene,


Decalcification increase availablity of fluoride
Abandon treatment

Periodontal
attachment Improve oral hygiene
loss

Root Avoid treatment in patients with


resorption resorbed, blunted, or tapered roots

If history of previous trauma to


Loss of vitality
incisors, counsel patient

1.5.1. Root resorption


I t is now accept ed t hat some root resorpt ion is inevit able as a consequence of
t oot h movement . During t he course of a convent ional t w o-year f ixed-appliance
t reat ment around 1 mm of root lengt h w ill be lost on average. How ever, t his

mean masks a w ide range of individual variat ion, as some pat ient s appear t o be
more suscept ible and undergo more marked root resorpt ion. Radiographic signs
w hich indicat e an increased suscept ibilit y include short ened root s w it h evidence
of previous root resorpt ion, pipet t e-shaped or blunt ed root s, and t eet h w hich
have previously suff ered an episode of t rauma. I n addit ion, more marked
resorpt ion is seen in cases w here ext ensive movement of root apices has been
undert aken.

1.5.2. Loss of periodontal support


As a result of reduced access f or cleansing, an increase in gingival inf lammat ion
is commonly seen f ollow ing t he placement of f ixed appliances. This normally
reduces or resolves f ollow ing removal of t he appliance, but some apical
migrat ion of periodont al at t achment and alveolar bony support is usual during a
t w o-year course of ort hodont ic t reat ment . I n most individuals t his is minimal, but
if oral hygiene is poor, more marked loss may occur.
Removable appliances may also be associat ed w it h gingival inf lammat ion,
part icularly of t he palat al t issues, in t he presence of poor oral hygiene.

1.5.3. Decalcification
Caries or decalcif icat ion occurs w hen a cariogenic plaque occurs in associat ion
w it h a high-sugar diet . The presence of a f ixed appliance predisposes t o plaque
accumulat ion as t oot h cleaning around t he component s of t he appliance is more
diff icult . Decalcif icat ion during t reat ment w it h f ixed appliances is a real risk, w it h
a report ed prevalence of bet w een 2 and 96 per cent (see Chapt er 17, Sect ion
17. 7).

1.5.4. Soft tissue damage


Traumat ic ulcerat ion can occur during t reat ment w it h bot h f ixed and removable
appliances, alt hough it is more commonly seen in associat ion w it h t he f ormer as
a removable appliance w hich is uncomf ort able is usually removed. O ver-
ent husiast ic apical movement , can lead t o a reduct ion in blood supply t o t he pulp
and even pulpal deat h. Teet h w hich have undergone a previous episode of t rauma
appear t o be part icularly suscept ible, probably because t he pulpal t issues are
already compromised.

Temporomandibular joint dysfunction syndrome


This is discussed in Sect ion 1. 7.

1.6. THE EFFECTIVENESS OF TREATM ENT


The decision t o embark upon ort hodont ic t reat ment must also consider t he
eff ect iveness of appliance t herapy in correct ing t he malocclusion of t he individual
concerned. This has several aspect s.

Are t he t oot h movement s planned at t ainable? This is considered in more


det ail in t he chapt er on t reat ment planning but , in brief , t oot h movement is
only f easible w it hin t he const raint s of t he skelet al and grow t h pat t erns of t he
individual pat ient . The w rong t reat ment plan, or f ailure t o ant icipat e adverse
grow t h changes, w ill reduce t he chances of success. I n addit ion, t he
probable st ablilit y of t he complet ed t reat ment needs t o be considered. I f a
st able result

is not possible, do t he benef it s conf erred by proceeding just if y prolonged


ret ent ion, or t he possibilit y of relapse?
There is a w ealt h of evidence t o show t hat ort hodont ic t reat ment is more
likely t o achieve a pleasing and successf ul result if f ixed rat her t han
removable appliances are used, and if t he operat or has had some
post graduat e t raining in ort hodont ics.
Pat ient co-operat ion.

The likelihood t hat ort hodont ic t reat ment w ill benef it a pat ient is increased if t he
malocclusion is severe and appliance t herapy is planned and carried out by an
experienced ort hodont ist . The likelihood of gain is reduced if t he malocclusion is
mild and t reat ment is undert aken by an inexperienced operat or.
I n essence, it may be bet t er not t o embark on t reat ment at all, rat her t han run
t he risk of f ailing t o achieve a w ort hw hile improvement .

Table 1. 3 Failure to achieve treatment objectives

Operator factors Patient factors


Errors of diagnosis Poor oral hygiene

Errors of treatment Failure to wear


planning appliances

Anchorage loss Failed appointments

Technique errors

1.7. THE TEM POROM ANDIBULAR JOINT AND


ORTHODONTICS
The aet iology and management of t emporomandibular pain dysf unct ion syndrome
(TMPDS) have aroused considerable cont roversy in all branches of dent ist ry.
The debat e has been part icularly heat ed regarding t he role of ort hodont ics, w it h
some aut hors claiming t hat ort hodont ic t reat ment can cause TMPDS, w hilst at
t he same t ime ot hers have advocat ed appliance t herapy in t he management of
t he condit ion.
There are a number of f act ors t hat have cont ribut ed t o t he conf usion surrounding
TMPDS. The object ive view is t hat TMPDS is of mult if act orial aet iology, w it h
psychological, t raumat ic, and occlusal f act ors all being implicat ed. O f t hese,
st ress is probably t he most import ant , w it h it s eff ect being mediat ed by para-
f unct ional act ivit y, f or example bruxism, w hich causes muscle pain and spasm.
Success has been claimed f or a w ide assort ment of t reat ment modalit ies,
ref lect ing bot h t he mult if act orial aet iology and t he self -limit ing nat ure of t he
condit ion. Apart f rom int ernal derangement of t he joint , t he sympt oms of TMPDS
usually respond t o any t reat ment w hich helps t o reduce abnormal paraf unct ional
muscle act ivit y.

1.7.1. Orthodontic treatment as a contributory factor in


TMPDS
A survey of t he lit erat ure reveals t hat t hose art icles claiming t hat ort hodont ic
t reat ment (w it h or w it hout ext ract ions) can cont ribut e t o t he development of
TMPDS are predominant ly of t he view point (based on t he aut hors opinion) and
case report t ype. I n cont rast , cont rolled longit udinal st udies have indicat ed a
t rend t ow ards a low er incidence of t he sympt oms of TMPDS among post -
ort hodont ic pat ient s compared w it h mat ched groups of unt reat ed pat ient s.
The consensus view is t hat ort hodont ic t reat ment , eit her alone or in combinat ion
w it h ext ract ions, does not c ause TMPDS.

1.7.2. The role of orthodontic treatment in the


prevention and management of TMPDS
Some aut hors maint ain t hat minor occlusal imperf ect ions lead t o abnormal pat hs
of closure and/ or bruxism, w hich t hen result in t he development of TMPDS. I f t his
w ere t he case, t hen given t he high incidence of malocclusion in t he populat ion
(50 7 5 per cent ), one w ould expect a higher prevalence of TMPDS t han t he
report ed 5 3 0 per cent . A number of caref ully cont rolled longit udinal st udies have
been carried out in t he USA, and t hese have f ound no relat ionship bet w een t he
signs and sympt oms of TMPDS and t he presence of non-f unct ional occlusal
cont act s or mandibular displacement s. How ever, ot her st udies have f ound a
small but st at ist ically signif icant associat ion bet w een TMPDS and crossbit es,
ant erior open bit e and Class I I I malocclusions. I t is import ant t o remember t he
mult if act orial nat ure of TMPDS perhaps, t he presence of a displacing cont act in
suscept ible individuals cont act may act as t he f ocus of a paraf unct ional habit
mediat ed by st ress.

PRINCIPAL SOURCES AND FURTHER READING


Ameri can Journal of O rthodonti cs and Dentof aci al O rthopedi cs, 101 (1)
(1992).
This is a special issue dedicat ed t o t he result s of several st udies set up by t he
American Associat ion of O rt hodont ist s t o invest igat e t he link bet w een ort hodont ic
t reat ment and t he t emporomandibular joint . I t is essent ial reading f or all t hose
involved in dent ist ry.

Harris, M. , Feinmann, C. , Wise, M. , and Treasure, F. (1993).


Temporomandibular joint and orof acial pain: clinical and medicolegal
management problems. Bri ti sh Dental Journal, 174, 129 3 6.

Discusses t he role of psychogenic f act ors in t he aet iology of TMPDS.

Holmes, A. (1992). The subject ive need and demand f or ort hodont ic
t reat ment . Bri ti sh Journal of O rthodonti cs, 19, 287 9 7.

Lut her, F. (1998). O rt hodont ics and t he TMJ: Where are w e now ? Angl e
O rthodonti st, 68, 295 3 18.

An aut horit at ive review of t he lit erat ure on t his subject .

Murray, A. M. (1989). Discont inuat ion of ort hodont ic t reat ment : a st udy of t he
cont ribut ing f act ors. Bri ti sh Journal of O rthodonti cs, 16, 1 7 .

O ff ice of Populat ion Censuses and Surveys (1994). Chi l dren's dental heal th
i n the Uni ted Ki ngdom 1993. HMSO , London.

Richmond, S. (1993). The provision of ort hodont ic care in t he general dent al


services of England and Wales: ext ract ion pat t erns, t reat ment durat ion,
appliance t ypes and st andards. Bri ti sh Journal of O rthodonti cs, 20, 345 5 0.

Salonen, L. , Mohlin, B. , G öt zlinger, B. , and Helldén, L. (1992). Need and


demand f or ort hodont ic t reat ment in an adult Sw edish populat ion. European
Journal of O rthodonti cs, 14, 359 6 8.

Shaw, W. C. , O B rien, K. D. , Richmond, S. and Brook, P. (1991). Q ualit y


cont rol in ort hodont ics: risk/ benef it considerat ions. Bri ti sh Dental Journal,
170, 33 7 .

A rat her pessimist ic view of ort hodont ics.

Tang, E. L. K. and Wei, S. H. Y. (1990) Assessing t reat ment eff ect iveness of
removable and f ixed ort hodont ic appliances w it h t he occlusal index. Ameri can
Journal of O rthodonti cs and Dentof aci al O rthopedi cs, 99, 550 6 .

The aut hors concluded t hat t he eff ect iveness of f ixed appliances (as measured
w it h t he occlusal index) is much great er t han t hat of removable appliances.

Turbill, E. A. , Richmond, S. , and Wright , J. L. (1999). A closer look at G DS


ort hodont ics in England and Wales 1: Fact ors inf luencing eff ect iveness.
Bri ti sh Dental Journal, 187, 211 1 6.

Wassell, R. W. (1989) Do occlusal f act ors play a part in t emporomandibular


dysf unct ion? Journal of Denti stry, 17, 101 1 0.
The rest orat ive view point .

Wheeler, T. T. McG orray, S. P. , Yurkiew icz, L. , Keeling, S. D. , and King, G . J.


(1994) O rt hodont ic t reat ment demand and need in t hird and f ourt h grade
schoolchildren. Ameri can Journal of O rthodonti cs and Dentof aci al
O rthopedi cs, 106, 22 3 3.

Cont ains a good discussion on t he need and demand f or t reat ment .


Authors: Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> Table of C ontents > 2 - The aetiology and c las s ific ation of m aloc c lus ion

2
The aetiology and classification of malocclusion

2.1. THE AETIOLOGY OF M ALOCCLUSION


The aet iology of malocclusion is a f ascinat ing subject about w hich t here is st ill
much t o elucidat e and underst and. At a basic level, malocclusion can occur as a
result of genet ically det ermined f act ors, w hich are inherit ed, or environment al
f act ors, or more commonly a combinat ion of bot h inherit ed and environment al
f act ors act ing t oget her. For example, f ailure of erupt ion of an upper cent ral
incisor may arise as a result of dilacerat ion f ollow ing an episode of t rauma
during t he deciduous dent it ion w hich led t o int rusion of t he primary predecessor
an example of environment al aet iology. Failure of erupt ion of an upper cent ral
incisor can also occur as a result of t he presence of a super-numerary t oot h a
scenario w hich quest ioning may reveal also aff ect ed t he pat ient 's parent ,
suggest ing an inherit ed problem. How ever, if in t he lat t er example caries (an
environment al f act or) has led t o early loss of many of t he deciduous t eet h, t hen
f orw ard drif t of t he f irst permanent molar t eet h may also lead t o superimposit ion
of t he addit ional problem of crow ding.
While it is relat ively st raight f orw ard t o t race t he inherit ance of syndromes such
as clef t lip and palat e (see Chapt er 21), it is more diff icult t o det ermine t he
aet iology of f eat ures w hich are in essence part of normal variat ion, and t he
pict ure is f urt her complicat ed by t he compensat ory mechanisms t hat exist .
Evidence f or t he role of inherit ed f act ors in t he aet iology of malocclusion has
come f rom st udies of f amilies and t w ins. The f acial similarit y of members of a
f amily, f or example t he prognat hic mandible of t he Hapsburg royal f amily, is
easily appreciat ed. How ever, more direct t est imony is provided in st udies of
t w ins and t riplet s, w hich indicat e t hat skelet al pat t ern and t oot h size and number
are largely genet ically det ermined.
Examples of environment al inf luences include digit -sucking habit s and premat ure
loss of t eet h as a result of eit her caries or t rauma. Sof t t issue pressures act ing
upon t he t eet h f or more t han 6 hours per day can also inf luence t oot h posit ion.
How ever, because t he sof t t issues including t he lips are by necessit y at t ached t o
t he underlying skelet al f ramew ork, t heir eff ect is also mediat ed by t he skelet al
pat t ern.
Crow ding is ext remely common in Caucasians, aff ect ing approximat ely t w o-t hirds
of t he populat ion. As w as ment ioned above, t he size of t he jaw s and t eet h are
mainly genet ically det ermined; how ever, environment al f act ors, f or example
premat ure deciduous t oot h loss, can precipit at e or exacerbat e crow ding. I n
evolut ionary t erms bot h jaw size and t oot h size appear t o be reducing. How ever,
crow ding is much more prevalent in modern populat ions t han it w as in prehist oric
t imes. I t has been post ulat ed t hat t his is due t o t he int roduct ion of a less
abrasive diet , so t hat less int erproximal t oot h w ear occurs during t he lif et ime of
an individual. How ever, t his is not t he w hole st ory, as a change f rom a rural t o

an urban lif e-st yle can also apparent ly lead t o an increase in crow ding af t er
about t w o generat ions.
Alt hough t his discussion may at f irst seem rat her t heoret ical, t he aet iology of
malocclusion is a vigorously debat ed subject . This is because if one believes t hat
t he basis of malocclusion is genet ically det ermined, t hen it f ollow s t hat
ort hodont ics is limit ed in w hat it can achieve. How ever, t he opposit e view point is
t hat every individual has t he pot ent ial f or ideal occlusion and t hat ort hodont ic
int ervent ion is required t o eliminat e t hose environment al f act ors t hat have led t o
a part icular malocclusion. Research suggest s t hat f or t he majorit y of
malocclusions t he aet iology is mult if act orial, and ort hodont ic t reat ment can
eff ect only limit ed skelet al change. Theref ore, as a pat ient 's skelet al and grow t h
pat t ern is largely genet ically det ermined, if ort hodont ic t reat ment is t o be
successf ul clinicians must recognize and w ork w it hin t hose paramet ers.
O f necessit y, t he above is a brief summary, but it can be appreciat ed t hat t he
aet iology of malocclusion is a complex subject , much of w hich is st ill not f ully
underst ood. The reader seeking more inf ormat ion is advised t o consult t he
publicat ions list ed in t he sect ion on f urt her reading.

2.2. CLASSIFYING M ALOCCLUSION


The cat egorizat ion of a malocclusion by it s salient f eat ures is helpf ul f or
describing and document ing a pat ient 's occlusion. I n addit ion, classif icat ions and
indices allow t he prevalence of a malocclusion w it hin a populat ion t o be
recorded, and also aid in t he assessment of need, diff icult y, and success of
ort hodont ic t reat ment .
Malocclusion can be recorded qualit at ively and quant it at ively. How ever, t he large
number of classif icat ions and indices w hich have been devised, are t est imony t o
t he problems inherent in bot h t hese approaches. All have t heir limit at ions, and
t hese should be borne in mind w hen t hey are applied.
Tw o t erms are of t en ment ioned in relat ion t o indices:

Validity Can t he index measure w hat it w as designed t o measure?


Reproducibility Does t he index give t he same result w hen recorded on t w o
diff erent occasions, and by diff erent examiners?
2.2.1. Qualitative assessment of malocclusion
Essent ially, a qualit at ive assessment is descript ive and t heref ore t his cat egory
includes t he diagnost ic classif icat ions of maloccusion. The main draw back t o a
qualit at ive approach is t hat malocclusion is a cont inuous variable so t hat clear
cut -off point s bet w een diff erent cat egories do not alw ays exist . This can lead t o
problems w hen classif ying borderline malocclusions. I n addit ion, alt hough a
qualit at ive classif icat ion is a helpf ul short hand met hod of describing t he salient
f eat ures of a malocclusion, it does not provide any indicat ion of t he diff icult y of
t reat ment .
Q ualit at ive evaluat ion of malocclusion w as at t empt ed hist orically bef ore
quant at ive analysis. O ne of t he bet t er know n classif icat ions w as devised by
Angle in 1899, but ot her classif icat ions are now more w idely used, f or example
t he Brit ish St andards I nst it ut e (1983) classif icat ion of incisor relat ionship.

2.2.2. Quantitative assessment of malocclusion


I n quant it at ive indices t w o diff ering approaches can be used:

Each f eat ure of a malocclusion is given a score and t he summed t ot al is t hen


recorded (e. g. t he PAR I ndex).
The w orst f eat ure of a malocclusion is recorded (e. g. t he I ndex of
O rt hodont ic Treat ment Need).

2.3. COM M ONLY USED CLASSIFICATIONS AND INDICES


2.3.1. Angle's classification
Angle's classif icat ion w as based upon t he premise t hat t he f irst permanent
molars erupt ed int o a const ant posit ion w it hin t he f acial skelet on, w hich could be
used t o assess t he ant eropost erior relat ionship of t he arches. I n addit ion t o t he
f act t hat Angle's classif icat ion w as based upon an incorrect assumpt ion, t he
problems experienced in cat egorizing cases w it h f orw ard drif t or loss of t he f irst
permanent molars have result ed in t his part icular approach being superseded by
ot her classif icat ions. How ever, Angle's classif icat ion is st ill used t o describe
molar relat ionship, and t he t erms used t o describe incisor relat ionship have been
adapt ed int o incisor classif icat ion.
Angle described t hree groups (Fig. 2. 1):

Cl ass I or neutroccl usi on t he mesiobuccal cusp of t he upper f irst molar


occludes w it h t he mesiobuccal groove of t he low er f irst molar. I n pract ice
discrepancies of up t o half a cusp w idt h eit her w ay w ere also included in t his
cat egory.
Cl ass II or di stoccl usi on t he mesiobuccal cusp of t he low er f irst molar
occludes dist al t o t he Class I posit ion. This is also know n as a post normal
relat ionship.
Cl ass III or mesi occl usi on t he mesiobuccal cusp of t he low er f irst molar
occludes mesial t o t he Class I posit ion. This is also know n as a prenormal
relat ionship.

2.3.2. British Standards Institute classification


This is based upon incisor relat ionship and is t he most w idely used descript ive
classif icat ion. The t erms used are similar t o t hose of Angle's classif icat ion,
w hich can be a lit t le conf using as no regard is t aken of molar relat ionship. The
cat egories def ined by Brit ish St andard 4492 are as f ollow s:

Cl ass I t he low er incisor edges occlude w it h or lie immediat ely below t he


cingulum plat eau of t he upper cent ral incisors (Fig. 2. 2).
Cl ass II t he low er incisor edges lie post erior t o t he cingulum plat eau of t he
upper incisors. There are t w o subdivisions of t his cat egory:
Di vi si on 1 t he upper cent ral incisors are proclined or of average
inclinat ion and t here is an increase in overjet (Fig. 2. 3).
Di vi si on 2 The upper cent ral incisors are ret roclined. The overjet is
usually minimal or may be increased (Fig. 2. 4).
Cl ass III The low er incisor edges lie ant erior t o t he cingulum plat eau of t he
upper incisors. The overjet is reduced or reversed (Fig. 2. 5).

As w it h any descript ive analysis it is diff icult t o classif y borderline cases. Some
w orkers have suggest ed int roducing a Class I I int ermediat e cat egory f or t hose
cases w here t he upper incisors are upright and t he overjet increased bet w een 4
and 6 mm. How ever, t his suggest ion has not gained w idespread accept ance.
Fig. 2. 1. Angle's classif icat ion.
Fig. 2. 2. I ncisor classif icat ion Class I .

Fig. 2. 3. I ncisor classif icat ion Class I I division 1.

Fig. 2. 4. I ncisor classif icat ion Class I I division 2.


Fig. 2. 5. I ncisor classif icat ion Class I I I .

Fig. 2. 6. I O TN ruler.

2.3.3. Summers occlusal index


This index w as developed by Summers, in t he USA, during t he 1960s. I t is
popular in t he USA, part icularly f or research purposes. G ood reproducibilit y has
been report ed and it has also been employed t o det ermine t he success of
t reat ment w it h accept able result s. The index scores nine def ined paramet ers
including molar relat ionship, overbit e, overjet , post erior crossbit e, post erior open
bit e, t oot h displacement , midline relat ion, maxillary median diast ema, and absent
upper incisors. Allow ance is made f or diff erent st ages of development by varying
t he w eight ing applied t o cert ain paramet ers in t he deciduous, mixed, and
permanent dent it ion.

2.3.4. Index of Orthodontic Treatment Need (IOTN)


The I ndex of O rt hodont ic Treat ment Need w as developed as a result of a
government init iat ive. The purpose of t he index w as t o help det ermine t he likely
impact of a malocclusion on an individual's dent al healt h and psychosocial w ell-
being. I t comprises t w o element s.

Dental health component


This w as developed f rom an index used by t he Dent al Board in Sw eden designed
t o ref lect t hose occlusal t rait s, w hich could aff ect t he f unct ion and longevit y of
t he dent it ion. The single w orst f eat ure of a malocclusion is not ed (t he index is
not cumulat ive) and cat egorized int o one of f ive grades ref lect ing need f or
t reat ment (Table 2. 1):

G rade 1 no need
G rade 2 lit t le need
G rade 3 moderat e need
G rade 4 great need
G rade 5 very great need.

A ruler has been developed t o help w it h assessment of t he dent al healt h


component (Fig. 2. 6), and t hese are available commercially.

Aesthetic component
This aspect of t he index w as developed in an at t empt t o assess t he aest het ic
handicap posed by a malocclusion and t hus t he likely psychosocial impact upon
t he pat ient a t ask f raught w it h pot ent ial pit f alls (see Chapt er 1). The aest het ic
component comprises a set of t en st andard phot ographs (Fig. 2. 7), w hich are
also graded f rom score 1, t he most aest het ically pleasing, t o score 10, t he least
aest het ically pleasing. Colour phot ographs are available f or use w it h a pat ient in
t he clinical sit uat ion and black-and-w hit e phot ographs f or scoring f rom st udy

models alone. The pat ient 's t eet h (or st udy models), in occlusion, are view ed
f rom t he ant erior aspect and t he appropriat e score det ermined by choosing t he
phot ograph t hat is t hought t o pose an equivalent aest het ic handicap. The scores
are cat egorized acccording t o need f or t reat ment as f ollow s:

score 1 or 2 none
score 3 or 4 slight
score 5, 6, or 7 moderat e/ borderline
score 8, 9, or 10 def init e.
Table 2. 1 T he Index of O rthodontic Treatment Need

Grade 1 (None)

Extremely minor malocclusions including


1
displacements less than 1 mm

Grade 2 (Little)

2a Increased overjet 3.6 6 mm with competent lips

2b Reverse overjet 0.1 1 mm

Anterior or posterior crossbite with up to 1 mm


2c discrepancy between retruded contact position
and intercuspal position

2d Displacement of teeth 1.1 2 mm

2e Anterior or posterior open bite 1.1 2 mm

Increased overbite 3.5 mm or more, without


2f
gingival contact

Prenormal or postnormal occlusions with no other


2g
anomalies; includes up to half a unit discrepancy.

Grade 3 (Moderate)

3a Increased overjet 3.6 6 mm with incompetent lips

3b Reverse overjet 1.1 3 .5 mm


Anterior or posterior crossbites with 1.1 2 mm
3c
discrepancy

3d Displacement of teeth 2.1 4 mm

3e Lateral or anterior open bite 2.1 4 mm

Increased and complete overbite without gingival


3f
trauma

Grade 4 (Great)

4a Increased overjet 6.1 9 mm

Reversed overjet greater than 3.5 mm with no


4b
masticatory or speech difficulties

Anterior or posterior crossbites with greater than


4c 2 mm discrepancy between retruded contact
position and intercuspal position.

4d Severe displacement of teeth, greater than 4 mm.

Extreme lateral or anterior open bites, greater


4e
than 4 mm.

Increased and complete overbite with gingival or


4f
palatal trauma.

Less extensive hypodontia requiring pre-


4h restorative orthodontic space closure to obviate
the need for a prosthesis
Posterior lingual crossbite with no functional
4l
occlusal contact in one or both buccal segments

Reverse overjet 1.1 3 .5 mm with recorded


4m
masticatory and speech difficulties

Partially erupted teeth, tipped and impacted


4t
against adjacent teeth

4x Supplemental teeth

Grade 5 (Very Great)

5a Increased overjet greater than 9 mm

Extensive hypodontia with restorative implications


5h (more than one tooth missing in any quadrant)
requiring pre-restorative orthodontics

Impeded eruption of teeth (with the exception of


third molars) due to crowding, displacement, the
5i
presence of supernumerary teeth, retained
deciduous teeth, and any pathological cause

Reverse overjet greater than 3.5 mm with


5m
reported masticatory and speech difficulties

5p Defects of cleft lip and palate

5s Submerged deciduous teeth


Reproduced with the kind permission of Vuman Ltd.

Fig. 2. 7. Aest het ic component of I O TN.

An average score can be t aken f rom t he t w o component s, but t he dent al healt h


component alone is more w idely used. The aest het ic component has been
crit icized f or being subject ive, and part icular diff icult y is experienced in
accurat ely assessing Class I I I malocclusions or ant erior open bit es, as t he
phot ographs are composed of Class I and Class I I cases.

2.3.5. Peer Assessment Rating (PAR)


The PAR index w as developed primarily t o measure t he success (or ot herw ise)
of t reat ment . Scores are recorded f or a number of paramet ers (list ed below ),
bef ore and at t he end of t reat ment , using st udy models. Unlike I O TN, t he scores
are cumulat ive; how ever, a w eight ing is accorded t o each component t o ref lect

current opinion in t he UK as t o t heir relat ive import ance. The f eat ures recorded
are list ed below, w it h t he current w eight ings in parent hesis:

crow ding by cont act point displacement (×1)


buccal segment relat ionship in t he ant eropost erior, vert ical, and t ransverse
planes (×1)
overjet (×6)
overbit e (×2)
cent relines (×4).

The diff erence bet w een t he PAR scores at t he st art and on complet ion of
t reat ment can be calculat ed, and f rom t his t he percent age change in PAR score,
w hich is a ref lect ion of t he success of t reat ment , is derived. A high st andard of
t reat ment is indicat ed by a mean percent age reduct ion of great er t han 70 per
cent . A change of 30 per cent or less indicat es t hat no appreciable improvement
has been achieved. The size of t he PAR score at t he beginning of t reat ment
gives an indicat ion of t he severit y of a malocclusion. O bviously it is diff icult t o
achieve an signif icant reduct ion in PAR in cases w it h a low pret reat ment score.

2.3.6 Index of Complexity Outcome and Need (ICON)


This new index incorporat es f eat ures of bot h t he I ndex of O rt hodont ic Need
(I O TN) and t he Peer Assessment Rat ing (PAR). The aest het ic component of
I O TN is included along w it h scores f or upper arch crow ding/ spacing; presence of
cross-bit e; overbit e/ open bit e, and buccal segment relat ionship. As in t he PAR,
w eight ings are added t o ref lect current ort hodont ic opinion. The sum of t he
scores and t heir w eight ings gives a pret reat ment score, w hich is said t o ref lect
t he need f or, and likely complexit y of , t he t reat ment required. Follow ing
t reat ment t he index is scored again t o give an improvement grade (pret reat ment
score minus 4 × post -t reat ment score) and t hus t he out come of t reat ment . This
ambit ious index is current ly undergoing evaluat ion.

PRINCIPAL SOURCES AND FURTHER READING


Angle, E. H. (1899). Classif icat ion of malocclusion. Dental Cosmos, 41,
248 6 4.

Markovic, M. (1992). At t he crossroads of oral f acial genet ics. European


Journal of O rthodonti cs, 14, 469 8 1.

A f ascinat ing st udy of t w ins and t riplet s w it h Class I I / 2 malocclusions.

Mossey, P. A. (1999). The herit abilit y of malocclusion. Bri ti sh Journal of


O rthodonti cs, 26, 103 1 3, 195 2 03.
Richmond, S. , Shaw, W. C. , O B rien, K. D. , Buchanan, I . B. , Jones, R. ,
St ephens, C. D. , et al . (1992). The development of t he PAR index (Peer
Assessment Rat ing): reliabilit y and validit y. European Journal of
O rthodonti cs, 14, 125 3 9.

The PAR index, part 1.

Richmond, S. , Shaw, W. C. , Robert s, C. T. , and Andrew s, M. (1992). The


PAR index (Peer Assessment Rat ing): met hods t o det ermine t he out come of
ort hodont ic t reat ment in t erms of improvement s and st andards. European
Journal of O rthodonti cs, 14, 180 7 .

The PAR index, part 2.

Summers, C. J. (1971). A syst em f or ident if ying and scoring occlusal


disorders. Ameri can Journal of O rthodonti cs, 59, 552 6 7.

For readers requiring f urt her inf ormat ion on Summers occlusal index.

Shaw, W. C. , O B rien, K. D. , and Richmond, S. (1991). Q ualit y cont rol in


ort hodont ics: indices of t reat ment need and t reat ment st andards. Bri ti sh
Dental Journal, 170, 107 1 2.

An int erest ing paper on t he role of indices, w it h good explanat ions of t he I O TN


and t he PAR index.

Tang, E. L. K. and Wei, S. H. Y. (1993). Recording and measuring


malocclusion: a review of t he lit erat ure. Ameri can Journal of O rthodonti cs
and Dentof aci al O rthopedi cs, 103, 344 5 1.

Usef ul f or t hose researching t he subject .


Authors: Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> Table of C ontents > 3 - Managem ent of the developing dentition

3
Management of the developing dentition

Many dent al pract it ioners f ind it diff icult t o judge w hen t o int ervene in a
developing malocclusion and w hen t o let nat ure t ake it s course. This is because
experience is only gained over years of caref ul observat ion, and decisions t o
int ercede are of t en made in response t o pressure exert ed by t he parent s t o do
somet hing . I t is hoped t hat t his chapt er w ill help impart some of t he f ormer, so
t hat t he reader is bet t er able t o resist t he lat t er.

3.1. NORM AL DENTAL DEVELOPM ENT


I t is import ant t o realize t hat normal in t his cont ext means average, rat her t han
ideal. An appreciat ion of w hat const it ut es t he range of normal development is
essent ial. O ne area in w hich t his is part icularly pert inent is erupt ion t imes (Table
3. 1).

3.1.1. Calcification and eruption times


Know ledge of t he calcif icat ion t imes of t he permanent dent it ion is invaluable if
one w ishes t o impress pat ient s and colleagues. I t is also helpf ul f or assessing
dent al as opposed t o chronological age, f or det ermining w het her a developing
t oot h not present on radiographic examinat ion can be considered absent , and f or
est imat ing t he t iming of any possible causes of localized hypocalcif icat ion or
hypoplasia (chronological hypoplasia).

3.1.2. The transition from primary to mixed dentition


The erupt ion of a baby's f irst t oot h is heralded by t he proud parent s as a major
landmark in t heir child's development . This milest one is described in many baby-
care books as occurring at 6 mont hs of age, w hich can lead t o unnecessary
concern as it is normal f or t he mandibular incisors t o erupt at any t ime in t he
f irst year. Dent al t ext books of t en dismiss t eet hing , ascribing t he sympt oms t hat
occur at t his t ime t o t he diminut ion of mat ernal ant ibodies. Any parent w ill be
able t o correct t his f allacy!
Erupt ion of t he primary dent it ion (Fig. 3. 1) is usually complet ed around 3 years
of age. The deciduous incisors erupt upright and spaced a lack of spacing
st rongly suggest s t hat t he permanent successors w ill be crow ded. O verbit e
reduces t hroughout t he primary dent it ion unt il t he incisors are edge t o edge,
w hich can cont ribut e t o marked at t rit ion.
The mixed dent it ion phase is usually heralded by t he erupt ion of eit her t he f irst
permanent molars or t he low er cent ral incisors. The low er labial segment t eet h
erupt bef ore t heir count erpart s in t he upper arch and develop lingual t o t heir

predecessors. I t is usual f or t here t o be some crow ding of t he permanent low er


incisors as t hey emerge int o t he mout h, w hich reduces w it h int ercanine grow t h.
As a result t he low er incisors of t en erupt slight ly lingually placed and/ or rot at ed
(Fig. 3. 2), but w ill usually align spont aneously if space becomes available. I f t he
arch is inherent ly crow ded, t his space short age w ill not resolve w it h int ercanine
grow t h.

Fig. 3. 1. Primary dent it ion.

Table 3. 1 Average calcification and eruption times

Calcification commences Eruption



(weeks in utero) (months)

Primary dentition

Central
12 1 6 6 7
incisors

Lateral
incisors 13 1 6 7 8

Canines 15 1 8 18 2 0

First molars 14 1 7 12 1 5

Second
16 2 3 24 3 6
molars

Root calcification complete 1 1 ˝ years after eruption

Calcification commences Eruption



(months) (years)

Permanent dentition

Mand. central
3 4 6 7
incisors

Mand. lateral
3 4 7 8
incisors

Mand. canines 4 5 9 1 0

Mand. first
21 2 4 10 1 2
premolars

Mand. second
27 3 0 11 1 2
premolars

Mand. first
Around birth 5 6
molars
Mand. second
30 3 6 12 1 3
molars

Mand. third
96 1 20 17 2 5
molars

Max. central
3 4 7 8
incisors

Max. lateral
10 1 2 8 9
incisors

Max. canines 4 5 11 1 2

Max. first
18 2 1 10 11
premolars

Max. second
24 2 7 10 1 2
premolars

Max. first
Around birth 5 6
molars

Max. second
30 3 6 12 1 3
molars

Max. third
84 1 08 17 2 5
molars

Root calcification complete 2 3 years after eruption

The upper permanent incisors also develop lingual t o t heir predecessors.


Addit ional space is gained t o accommodat e t heir great er w idt h because t hey
erupt ont o a w ider arc and are more proclined t han t he primary incisors. I f t he
arch is int rinsically crow ded, t he lat eral incisors w ill not be able t o move labially
f ollow ing erupt ion of t he cent ral incisors and t heref ore may erupt palat al t o t he
arch. Pressure f rom t he developing lat eral incisor of t en gives rise t o spacing
bet w een t he cent ral incisors w hich resolves as t he lat erals erupt . They in t urn
are t ilt ed dist ally by t he canines lying on t he dist al aspect of t heir root . This
lat t er st age of development used t o be described as t he ugly duckling st age of
development (Fig. 3. 3), alt hough it is probably diplomat ic t o describe it as
normal dent al development t o concerned parent s. As t he canines erupt , t he
lat eral incisors usually upright t hemselves and t he spaces close. The upper
canines

develop palat ally, but migrat e labially t o come t o lie slight ly labial and dist al t o
t he root apex of t he lat eral incisors. I n normal development t hey can be palpat ed
buccally f rom as young as 8 years of age.

Fig. 3.2. Crowding of the labial segment reducing with


growth in intercanine width: (a), (b), (c) age 8 years;
(d), (e), (f) age 9 years.

(a)

(b)
(c)

(d)

(e)

(f)

The combined w idt h of t he deciduous canine, f irst molar, and second molar is
great er t han t hat of t heir permanent successors, part icularly in t he low er arch.
This diff erence in w idt hs is called t he leew ay space (Fig. 3. 4) and in general is
of t he order of 1 1 . 5 mm in t he maxilla and 2 2 . 5 mm in t he mandible (in
Caucasians). This means t hat if t he deciduous buccal segment t eet h are ret ained
unt il t heir normal exf oliat ion t ime, t here w ill be suff icient space f or t he
permanent canine and premolars.
The deciduous second molars usually erupt w it h t heir dist al surf aces f lush
ant eropost eriorly. The t ransit ion t o t he st epped Class I molar relat ionship occurs

during t he mixed dent it ion as a result of diff erent ial mandibular grow t h and/ or t he
leew ay space.

Fig. 3. 3. Ugly duckling st age.

Fig. 3. 4. Leew ay space.

3.1.3. Development of the dental arches


Intercanine width is measured across t he cusps of t he deciduous/ permanent
canines, and during t he primary dent it ion an increase of around 1 2 mm is seen.
I n t he mixed dent it ion an increase of about 3 mm occurs, but t his grow t h is
largely complet ed around a development al st age of 9 years w it h some minimal
increase up t o age 13. Af t er t his t ime a gradual decrease is t he norm.
Arch width is measured across t he arch bet w een t he lingual cusps of t he second
deciduous molars or second premolars. Bet w een t he ages of 3 and 18 years an
increase of 2 3 mm occurs; how ever, f or clinical purposes arch w idt h is largely
est ablished in t he mixed dent it ion.
Arch circumference is det ermined by measuring around t he buccal cusps and
incisal edges of t he t eet h t o t he dist al aspect of t he second deciduous molars or
second premolars. O n average, t here is lit t le change w it h age in t he maxilla;
how ever, in t he mandible arch circumf erence decreases by about 4 mm because
of t he leew ay space. I n individuals w it h crow ded mout hs a great er reduct ion may
be seen.
I n summary, on t he w hole t here is lit t le change in t he size of t he arch ant eriorly
af t er t he est ablishment of t he primary dent it ion, except f or an increase in
int ercanine w idt h w hich result s in a modif icat ion of arch shape. G row t h
post eriorly provides space f or t he permanent molars, and considerable
apposit ional vert ical grow t h occurs t o maint ain t he relat ionship of t he arches
during vert ical f acial grow t h.

3.2. ABNORM ALITIES OF ERUPTION AND EXFOLIATION


3.2.1. Screening
Early det ect ion of any abnormalit ies in t oot h development and erupt ion is
essent ial t o give t he opport unit y f or int ercept ive act ion t o be t aken. This requires
caref ul observat ion of t he developing dent it ion f or evidence of any problems, f or
example deviat ions f rom t he normal sequence of erupt ion. I f an abnormalit y is
suspect ed t hen f urt her invest igat ion including radiographs is indicat ed. Around 9
t o 10 years of age it is import ant t o palpat e t he buccal sulcus f or t he permanent
maxillary canines in order t o det ect any abnormalit ies in t he erupt ion pat h of t his
t oot h.

3.2.2. Natal teeth


A t oot h, w hich is present at birt h, or erupt s soon af t er, is described as a nat al
t oot h. These most commonly arise ant eriorly in t he mandible and are t ypically a
low er primary incisor, w hich has erupt ed premat urely (Fig. 3. 5). Because root
f ormat ion is not complet e at t his st age, nat al t eet h can be quit e mobile, but t hey
usually become f irmer relat ively quickly. I f t he t oot h (or t eet h) int erf eres w it h
breast f eeding or is so mobile t hat t here is a danger of inhalat ion, removal is
indicat ed and t his can usually be accomplished w it h t opical anaest hesia. I f t he
t oot h is sympt omless, it can be lef t i n si tu.
Fig. 3. 5. Nat al t oot h present at birt h.

3.2.3. Eruption cyst


An erupt ion cyst is caused by an accumulat ion of f luid or blood in t he f ollicular
space overlying t he crow n of an erupt ing t oot h (Fig. 3. 6). They usually rupt ure
spont aneously, but very occasionally marsupializat ion may be necessary.

Fig. 3. 6. Erupt ion cyst .

3.2.4. Failure of/delayed eruption


There is a w ide individual variat ion in erupt ion t imes, w hich is illust rat ed by t he
pat ient s in Fig. 3. 7. Where t here is a generalized t ardiness in t oot h erupt ion in
an ot herw ise f it child, a period of observat ion is indicat ed. How ever, t he
f ollow ing may be indicat ors of some abnormalit y and t heref ore w arrant f urt her
invest igat ion (Fig. 3. 8):
A disrupt ion in t he normal sequence of erupt ion.
An asymmet ry in erupt ion pat t ern bet w een cont ralat eral t eet h. I f a t oot h on
one side of t he arch has erupt ed and 6 mont hs lat er t here is st ill no sign of
it s equivalent on t he ot her side, radiographic examinat ion is indicat ed.

Fig. 3.7. (a) Normal variation in eruption times: (a)


patient aged 12.5 years with deciduous canines and
molars still present; (b), (c) patient aged nine years
with all permanent teeth to the second molars erupted.

(a)

(b)

(c)

Table 3. 2 Causes of delayed eruption


Generalized causes
Hereditary gingival fibromatosis
Down syndrome
Cleidocranial dysostosis
Cleft lip and palate
Ricketts
Localized causes
Congenital absence
Crowding
Delayed exfoliation of primary predecessor
Supernumerary tooth (see below)
Dilaceration
Abnormal position of crypt
Primary failure of eruption

Fig. 3. 8. Disrupt ion of normal erupt ion sequence as 21/ 2 erupt ed, but / 1
unerupt ed.

3.3. M IXED DENTITION PROBLEM S


3.3.1. Premature loss of deciduous teeth
Balancing extraction is t he removal of t he cont ralat eral t oot h. Compensating
extraction is t he removal of t he equivalent opposing t oot h.
The major eff ect of early loss of a primary t oot h, w het her due t o caries,
premat ure exf oliat ion, or planned ext ract ion, is localizat ion of pre-exist ing
crow ding. I n an uncrow ded mout h t his w ill not occur. How ever, w here some
crow ding exist s and a primary t oot h is ext ract ed, t he adjacent t eet h w ill drif t or
t ilt around int o t he space provided. The ext ent t o w hich t his occurs depends upon
t he degree of crow ding, t he pat ient 's age, and t he sit e. O bviously, as t he degree
of crow ding increases so does t he pressure f or t he remaining t eet h t o move int o
t he ext ract ion space. The younger t he child is w hen t he primary t oot h is
ext ract ed, t he great er is t he pot ent ial f or drif t ing t o ensue. The eff ect of t he sit e
of t oot h loss is best considered by t oot h t ype, but it is import ant t o bear in mind
t he increased pot ent ial f or mesial drif t in t he maxilla.

Deciduous incisor: premat ure loss of a deciduous incisor has lit t le impact ,
mainly because t hey are shed relat ively early in t he mixed dent it ion.
Deciduous canine: unilat eral loss of a primary canine in a crow ded mout h
w ill lead t o a cent reline shif t (Fig. 3. 9). As t his is a diff icult problem t o t reat ,
of t en requiring f ixed appliances, prevent ion is pref erable and t heref ore
premat ure loss of a deciduous canine should be balanced in any pat ient w it h
even t he mildest crow ding.
Deciduous first molar: unilat eral loss of t his t oot h may result in a cent re-
line shif t . I n most cases an aut omat ic balancing ext ract ion is not necessary,
but t he cent reline should be kept under observat ion and, if indicat ed, a t oot h
on t he opposit e side of t he arch removed.
Deciduous second molar: if a second primary molar is ext ract ed t he f irst
permanent molar w ill drif t f orw ards (Fig. 3. 10). This is part icularly marked if
loss occurs bef ore t he erupt ion of t he permanent t oot h and f or t his reason it
is bet t er, if at all possible, t o t ry t o preserve t he second deciduous molar at
least unt il t he f irst permanent molar has appeared. I n most cases balancing
or compensat ing ext ract ions of ot her sound second primary molars is not
necessary. How ever, w here ext ract ion of a carious upper deciduous molar
alone w ould change t he molar relat ionship f rom a half -unit Class I I t o a f ull
Class I I , it may be advisable t o consider balancing w it h t he ext ract ion of t he
low er second deciduous molar.
Fig. 3. 9. Cent re-line shif t t o pat ient 's lef t ow ing t o early unbalanced loss of
low er lef t deciduous canine.

Fig. 3. 10. Loss of a low er second deciduous molar leading t o f orw ard drif t of
f irst permanent molar.

I t should be emphasized t hat t he above are suggest ions, not rules, and at all
t imes a degree of common sense and f orw ard planning should be applied. For
example, if ext ract ion of a carious f irst primary molar is required and t he
cont ralat eral t oot h is also doubt f ul, t hen it might be pref erable in t he long t erm
t o ext ract bot h. Also, in children w it h an absent permanent t oot h (or t eet h) early
ext ract ion of t he primary buccal segment t eet h may be advant ageous t o
encourage f orw ard movement of t he f irst permanent molars if space closure
(rat her t hen space opening) is planned.
The eff ect of early ext ract ion of a primary t oot h on t he erupt ion of it s successor
is variable and w ill not necessarily result in a hast ening of erupt ion.

3.3.2. Retained deciduous teeth


A diff erence of more t han 6 mont hs bet w een t he shedding of cont ralat eral t eet h
should be regarded w it h suspicion. Provided t hat t he permanent successor is

present , ret ained primary t eet h should be ext ract ed, part icularly if t hey are
causing def lect ion of t he permanent t oot h (Fig. 3. 11).

Fig. 3. 11. Ret ained primary t oot h cont ribut ing t o def lect ion of t he permanent
successor.

3.3.3. Infra-occluded (submerged) primary molars


I nf ra-occlusion is now t he pref erred t erm f or describing t he process w here a
t oot h f ails t o achieve or maint ain it s occlusal relat ionship w it h adjacent or
opposing t eet h. Most inf ra-occluded deciduous t eet h erupt int o occlusion, but
subsequent ly become s ubmerged because bony grow t h and development of t he
adjacent t eet h cont inues (Fig. 3. 12). Est imat es vary, but t his anomaly w ould
appear t o occur in around 1 9 per cent of children.
Resorpt ion of t he primary t eet h is not a cont inuous process. I n f act , resorpt ion
is int erchanged w it h periods of repair, alt hough in most cases t he f ormer
prevails. I f a t emporary predominance of repair occurs t his can result in
ankylosis and inf ra-occlusion of t he aff ect ed primary molar.
Fig. 3. 12. Ankylosed primary molars.

The result s of recent epidemiological st udies have suggest ed a genet ic t endency


t o t his phenomenon and also an associat ion w it h ot her dent al anomalies including
ect opic erupt ion of f irst permanent molars, palat al displacement of maxillary
canines, and congenit al absence of premolar t eet h. Theref ore, it is advisable t o
be vigilant in pat ient s exhibit ing any of t hese f eat ures.
Where a permanent successor exist s t he phenomenon is usually t emporary, and
st udies have show n no diff erence in t he age at exf oliat ion of a submerged
primary molar compared w it h an unaff ect ed cont ralat eral t oot h. Theref ore
ext ract ion of a submerged primary t oot h is only necessary under t he f ollow ing
condit ions:

There is a danger of t he t oot h disappearing below gingival level (Fig. 3. 13).


Root f ormat ion of t he permanent t oot h is nearing complet ion (as erupt ive
f orce reduces markedly af t er t his event ).
The permanent successor is missing, as in t his sit uat ion t he submergence
may be progressive.

Fig. 3. 13. Marked submergence of deciduous molar (w it h second premolar


aff ect ed).

3.3.4. Impacted first permanent molars


I mpact ion of a f irst permanent molar t oot h against t he second deciduous molar
occurs in approximat ely 2 6 per cent of children and is indicat ive of crow ding. I t
most commonly occurs in t he upper arch (Fig. 3. 14). Spont aneous disimpact ion
may occur, but t his is rare af t er 8 years of age. Mild cases can somet imes be
managed by t ight ening a brass separat ing w ire around t he cont act point bet w een
t he t w o t eet h over a period of about 2 mont hs. This can have t he eff ect of
pushing t he permanent molar dist ally, t hus let t ing it jump f ree. I n more severe
cases t he impact ion can be kept under observat ion, alt hough ext ract ion of t he
deciduous t oot h may be indicat ed if it becomes abscessed or t he permanent
t oot h becomes carious and rest orat ion precluded by poor access. The result ant
space loss can be dealt w it h in t he permanent dent it ion.

3.3.5. Dilaceration
Dilacerat ion is a dist ort ion or bend in t he root of a t oot h.

Aetiology
There appear t o be t w o dist inct aet iologies:

Development al t his anomaly usually aff ect s an isolat ed cent ral incisor and
occurs in f emales more of t en t han males. The crow n of t he aff ect ed t oot h is
t urned upw ard and labially and no dist urbance of enamel and dent ine is seen
(Fig. 3. 15).
Trauma int rusion of a deciduous incisor leads t o displacement of t he
underlying developing permanent t oot h germ. Charact erist ically, t his causes
t he developing permanent t oot h crow n t o be def lect ed palat ally, and t he
enamel and dent ine f orming at t he t ime of t he injury are dist urbed, giving rise
t o hypoplasia. The sexes are equally aff ect ed and more t han one t oot h may
be involved depending upon t he ext ent of t he t rauma.
Fig. 3. 14. I mpact ed bilat eral upper f irst permanent molars.

Fig. 3. 15. A dilacerat ed cent ral incisor.

M anagement
Dilacerat ion usually causes f ailure of erupt ion. Where t he dilacerat ion is severe
t here is of t en no alt ernat ive but t o remove t he aff ect ed t oot h. I n milder cases it
may be possible t o expose t he crow n surgically and apply t ract ion t o align t he
t oot h, provided t hat t he root apex w ill be sit ed w it hin cancellous bone at t he
complet ion of crow n alignment .

3.3.6. Supernumerary teeth


A supernumerary t oot h is one t hat is addit ional t o t he normal series. This
anomaly occurs in t he permanent dent it ion in approximat ely 2 per cent of t he

populat ion and in t he primary dent it ion in less t han 1 per cent , t hough a super-
numerary in t he deciduous dent it ion is of t en f ollow ed by a supernumerary in t he
permanent dent it ion. The aet iology is not complet ely underst ood, but suggest ions
include an off shoot of t he dent al lamina of t he permanent dent it ion or a t ert iary
dent it ion. This anomaly occurs more commonly in males t han f emales.
Supernumerary t eet h are also commonly f ound in t he region of t he clef t in
individuals w it h a clef t of t he alveolus.
Supernumerary t eet h can be described according t o t heir morphology or posit ion
in t he arch.

Fig. 3. 16. A supplement al low er lat eral incisor.

M orphology
Supplemental: t his t ype resembles a t oot h and occurs at t he end of a t oot h
series, f or example an addit ional lat eral incisor, second premolar, or f ourt h
molar (Fig. 3. 16).
Conical: t he conical or peg-shaped supernumerary most of t en occurs
bet w een t he upper cent ral incisors (Fig. 3. 17). I t is said t o be more
commonly associat ed w it h displacement of t he adjacent t eet h, but can also
cause f ailure of erupt ion or have no eff ect at all.
Tuberculate: t his t ype is described as being barrel-shaped, but usually any
supernumerary w hich does not f all int o t he conical or supplement al
cat egories is included. Classically, t his t ype is associat ed w it h f ailure of
erupt ion (Fig. 3. 18).
O dontome: This variant is rare. Bot h compound and complex f orms have
been described.
Fig. 3. 17. Tw o conical supernumeraries lying bet w een 1/ 1 w it h / A ret ained.

Position
Supernumerary t eet h can occur w it hin t he arch, but w hen t hey develop bet w een
t he cent ral incisors t hey are of t en described as a mesiodens. A supernumerary
t oot h dist al t o t he arch is called a dist omolar, and one adjacent t o t he molars is
know n as a paramolar.

Effects of supernumerary teeth and their management


Failure of eruption
The presence of a supernumerary t oot h is t he most common reason f or t he non-
appearance of a maxillary cent ral incisor. How ever, f ailure of erupt ion of any
t oot h in eit her arch can be caused by a supernumerary.
Management of t his problem involves removing t he supernumerary t oot h and
ensuring t hat t here is suff icient space t o accommodat e t he unerupt ed t oot h in t he
arch. I f t he t oot h does not erupt spont aneously w it hin 1 year, t hen a second
operat ion t o expose it and apply ort hodont ic t ract ion may be required.
Management of a pat ient w it h t his problem is illust rat ed in Fig. 3. 19.
Fig. 3. 18. A t uberculat e supernumerary lying occlusal t o 2/ .

Displacement
The presence of a supernumerary t oot h can be associat ed w it h displacement or
rot at ion of an erupt ed permanent t oot h (Fig. 3. 20). Management involves f irst ly
removal of t he supernumerary, usually f ollow ed by f ixed appliances t o align t he
aff ect ed t oot h or t eet h. I t is said t hat t his t ype of displacement has a high
t endency t o relapse f ollow ing t reat ment , but t his may be a ref lect ion of t he f act
t hat t he malposit ion is usually in t he f orm of a rot at ion or an apical displacement
w hich are part icularly liable t o relapse.

Fig. 3.19. (a) Management of a patient with failure of


eruption of the upper central incisors owing to the
presence of two supernumerary teeth: (a) patient on
presentation aged 10 years; (b) radiograph showing
unerupted central incisors and associated conical
supernumerary teeth; (c) following removal of the
supernumerary teeth a URA was fitted to open space
for the central incisors, until 1/ erupted 10 months
later; (d) 7 months later /1 erupted and a second URA
with a buccal spring was used to align /1; (e) occlusion
3 years after initial presentation.
(a)

(b)

(c)

(d)
(e)

Fig. 3. 20. Displacement of 1/ 1 caused by t w o erupt ed conical supernumerary


t eet h.

Fig. 3. 21. Crow ding due t o t he presence of t w o supplement al upper lat eral
incisors.

Crowding
This is caused by t he supplement al t ype and is t reat ed by removing t he most
poorly f ormed or more displaced t oot h (Fig. 3. 21).

No effect
O ccasionally a supernumerary t oot h (usually of t he conical t ype) is det ect ed as
a chance f inding on a radiograph of t he upper incisor region (Fig. 3. 22).
Provided t hat t he ext ra t oot h w ill not int erf ere w it h any planned movement of t he
upper incisors, it can be lef t i n si tu under radiographic observat ion. I n pract ice
t hese t eet h usually remain sympt omless and do not give rise t o any problems.

Fig. 3.22. Chance finding of a supernumerary on


routine radiographic examination.

(a)

(b)
3.3.7. Habits
The eff ect of a habit w ill depend upon t he f requency and int ensit y of indulgence.
This problem is discussed in great er det ail in Chapt er 9, Sect ion 9. 1. 4.

3.3.8. First permanent molars of poor long-term


prognosis
Treat ment planning f or a child w it h poor-qualit y f irst permanent molars is alw ays
diff icult because several compet ing f act ors have t o be considered bef ore a
decision can be reached f or a part icular individual. First permanent molars are
never t he f irst t oot h of choice f or ext ract ion as t heir posit ion w it hin t he arch
means t hat lit t le space is provided ant eriorly f or relief of crow ding or correct ion
of t he incisor relat ionship unless appliances are used. Removal of maxillary f irst
molars of t en compromises anchorage in t he upper arch, and a good spont aneous
result in t he low er arch f ollow ing ext ract ion of t he f irst molars is rare. How ever,
pat ient s f or w hom enf orced ext ract ion of t he f irst molars is required are of t en
t he least able t o support complicat ed t reat ment . Finally, it has t o be
remembered t hat , unless t he caries rat e is reduced, t he premolars may be
similarly aff ect ed a f ew years lat er. Nevert heless, if a t w o-surf ace rest orat ion is
present or required in t he f irst permanent molar of a child, t he prognosis f or t hat
t oot h and t he remaining

f irst molars should be considered as t he planned ext ract ion of f irst permanent
molars of poor qualit y may be pref erable t o t heir enf orced ext ract ion lat er on
(Fig. 3. 23).
Fig. 3. 23. All f our f irst permanent molars w ere ext ract ed in t his pat ient
because of t he poor long-t erm prognosis f or 6 and / 6.

Fact ors t o consider w hen assessing f irst permanent molars of poor long-t erm
prognosis
I t is impossible t o produce hard and f ast rules regarding t he ext ract ion of f irst
permanent molars, and t heref ore t he f ollow ing should only be considered a
st art ing point :

Check f or t he presence of all permanent t eet h. I f any are absent , ext ract ion
of t he f irst permanent molar in t hat quadrant should be avoided.
I f t he dent it ion is uncrow ded, ext ract ion of f irst permanent molars should be
avoided as space closure w ill be diff icult .
Remember t hat in t he maxilla t here is a great er t endency f or mesial drif t and
so t he t iming of t he ext ract ion of upper f irst permanent molars is less
crit ical.
I n t he low er arch a good spont aneous result is more likely if :
a. t he low er second permanent molar has developed as f ar as it s
bif urcat ion;
b. t he angle bet w een t he long axis of t he crypt of t he low er second
permanent molar and t he f irst permanent molar is bet w een 15° and 30°;
c. t he crypt of t he second molar overlaps t he root of t he f irst molar (a
space bet w een t he t w o reduces t he likelihood of good space closure).
Ext ract ion of t he f irst molars w ill relieve buccal segment crow ding, but w ill
have lit t le eff ect on a crow ded labial segment .
I f space is needed ant eriorally f or t he relief of labial segment crow ding or
f or ret ract ion of incisors (i. e. t he upper arch in Class I I cases or t he low er
arch in Class I I I cases), t hen it may be prudent t o delay ext ract ion of t he
f irst molar, if possible, unt il t he second permanent molar has erupt ed in t hat
arch. The space can t hen be ut ilized f or correct ion of t he labial segment .
Serious considerat ion should be given t o ext ract ing t he opposing upper f irst
permanent molar, should ext ract ion of a low er molar be necessary. I f t he
upper molar is not ext ract ed it w ill over-erupt and prevent f orw ard drif t of
t he low er second molar (Fig. 3. 24).
A compensat ing ext ract ion in t he low er arch (w hen ext ract ion of an upper
f irst permanent molar is necessary) should be avoided w here possible as a
good spont aneous result in t he mandibular arch is less likely.
I mpact ion of t he t hird permanent molars is less likely, but not impossible,
f ollow ing ext ract ion of t he f irst molar.

Fig. 3. 24. O ver-erupt ion of 6/ prevent ing f orw ard movement of t he low er
right second permanent molar.

3.3.9. Median diastema


Prevalence
Median diast ema occurs in 98 per cent of 6-year-olds, 49 per cent of 11-year-
olds, and 7 per cent of 12 1 8-year-olds.

Aetiology
Fact ors, w hich have been considered t o lead t o a median diast ema include t he
f ollow ing:

physiological (normal dent al development )


small t eet h in large jaw s (a spaced dent it ion)
missing t eet h
midline supernumerary t oot h/ t eet h
proclinat ion of t he upper labial segment
prominent f raenum.
Fig. 3. 25. Pat ient w it h missing 2/ 2 and a median diast ema w it h a low f raenal
at t achment .

A median diast ema is normally present bet w een t he maxillary permanent cent ral
incisors w hen t hey f irst erupt . As t he lat eral incisors and t hen t he canines
emerge t he diast ema usually closes. Theref ore a midline diast ema is a normal
f eat ure of t he developing dent it ion; how ever, if it persist s af t er erupt ion of t he
canines, it is unlikely t hat it w ill close spont aneously.
I n t he deciduous dent it ion t he upper midline f raenum runs bet w een t he cent ral
incisors and at t aches int o t he incisive papilla area. How ever, as t he cent ral
incisors move t oget her w it h erupt ion of t he lat eral incisors, it t ends t o migrat e
round ont o t he labial aspect . I n a spaced upper arch, or w here t he upper lat eral
incisors are missing (Fig. 3. 25), t his recession of t he f raenal at t achment is less
likely t o occur and in such cases it is obviously not appropriat e t o at t ribut e t he
persist ence of a diast ema t o t he f raenum it self . How ever, in a small proport ion
of cases t he upper midline f raenum can cont ribut e t o t he persist ence of a
diast ema. Fact ors, w hich may indicat e t hat t his is t he case include t he f ollow ing:

When t he f raenum is placed under t ension t here is blanching of t he incisive


papilla.
Radiographically, a not ch can be seen at t he crest of t he int erdent al bone
bet w een t he upper cent ral incisors (Fig. 3. 26).
The ant erior t eet h may be crow ded.
Fig. 3. 26. Not ch in int erdent al bone bet w een 1/ 1 associat ed w it h a f raenal
insert ion running bet w een 1/ 1 int o t he incisive papilla.

M anagement
I t is advisable t o t ake a periapical radiograph t o exclude t he presence of a
midline supernumerary t oot h prior t o planning t reat ment f or a midline diast ema.
I n t he developing dent it ion a diast ema of less t han 3 mm rarely w arrant s
int ervent ion; in part icular, ext ract ion of t he deciduous canines should be avoided
as t his w ill t end t o make t he diast ema w orse. How ever, if t he diast ema is
great er t han 3 mm and t he lat eral incisors are present , it may be necessary t o
consider appliance t reat ment t o approximat e t he cent ral incisors t o provide
space f or t he lat erals and canines t o erupt . How ever, care should be t aken t o
ensure t hat t he root s of t he t eet h being moved are not pressed against any
unerupt ed crow ns as t his can lead t o root resorpt ion. I f t he crow ns of t he t eet h
are t ilt ed dist ally, an

upper removable appliance (URA) can be used t o approximat e t he t eet h, but


f ixed appliances are required f or bodily movement . Closure of a diast ema has a
not able t endency t o relapse, t heref ore long-t erm ret ent ion is required. This is
most readily accomplished by placement of a bonded ret ainer.

3.4. SERIAL EXTRACTION


Serial ext ract ion w as f irst advocat ed in 1948 by Kjellgren, a Sw edish
ort hodont ist , as a solut ion t o a short age of ort hodont ist s. Kjellgren hoped t hat
his scheme w ould f acilit at e t he t reat ment of pat ient s w it h st raight f orw ard
crow ding by t heir ow n dent ist s, t hus minimizing demands upon t he ort hodont ic
service. He suggest ed t he employment of a planned sequence of ext ract ions
designed t o allow crow ded incisor segment s t o align spont aneously during t he
mixed dent it ion by shif t ing labial segment crow ding t o t he buccal segment s
w here it could be dealt w it h by premolar ext ract ions.

3.4.1. Classical technique


Ext ract ion of t he deciduous canines, as t he lat eral incisors w ere are
erupt ing. This st ep w as designed t o allow t he incisors t o align.
Ext ract ion of t he f irst deciduous molars w hen t heir root s w ere approximat ely
half resorbed. The purpose of t his w as is t o hast en t he erupt ion of t he f irst
premolars.
Ext ract ion of t he f irst premolars on erupt ion.

3.4.2. Pitfalls and disadvantages


This approach involves put t ing t he child t hrough several sequences of
ext ract ions.
As int ercanine grow t h cont inues up t o around 13 years of age, it is diff icult
t o assess accurat ely how crow ded a child's t eet h w ill act ually be at t he
st age w hen serial ext ract ion is usually embarked upon.
Ext ract ion of t he deciduous canines and f irst molars w ill allow f orw ard drif t
of t he buccal segment t eet h and an eff ect ive increase in ant erior crow ding.
This may be unhelpf ul in a child w it h severe crow ding.
Ext ract ion of low er deciduous canines may result in t he low er incisors t ilt ing
lingually, causing an increase in overbit e. Theref ore serial ext ract ion should
be avoided in Class I I division 2 cases.
Appliance t herapy may st ill be required.

3.4.3. Conclusion
The t echnique of serial ext ract ion can produce a nice result in caref ully select ed
cases, namely Class I w it h moderat e crow ding and all permanent t eet h present
in a good posit ion, but of t en t his t ype of case also responds w ell t o ext ract ion of
t he f irst premolars upon erupt ion. O mit t ing t he deciduous ext ract ions removes
some of t he pot ent ial pit f alls and diminishes t he guessw ork involved, and, most
import ant ly, reduces t he number of ext ract ions required.

3.4.4. Indications for the extraction of deciduous


canines
Nevert heless t here are a number of occasions w here t he t imely ext ract ion of t he
deciduous canines may avoid more complicat ed t reat ment lat er:

I n a crow ded upper arch t he erupt ing lat eral incisors may be f orced palat ally.
I n a Class I malocclusion t his w ill result in a crossbit e and in addit ion t he
apex of an aff ect ed t oot h w ill be palat ally posit ioned, making lat er correct ion
more diff icult . Ext ract ion of t he deciduous canines w hilst t he lat eral incisors
are erupt ing of t en result s in t heir being able t o escape spont aneously int o a
bet t er posit ion.
I n a crow ded low er labial segment one incisor may be pushed t hrough t he
labial plat e of bone, result ing in a compromised labial periodont al
at t achment . Relief of crow ding by ext ract ion of t he low er deciduous canines
usually result s in t he low er incisor moving back int o t he arch and improves
periodont al support (Fig. 3. 27).
Ext ract ion of t he low er deciduous canines in a Class I I I malocclusion can be
advant ageous (Fig. 3. 28).
To provide space f or appliance t herapy in t he upper arch, f or example
correct ion of an inst anding lat eral incisor, or t o f acilit at e erupt ion of a incisor
prevent ed f rom erupt ing by a supernumerary t oot h.
To improve t he posit ion of a displaced permanent canine (see Chapt er 14).

Fig. 3.27. (a) In this patient all four deciduous canines


were extracted to relieve the labial segment crowding;
(b) note how the periodontal condition of the lower right
central incisor has improved six months later(b)

(a)
(b)

Fig. 3.28. (a) Class III prior to extraction of the lower


deciduous canines; (b) same patient 13 months later.

(a)

(b)

PRINCIPAL SOURCES AND FURTHER READING


Bishara, S. E. (1997). Arch w idt h changes f rom 6 w eeks t o 45 years of age.
Ameri can Journal of O rthodonti cs and Dentof aci al O rthopedi cs, 111, 401 9 .

Fost er, T. D. and G rundy, M. C. (1986). O cclusal changes f rom primary t o


permanent dent it ions. Bri ti sh Journal of O rthodonti cs, 13, 187 9 3.

G orlin, R. J. , Cohen, M. M. , and Levin, L. S. (1990). Syndromes of the head


and neck (3rd edn). O xf ord Universit y Press, O xf ord.

Source of calcif icat ion and erupt ion dat es (and a vast ammount of addit ional
inf ormat ion not direct ly relat ed t o t his chapt er).

Kjellgren, B. (1948). Serial ext ract ion as a correct ive procedure in dent al
ort hopaedic t herapy. Acta O dontol ogi ca Scandi navi ca, 8, 17 4 3.

Kurol, J. and Bjerklin, K. (1986). Ect opic erupt ion of maxillary f irst permanent
molars: a review. Journal of Denti stry f or Chi l dren, 53, 209 1 5.

All you need t o know about impact ed f irst permanent molars.

Kurol, J. and Koch, G . (1985). The eff ect of ext ract ion of inf raoccluded
deciduous molars: a longit udinal st udy. Ameri can Journal of O rthodonti cs, 87,
46 5 5.

Larsson, E. (1988). Treat ment of children w it h a prolonged dummy or f inger


sucking habit . European Journal of O rthodonti cs, 10, 244 8 .

Mackie, I . C. , Blinkhorn, A. S. , and Davies, P. H. J. (1989). The ext ract ion of


permanent molars during t he mixed-dent it ion period a guide t o t reat ment
planning. Journal of Paedi atri c Denti stry, 5, 85 9 2.

Peck, S. M. , Peck, L. , and Kat aja, M. (1994). The palat ally displaced canine
as a dent al anomally of genet ic origin. Angl e O rthodonti st, 64, 249 2 56.

St ew art , D. J. (1978). Dilacerat e unerupt ed maxillary incisors. Bri ti sh Dental


Journal , 145, 229 3 3.

Welbury, R. R. (ed. ). (1996). Paedi atri c Denti stry. O xf ord Universit y Press,
O xf ord.
Authors: Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> Table of C ontents > 4 - Fac ial gr ow th ( N. E . C ar ter )

4
Facial growth (N. E. Carter)

4.1. INTRODUCTION
O rt hodont ic t reat ment is usually carried out on children at a t ime w hen t he f ace
is grow ing. The clinician must be aw are of t he impact of grow t h upon t he
progress and out come of t reat ment , and of how grow t h may hinder or help
t reat ment . O rt hodont ic t reat ment it self may have some eff ect upon t he grow t h of
t he f ace, and a basic know ledge of t he processes of f acial grow t h is essent ial
f or t he pract ising clinical ort hodont ist .

Fig. 4. 1. Synchondrosis: ossif icat ion is t aking place on bot h sides of t he


primary grow t h cart ilage (Phot o: D. J. Reid).

The f ace is a very complex st ruct ure, and it s grow t h and development are t he
result of many int eract ing processes. The purpose of t his brief account is t o
highlight just a f ew aspect s of f acial grow t h w hich are relevant t o clinical
ort hodont ic pract ice, part icularly t he lat er st ages of grow t h w hich very of t en
coincide w it h ort hodont ic t reat ment . O f course, f acial appearance is t he result of
grow t h of bot h hard and sof t t issues, but t he t eet h are hard t issue st ruct ures
and t he main f ocus of st udy has been on grow t h of t he bony f acial skelet on.

4.2. M ECHANISM S OF BONE GROWTH


Bone is laid dow n in t w o w ays: by replacing cart ilage and by membrane act ivit y.
Bone does not grow int erst it ially, i. e. it does not expand by cell division w it hin it s
mass; rat her, it grow s by act ivit y at t he margins of t he bone t issue.

4.2.1. Endochondral ossification


At cart ilaginous grow t h cent res, chondroblast s lay dow n a mat rix of cart ilage
w it hin w hich ossif icat ion occurs. At primary grow t h cent res, t hese cells are
aligned in columns along t he direct ion of grow t h, in w hich t here are recognizable
zones of cell division, cell hypert rophy, and calcif icat ion (Fig. 4. 1). This process
is seen in bot h t he epiphyseal plat es of long bones and t he synchondroses of t he
cranial base. G row t h at t hese primary cent res causes expansion despit e any
opposing compressive f orces such as t he w eight of t he body on t he long bones,
and t hus t he bones on eit her side of t he spheno-occipit al synchondrosis are
moved apart as it grow s. Condylar cart ilage also lays dow n bone, and f or a long
t ime t his w as t hought t o be a similar mechanism t o epiphyseal grow t h, but
development ally it is a secondary cart ilage and it s st ruct ure is diff erent
Prolif erat ing condylar cart ilage cells do not show t he ordered columnar
arrangement seen in epiphyseal cart ilage, and t he art icular surf ace is covered by
a layer of dense f ibrous connect ive t issue (Fig. 4. 2). The role of t he condylar
cart ilage during grow t h is not yet f ully underst ood, but it is clear t hat it is
diff erent f rom t hat of t he primary cart ilages and it s grow t h seems t o be a
react ive process in response t o t he grow t h of ot her st ruct ures in t he f ace.

Fig. 4. 2. Condylar cart ilage of young adult (Phot o: D. J. Reid).


4.2.2. Intramembranous ossification
Bone is bot h laid dow n and resorbed by t he invest ing periost eum and by t he
endost eum w it hin t he bone. These processes of deposit ion and resorpt ion
t oget her const it ut e remodelling ( Fig. 4. 3). G row t h does not consist simply of
enlargement of a bone by deposit ion on it s surf ace: periost eal (surf ace)
remodelling is also needed t o maint ain t he overall shape of t he bone as it grow s.
Thus, as w ell as having areas w here new bone is being laid dow n, a grow ing
bone alw ays undergoes resorpt ion of some part s of it s surf ace. At t he same
t ime, endost eal remodelling maint ains t he int ernal archit ect ure of cort ical plat es
and t rabeculae, but of course it cannot cause t he bone t o enlarge. Remodelling
is a very import ant mechanism of f acial grow t h, and t he complex pat t erns of
surf ace remodelling brought about by t he periost eum w hich invest s t he f acial
skelet on have been st udied ext ensively.

Fig. 4. 3. Periost eal remodelling, show ing reversal lines w here bone
resorpt ion has been f ollow ed by deposit ion (Phot o: D. J. Reid).

The bones of t he f ace and skull art iculat e t oget her most ly at sutures, and
grow t h at sut ures can be regarded as a special kind of periost eal remodelling
an inf illing of bone in response t o t ensional grow t h f orces separat ing t he bones
on eit her side (Fig. 4. 4).
G row t h w hich causes t he mass of a bone t o be moved relat ive t o it s neighbours
is know n as displacement of t he bone; an example is f orw ard and dow nw ard
t ranslat ion of t he maxillary complex (Fig. 4. 5). The change in posit ion of a bony

st ruct ure ow ing t o remodelling of t hat st ruct ure is called drift, and Fig. 4. 6
show s an example of t his w here t he palat e moves dow nw ards during grow t h as a
result of bone being laid dow n on it s inf erior surf ace and resorbed on it s
superior surf ace.
Fig. 4. 4. Cranial sut ure (Phot o: D. J. Reid).

Fig. 4. 5. Forw ard and dow nw ard displacement of t he maxillary complex


associat ed w it h deposit ion of bone at sut ures. (Af t er Enlow, D. H. : Facial
G row t h, W. B. Saunders Co. , Philadelphia, 1990. )
Fig. 4. 6. Dow nw ards migrat ion of t he hard palat e due t o drif t . (From Enlow,
D. H. : Facial G row t h, W. B. Saunders Co. , Philadelphia, 1990. )

4.3. GROWTH PATTERNS


I t is not int ended t o describe in any det ail here t he processes by w hich t he f ace
grow s, rat her t o give a pict ure of t he pat t erns of f acial grow t h. Early
cephalomet ric grow t h st udies gave t he impression t hat , overall, as t he f ace
enlarges it grow s dow nw ards and f orw ards aw ay f rom t he cranial base (Fig.
4. 7). How ever, it is now know n t hat grow t h of t he f ace is much more complex
t han t his, involving many grow t h processes in t he mandible, mid-f ace, cranial
base, and so on. All of t hese are going on at t he same t ime, and t he overall
pat t ern of grow t h result s f rom t he int erplay bet w een t hem. They must all
harmonize w it h each ot her if a normal f acial pat t ern is t o result , and small
deviat ions f rom a harmonious f acial grow t h pat t ern w ill cause discrepancies of
major signif icance t o t he ort hodont ist .
Diff erent syst ems have diff erent grow t h pat t erns in t erms of rat e and t iming, and
f our main t ypes are recognized: neural, somat ic, genit al, and lymphoid (Fig. 4. 8).
The f irst t w o are most relevant here.
Neural growth is essent ially t hat w hich is det ermined by grow t h of t he brain,
and t he calvarium f ollow s t his pat t ern of grow t h in ot her w ords t he bones grow
in response t o t he grow t h of anot her st ruct ure. There is rapid grow t h in t he early
years of lif e, but t his slow s unt il by about t he age of 8 years grow t h is almost
complet e. The orbit s also f ollow a neural grow t h pat t ern.
Somatic growth is t hat f ollow ed by most st ruct ures. I t is seen in t he long bones,
amongst ot hers, and is t he pat t ern f ollow ed by increase in body height . Unlike
neural grow t h, somat ic bone grow t h seems t o be more an int rinsic propert y of
t he bones and under f airly t ight genet ic cont rol. G row t h is f airly rapid in
t he early years, but slow s in t he prepubert al period. The pubert al grow t h spurt is
a t ime of very rapid grow t h, w hich is f ollow ed by f urt her slow er grow t h. The
pubert al grow t h spurt occurs on average at 12 years in girls, but in boys it is
lat er at about 14 years. Alt hough t he t iming of f acial grow t h has been st udied
less ext ensively t han t he t iming of grow t h in st at ure, grow t h of t he f acial
skelet on f ollow s approximat ely a somat ic grow t h pat t ern.

Fig. 4. 7. Superimposit ions on t he cranial base show ing overall dow nw ards
and f orw ards direct ion of f acial grow t h. Solid line 8 years, broken line 18
years of age.
Fig. 4. 8. Post nat al grow t h pat t erns show n as percent ages of t ot al increase
(From Scammon, R. E. : The Measurement of Man, Universit y of Minnesot a
Press, 1930. )

Thus diff erent part s of t he skull f ollow diff erent grow t h pat t erns, w it h much of
t he grow t h of t he f ace occurring lat er t han t he grow t h of t he cranial vault . As a
result t he proport ions of t he f ace t o t he cranium change during grow t h, and t he
f ace of t he child represent s a much smaller proport ion of t he skull t han t he f ace
of t he adult (Fig. 4. 9).

Fig. 4. 9. The f ace in t he neonat e represent s a much smaller proport ion of


t he skull t han t he f ace of t he adolescent (Phot o: B. Hill).
4.4. CALVARIUM
The calvarium is t hat part of t he skull w hich develops f rom t he membrane bones
surrounding t he brain and t heref ore it f ollow s t he neural grow t h pat t ern. I t
comprises t he f ront al bones, t he pariet al bones, and t he squamous part s of t he
t emporal and occipit al bones. These bones art iculat e w it h each ot her at sut ures,
w hich at birt h are not yet unit ed. Six f ont anelles are also present at birt h w hich
close by 18 mont hs. By t he age of 6 years t he calvarium has developed inner
and out er cort ical t ables w hich enclose t he diploë. I t s grow t h consist s of a
combinat ion of drif t and displacement . Drif t occurs because t he int racranial
aspect s of t he bones are resorbed w hile bone is laid dow n on t he ext ernal
surf aces. There is displacement as t he bones are separat ed by t he grow ing
brain, w it h f ill-in bone grow t h occurring at t he sut ures t o maint ain cont inuit y of
t he cranial vault .

4.5. CRANIAL BASE


G row t h of t he cranial base is inf luenced by bot h neural and somat ic grow t h
pat t erns. As in t he calvarium, t here is bot h remodelling and sut ural inf illing as t he
brain enlarges, but t here are also primary cart ilaginous grow t h sit es in t his
region t he synchondroses. O f t hese, t he spheno-occipit al synchondrosis is of
special int erest as it makes an import ant cont ribut ion t o grow t h of t he cranial
base during childhood, cont inuing t o grow unt il about 15 years of age, and f using
at approximat ely 20 years. Thus t he middle cranial f ossa enlarges bot h by
ant eropost erior grow t h at t he spheno-occipit al synchondrosis and by
remodelling. The ant erior cranial f ossa enlarges and increases in ant eropost erior
lengt h by remodelling, w it h resorpt ion int racranially and corresponding
ext racranial deposit ion.
Fig. 4. 10. Ant ero-post erior grow t h at t he spheno-occipit al synchondrosis
aff ect s t he ant eropost erior relat ionship of t he jaw s.

The spheno-occipit al synchondrosis is ant erior t o t he t emporomandibular joint s


but post erior t o t he ant erior cranial f ossa, and t heref ore it s grow t h is signif icant
clinically as it inf luences t he overall f acial skelet al pat t ern (Fig. 4. 10). G row t h at
t he spheno-occipit al synchondrosis increases t he lengt h of t he cranial base, and
since t he maxillary complex lies beneat h t he ant erior cranial f ossa w hile t he
mandible art iculat es w it h t he skull at t he t emporomandibular joint s w hich lie
beneat h t he middle cranial f ossa, t he cranial base plays an import ant part in
det ermining how t he mandible and maxilla relat e t o each ot her. For example, a
Class I I skelet al f acial pat t ern is of t en associat ed w it h t he presence of a long
cranial base w hich causes t he mandible t o be set back relat ive t o t he maxilla.
I n t he same w ay, t he overall shape of t he cranial base aff ect s t he jaw
relat ionship, w it h a smaller cranial base angle t ending t o cause a Class I I I
skelet al pat t ern, and a larger cranial base angle being more likely t o be
associat ed w it h a Class I I skelet al pat t ern (Fig. 4. 11).
The ant erior part of t he cranial base is used in cephalomet ric analysis as a
ref erence st ruct ure f rom w hich measurement s can be t aken, remot e f rom t he
f ace it self and t hus unaff ect ed by ort hodont ic t reat ment . I t is of t en represent ed
by t he Sella Nasion line (see Chapt er 6).

Fig. 4. 11. View (i) Low cranial base angle associat ed w it h Class I I I skelet al
pat t ern. View (ii) Large cranial base angle associat ed w it h a Class I I
skelet al pat t ern.
4.6. M AXILLARY COM PLEX
The maxilla derives f rom t he maxillary processes of t he f irst pharyngeal arch and
f rom t he f ront al process. O ssif icat ion is int ramembranous, beginning lat erally t o
t he cart ilaginous nasal capsule.
Clinical ort hodont ic pract ice is primarily concerned w it h t he dent it ion and it s
support ing alveolar bone w hich is part of t he maxilla and premaxilla. How ever,
t he middle t hird of t he f acial skelet on is a complex st ruct ure and also includes,
among ot hers, t he palat al, zygomat ic, et hmoid, vomer, and nasal bones. These
art iculat e w it h each ot her and w it h t he ant erior cranial base at sut ures. G row t h
of t he maxillary complex occurs in part by displacement w it h f ill-in grow t h at
sut ures and in part by drif t and periost eal remodelling.
The maxilla enlarges ant eropost eriorly by deposit ion of bone post eriorly at t he
t uberosit ies, w hich of course also lengt hens t he dent al arch. Forw ard grow t h of
t he maxilla is t hus ant erior displacement as bone is laid dow n on it s post erior
aspect (see Fig. 4. 5). The zygomat ic bones are also carried f orw ards,
necessit at ing inf illing at sut ures, and at t he same t ime t hey enlarge and remodel.
I n t he upper part of t he f ace, t he et hmoids and nasal bones grow f orw ards by
deposit ion on t heir ant erior surf aces, w it h corresponding remodelling f urt her
back, including in t he air sinuses, t o maint ain t heir anat omical f orm.
Dow nw ard grow t h occurs by vert ical development of t he alveolar process and
erupt ion of t he t eet h, and also by inf erior drif t of t he hard palat e, i. e. t he palat e
remodels dow nw ards by deposit ion of bone on it s inf erior surf ace (t he palat al
vault ) and resorpt ion on it s superior surf ace (t he f loor of t he nose and maxillary
sinuses) (see Fig. 4. 6). These changes are also associat ed w it h some dow nw ard
displacement of t he bones as t hey enlarge, again necessit at ing inf illing at
sut ures. Lat eral grow t h in t he mid-f ace occurs by displacement apart of t he t w o
halves of t he maxilla, w it h deposit ion of bone at t he midline sut ure. I nt ernal
remodelling leads t o enlargement of t he air sinuses and nasal cavit y as t he
bones of t he mid-f ace increase in size.
Thus t here are complex pat t erns of surf ace remodelling on t he ant erior and
lat eral surf aces of t he maxilla w hich maint ain t he overall shape of t he bone as it
enlarges. Despit e being t ranslat ed ant eriorly, much of t he ant erior surf ace of t he
maxilla is in f act resorpt ive in order t o maint ain t he concave cont ours beneat h
t he pyrif orm f ossa and zygomat ic but t resses.
Maxillary grow t h ceases on average at about 15 years in girls and rat her lat er,
at about 17 years, in boys.
Fig. 4. 12. G row t h at t he condylar cart ilage elongat es t he mandible, causing
ant erior displacement , w hile it s shape is maint ained by remodelling, including
post erior drif t of t he ramus. (Af t er Enlow, D. H. 1990 Faci al growth,
Saunders, Philadelphia, 1990. ).

4.7. M ANDIBLE
The mandible derives f rom t he f irst pharyngeal arch and is a membrane bone,
ossif ying lat erally t o Meckel's cart ilage. Secondary cart ilages appear, including
t he condylar cart ilage, but t he role of t he condylar cart ilage in t he grow t h of t he
mandible is not yet ent irely clear. I t seems probable t hat , since it is a secondary
cart ilage, it is not a primary grow t h cent re in it s ow n right , but rat her it grow s in
response t o some ot her cont rolling f act ors. How ever, w hat is clear is t hat normal
grow t h at t he condylar cart ilage is required f or normal mandibular grow t h t o t ake
place.
How ever, most mandibular grow t h occurs as a result of periost eal act ivit y.
Muscular processes develop at t he angles of t he mandible and t he coronoids,
and t he alveolar processes develop vert ically t o keep pace w it h t he erupt ion of
t he t eet h. As t he mandible elongat es w it h grow t h at t he condylar cart ilage, so it s
ant erior part is displaced f orw ards, w hile at t he same t ime periost eal
remodelling

maint ains it s shape (Fig. 4. 12). Bone is laid dow n on t he post erior margin of t he
vert ical ramus and resorbed on t he ant erior margin, and t his post erior drif t of t he
ramus allow s lengt hening of t he dent al arch post eriorly. At t he same t ime t he
vert ical ramus becomes t aller t o accommodat e t he increase in height of t he
alveolar processes. Remodelling also brings about an increase in t he w idt h of
t he mandible, part icularly post eriorly. Lengt hening of t he mandible and ant erior
remodelling t oget her cause t he chin t o become more prominent , an obvious
f eat ure of f acial mat urat ion especially in males. I ndeed, just as in t he maxilla,
t he w hole surf ace of t he mandible undergoes many complex pat t erns of
remodelling as it grow s in order t o maint ain it s proper anat omical f orm.
Fig. 4. 13. Direct ion of condylar grow t h and mandibular grow t h rot at ions:
View (i) Forw ard rot at ion
View (ii) Backw ard rot at ion

Mandibular grow t h ceases rat her lat er t han maxillary grow t h, on average at
about 17 years in girls and 19 years in boys, alt hough it may cont inue f or longer.

4.8. GROWTH ROTATIONS


Early st udies of f acial grow t h indicat ed t hat during childhood t he f ace enlarges
progressively and consist ent ly, grow ing dow nw ards and f orw ards aw ay f rom t he
cranial base (see Fig. 4. 7). These st udies looked only at average t rends and
f ailed t o demonst rat e t he huge variat ion w hich exist s bet w een t he grow t h
pat t erns of individual children. Lat er w ork by Björk has show n t hat t he direct ion
of f acial grow t h is curved, giving a rot at ional eff ect (Fig. 4. 13). The grow t h
rot at ions

w ere demonst rat ed by placing small t it anium implant s int o t he surf ace of t he
f acial bones, and subsequent ly t aking cephalomet ric radiographs at int ervals
during grow t h. Since bone does not grow int erst it ially, t he implant s could be
used as f ixed ref erence point s on t he serial radiographs f rom w hich t o measure
t he grow t h changes.
Fig. 4. 14. Mandibular grow t h rot at ions ref lect t he rat io bet w een t he ant erior
and post erior f ace height s, here show n relat ive t o t he Frankf ort horizont al
plane: (i) f orw ard rot at ion, (ii) backw ard rot at ion.

Fig. 4. 15. Forw ard grow t h rot at ion. Solid line 11 years, broken line 18 years
of age.
Fig. 4. 16. Backw ard grow t h rot at ion. Solid line 12 years, broken line 19
years of age.

G row t h rot at ions are most obvious and have t heir great est impact on t he
mandible; t heir eff ect s on t he maxilla are small and are almost complet ely
masked by surf ace remodelling. I n t he mandible, how ever, t heir eff ect is
signif icant , part icularly in t he vert ical dimension. Mandibular grow t h rot at ions
result f rom t he int erplay of t he grow t h of a number of st ruct ures w hich t oget her
det ermine t he rat io of post erior t o ant erior f acial height s (Fig. 4. 14). The
post erior f ace height is det ermined by f act ors including t he direct ion of t he
grow t h at t he condyles and vert ical grow t h at t he spheno-occipit al
synchondrosis. The ant erior f acial height is aff ect ed by t he erupt ion of t eet h and
vert ical grow t h of t he sof t t issues, including t he mast icat ory musculat ure and t he
suprahyoid musculat ure and f asciae, w hich are in t urn inf luenced by grow t h of
t he spinal column. The overall direct ion of grow t h rot at ion is t hus t he result of
t he grow t h of many st ruct ures.
Forw ard grow t h rot at ions are more common t han backw ard rot at ions, w it h t he
average being a mild f orw ard rot at ion w hich produces a w ell-balanced f acial
appearance. A marked f orw ard grow t h rot at ion t ends t o result in reduced
ant erior vert ical f acial proport ions and an increased overbit e (Fig. 4. 15), and t he
more severe t he f orw ard rot at ion t he more diff icult it w ill be t o reduce t he
overbit e. Similarly, a more backw ard rot at ion w ill t end t o produce increased
ant erior vert ical f acial proport ions and a reduced overbit e or ant erior open bit e
(Fig. 4. 16).
Not only is t he vert ical dimension aff ect ed, but t here are also import ant ant ero-
post erior eff ect s. For example, correct ion of a Class I I malocclusion w ill be
helped by a f orw ard grow t h rot at ion but made more diff icult by a backw ard
rot at ion. G row t h rot at ions may also have an eff ect on t he posit ion of t he low er
labial segment . A f orw ard grow t h rot at ion t ends t o cause ret roclinat ion of t he
low er labial segment w hich is of t en associat ed w it h short ening of t he dent al arch
ant eriorly and crow ding of t he low er incisors. A possible explanat ion f or t his is
t hat , as t he low er arch is

carried f orw ards w it h mandibular grow t h, f orw ard movement of t he low er incisor
crow ns is limit ed by cont act w it h t he upper incisors, causing t hem t o crow d. This
is common in t he very lat e st ages of grow t h w hen mandibular grow t h cont inues
af t er maxillary grow t h has f inished, alt hough f acial grow t h is only one of a
number of possible aet iological f act ors in lat e low er incisor crow ding.
Thus grow t h rot at ions play an import ant part in t he aet iology of cert ain
malocclusions and must be t aken int o account in planning ort hodont ic t reat ment .
I t is necessary t o t ry t o assess t he direct ion of mandibular grow t h rot at ion
clinically. This is not ent irely st raight f orw ard since t he eff ect of grow t h rot at ion
upon t he mandible is masked t o some ext ent by surf ace remodelling, part icularly
along t he low er border of t he mandible and at t he angle. How ever, it is possible
t o make a usef ul assessment of a pat ient 's f acial grow t h pat t ern by examining
t he ant erior f acial proport ions and mandibular plane angle as described in
Chapt er 5. I ncreased f acial proport ions and a st eep mandibular plane indicat e
t hat t he direct ion of mandibular grow t h has a subst ant ial dow nw ard component ,
w hile reduced f acial proport ions and a horizont al mandibular plane suggest t hat
t he direct ion of grow t h is more f orw ards. I t is also helpf ul t o examine t he shape
of t he low er border of t he mandible. A concave low er border w it h a marked
ant egonial not ch is associat ed w it h a backw ard rot at ion, w hile a convex low er
border is associat ed w it h a f orw ard grow t h rot at ion (see Figs 4. 15 and 4. 16).

4.9. GROWTH OF THE SOFT TISSUES


The import ance of t he oral musculat ure in ort hodont ic pract ice is t hat it
inf luences signif icant ly t he f orm of t he dent al arches, since t he t eet h lie in a
posit ion of equilibrium bet w een t he lingual and bucco-labial musculat ure.
Theref ore t hey are import ant f act ors in t he aet iology of malocclusion, and
great ly aff ect t he st abilit y of t he result af t er ort hodont ic t reat ment .
The f acial musculat ure is w ell developed at birt h, considerably in advance of t he
limbs, because of t he need f or t he baby t o suckle and maint ain t he airw ay. O t her
f unct ions soon develop: mast icat ion as t eet h erupt , f acial expressions, a mat ure
sw allow ing pat t ern (as opposed t o suckling), and speech.
The lips, t ongue, and cheeks guide t he erupt ing t eet h t ow ards each ot her t o
achieve a f unct ional occlusion. This serves as a compensat ory mechanism f or a
discrepancy in t he skelet al pat t ern; f or example, in a Class I I I subject t he low er
incisors may become ret roclined and t he upper incisors proclined t o obt ain
incisor cont act . Somet imes t his compensat ory mechanism f ails, eit her because
t he skelet al problem is t oo severe or t he sof t t issue behaviour is abnormal. An
example of t his is w here low er lip f unct ion w orsens a Class I I division 1
malocclusion by act ing behind t he upper incisors rat her t han ant eriorly t o t hem.
I n t he lat e st ages of grow t h t he lips lengt hen as t hey mat ure, t ending t o become
more compet ent .
Muscle grow t h must be coordinat ed w it h t he grow t h of t he associat ed bones,
w it h t he muscles lengt hening as t heir bony at t achment s separat e. Neuromuscular
act ivit y regulat es t he posit ions of t he jaw s, and it has been suggest ed t hat t he
w hole process of f acial skelet al grow t h is det ermined by t he sof t t issues w hich
surround t he bones.

4.10. CONTROL OF FACIAL GROWTH


The mechanisms t hat cont rol f acial grow t h are poorly underst ood but are t he
subject of considerable int erest and research. As w it h all grow t h and
development ,

t here is an int eract ion bet w een genet ic and environment al f act ors, but if
environment al f act ors can make a signif icant impact on f acial grow t h t hen t he
possibilit y exist s f or clinicians t o alt er f acial grow t h w it h appliances.
I t is of t en diff icult t o dist inguish t he eff ect s of heredit y and environment , but it is
helpf ul t o consider how t ight ly t he grow t h and development of a st ruct ure or
t issue are under genet ic cont rol. Tw o simple examples illust rat e t his: gender is
genet ically det ermined and does not change no mat t er how ext reme t he
environment al condit ions, w hile obesit y is very st rongly aff ect ed by t he nat ure
and amount of f ood consumed. Most st ruct ures, including t he f acial skelet on and
sof t t issues, are inf luenced by bot h genet ic and environment al f act ors, and t he
eff ect t hat t he lat t er can have depends upon how t ight ly grow t h is under genet ic
cont rol.
G enet ic cont rol is undoubt edly signif icant in f acial grow t h, as is clearly show n by
f acial similarit ies in members of a f amily. The ext ent t o w hich t he f acial skelet on
it self is under genet ic cont rol has been debat ed at lengt h in recent decades, w it h
t he development of t w o opposing schools of t hought . G row t h at t he primary
cart ilages is regarded as being under t ight genet ic cont rol, w it h t he cart ilage
it self cont aining t he necessary genet ic programming. Theref ore t hose w ho view
grow t h of t he w hole f acial skelet on as being direct ly and t ight ly genet ically
cont rolled have looked f or primary cart ilaginous grow t h cent res in t he f acial
bones. The condylar cart ilages seemed t o f ulf il t his role in t he mandible, w hile
t he nasal sept al cart ilage w as t hought t o serve a similar f unct ion in t he maxilla.
How ever, t he st ruct ure and behaviour of t hese cart ilages is diff erent f rom
primary grow t h cart ilages, and at present it is t hought t hat , w hile t heir presence
is necessary f or normal grow t h t o t ake place, t hey are probably not primary
grow t h cent res in t heir ow n right .
The ot her school of t hought proposed t hat bone grow t h it self is only under loose
genet ic cont rol and t akes place in response t o grow t h of t he surrounding sof t
t issues t he functional matrix w hich invest s t he bone. This idea looks t o t he
example of t he neural grow t h pat t ern of t he calvarium and orbit s, w hich develop
int ramembranously and enlarge in response t o grow t h of t he brain and eyes.
How ever, t he f unct ional mat rix t heory ran int o diff icult y w it h regard t o f acial
grow t h as t here are no similarly expanding st ruct ures w it hin t he middle and low er
f ace. I t has at t ract ed a lot of at t ent ion as, if t aken t o it s logical conclusion, it
implies t hat ort hodont ic appliances can be used t o alt er f acial grow t h.
There is much yet t o be underst ood about how grow t h of t he f ace is cont rolled.
As t o w het her appliances inf luence f acial grow t h, t he t rut h appears t o lie some-
w here bet w een t he t w o ext remes of opinion, but research in t his f ield f aces
considerable problems, some of w hich are discussed in Chapt er 18 in relat ion t o
f unct ional appliances. At present , t he evidence is t hat t he impact of current
ort hodont ic t reat ment met hods on f acial grow t h is on average quit e small, but
t here is considerable variat ion in t he response of individual pat ient s.

4.11. GROWTH PREDICTION


I t w ould be ext remely usef ul if w e could predict t he f ut ure grow t h of a child's
f ace, part icularly in cases w hich are at t he limit s of w hat ort hodont ic t reat ment
can achieve. For grow t h predict ion t o be usef ul clinically it w ould need t o be able
t o predict t he amount , direct ion, and t iming of grow t h of t he various part s of t he
f acial skelet on t o a high level of accuracy.
At present t here are no know n predict ors w hich can be measured, eit her
clinically on t he pat ient or f rom radiographs, w hich w ill enable f ut ure grow t h t o
be predict ed w it h t he necessary precision. Much w ork has been done t o t ry t o
f ind

measurement s w hich can be t aken f rom cephalomet ric radiographs w hich w ill
predict f ut ure f acial grow t h t o a usef ul level of precision, but so f ar w it h limit ed
success. Assessment of st at ure (height ) and secondary sex charact erist ics help
t o indicat e w het her t he pat ient has ent ered t he pubert al grow t h spurt , an
import ant observat ion w hen f unct ional appliances are being considered. Since
grow t h of t he jaw s f ollow s a somat ic grow t h pat t ern, t he possibilit y has been
invest igat ed t hat observat ion of t he development al st age of ot her part s of t he
skelet on w ould give an indicat ion of t he st age of f acial development . The st age
of mat urat ion of t he met acarpal bones and t he phalanges as seen on a hand w rist
radiograph is used as a measure of skelet al development , but t he correlat ion of
t his w it h jaw grow t h has been f ound t o be t oo poor t o give clinically usef ul
inf ormat ion.
The best w hich can be done is t o add average grow t h increment s t o t he pat ient 's
exist ing f acial pat t ern, but t his has only limit ed value. This can be done manually
using a grid superimposed on t he pat ient 's lat eral cephalomet ric t racing, and
average annual grow t h increment s are read off t o predict t he change in posit ion
of t he various cephalomet ric landmarks. Comput er programs can be used f or t he
same purpose, af t er t he point s and out lines f rom t he lat eral skull radiograph
have been digit ized. These programs can ref ine t he predict ion process f urt her
but t hey st ill have t o make some assumpt ions about t he rat e and direct ion of
f acial grow t h. Unf ort unat ely, t he assumpt ion t hat a pat ient 's f ut ure grow t h
pat t ern w ill be average is least appropriat e in t hose individuals w hose f acial
grow t h diff ers signif icant ly f rom t he average, and w ho are t he very subject s
w here accurat e predict ion w ould be most usef ul. As grow t h proceeds, t he rat e
and direct ion of grow t h in an individual vary enough t hat st udy of t he past
pat t ern of a pat ient 's f acial grow t h does not allow predict ion of f ut ure grow t h t o
t he level of precision required f or it t o be clinically usef ul. How ever, many
clinicians f ind it helpf ul t o assess t he direct ion of mandibular grow t h rot at ion
(see Sect ion 4. 8) on t he assumpt ion t hat t his pat t ern is likely t o cont inue.
Clinical experience has show n t hat f or most pat ient s, w hose grow t h pat t erns are
close t o t he average, it can be assumed f or t reat ment -planning purposes t hat
t heir grow t h w ill cont inue t o be average.

PRINCIPAL SOURCES AND FURTHER READING


Björk, A. and Skieller, V. (1983). Normal and abnormal grow t h of t he
mandible. A synt hesis of longit udinal cephalomet ric implant st udies over a
period of 25 years. European Journal of O rthodonti cs, 5, 1 4 6.

A summary of t he implant w ork on mandibular grow t h rot at ions.

Enlow, D. H. and Hans M. G . (1996). Essenti al s of f aci al growth. Saunders,


Philadelphia.
The Bible of f acial grow t h.

Houst on, W. J. B. (1979). The current st at us of f acial grow t h predict ion: a


review. Bri ti sh Journal of O rthodonti cs, 6, 11 1 7.
An aut horit at ive assessment of t he value of grow t h predict ion.

Houst on, W. J. B. (1988). Mandibular grow t h rot at ions t heir mechanism and
import ance. European Journal of O rthodonti cs, 10, 369 7 3.
A concise review of t he aet iology and clinical import ance of grow t h rot at ions.

Mills, J. R. E. (1983). A clinician looks at f acial grow t h. Bri ti sh Journal of


O rthodonti cs, 10, 57 7 2.
A clear descript ion of t he f acial grow t h processes f rom a clinical ort hodont ic
view point .
Authors: Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> Table of C ontents > 5 - O r thodontic as s es s m ent

5
Orthodontic assessment

A brief examinat ion of t he developing occlusion should be carried out around 7 t o


8 years of age t o check upon t he presence and posit ion of t he permanent incisor
t eet h and t o help det ect at an early st age any incipient problems w hich may
hinder t he normal erupt ion sequence (see Chapt er 3). Radiographic examinat ion
is indicat ed at t his st age if an abnormalit y is suspect ed. I n general dent al
pract ice, a child's dent al and occlusal development should be checked yearly,
and f rom around 10 years of age t he rout ine dent al examinat ion should be
ext ended t o include palpat ion f or unerupt ed maxillary permanent canines in t he
buccal sulcus.

5.1. PURPOSE AND AIM S OF AN ORTHODONTIC


ASSESSM ENT
Prior t o t he commencement of ort hodont ic t reat ment a f ull examinat ion (including
radiographs) and assessment of t he occlusion needs t o be carried out , w hich f or
most children is not bef ore t he erupt ion of t he permanent dent it ion. How ever, f or
t hose w it h a skelet al discrepancy w here t reat ment may need t o be t imed t o
coincide w it h t he pubert al grow t h spurt , it may be prudent t o carry out a f ull
assessment earlier.
The purpose of an ort hodont ic assessment is t o evaluat e and record t he f eat ures
of a malocclusion in preparat ion f or planning t reat ment , if indicat ed. The
f ollow ing approach is suggest ed because it has been successf ully used by t he
aut hor and ot hers, but t he exact sequence of t he examinat ion is unimport ant .
How ever, a consist ent logical approach is essent ial t o avoid omissions.

5.2. EQUIPM ENT


5.2.1. Instruments
A mirror, probe, and st ainless st eel ort hodont ic (or engineer's) rule are required.

5.2.2. Study models


The assist ance provided by a set of st udy models during assessment and
t reat ment planning cannot be over-emphasized. I n addit ion, t hey are essent ial as
a pret reat ment record if any appliance t herapy is t o be carried out . To be of
value t he st udy models should include all erupt ed t eet h, t he palat e, and t he f ull
sulcus dept h. They should at least be t rimmed so t hat t he upper and low er bases
are parallel w it h t he occlusal plane; how ever, t radit ionally ort hodont ic st udy
models are t rimmed so t hat t he heels and sides are f lush (Fig. 5. 1), allow ing t he
models t o be placed dow n in any posit ion and remain in occlusion.

Fig. 5.1. Trimmed orthodontic models.

(a)

(b)

5.2.3. Radiographs
See Sect ion 5. 8.

5.3. PRESENTING COM PLAINT


I t is ext remely import ant t o det ermine t he pat ient 's opinion regarding t he posit ion
and alignment of t heir t eet h. I t is not uncommon f or an ort hodont ic opinion t o be
sought at t he inst igat ion of a anxious parent w hen t he child concerned is quit e
happy w it h t heir occlusion and cert ainly not prepared t o ent ert ain t he idea of
w earing appliances. No mat t er how ent husiast ic a pat ient 's parent s may be f or
t heir off spring t o undergo ort hodont ic t reat ment , if t he child it self is not w illing,
t hen a successf ul out come is less likely. Adult pat ient s are usually keen and
cooperat ive once t hey have decided t o go ahead w it h appliance t reat ment .
I t is also import ant t o ascert ain exact ly w hich f eat ures of t he occlusion concern
t he pat ient . A child may be more concerned about t he mild rot at ion of an upper
cent ral incisor t han increased overjet , part icularly if ot her members of t he f amily
have Class I I division 1 malocclusions. Nat urally t hey w ill not be cont ent if , at t he
complet ion of t reat ment f or t heir increased overjet t he rot at ion is st ill present .
I t is of t en helpf ul t o det ermine t he t ypes of appliance t hat t he pat ient is w illing t o
accept examples of t he diff erent appliances or good colour pict ures are
invaluable at t his st age.

5.4. DENTAL HISTORY


Regular dent al care and good oral healt h are an essent ial prerequisit e t o
ort hodont ic t reat ment . The pat ient 's past dent al hist ory should include det ails of
any previous appliance t herapy. I f permanent t eet h have been ext ract ed, t he
t iming of t hese ext ract ions and t he reason f or removal should be ascert ained if
possible.

5.5. M EDICAL HISTORY


A t horough medical hist ory should be t aken. Condit ions w hich might aff ect
ort hodont ic t reat ment include t he f ollow ing:

Rheumat ic f ever. I f a pat ient is suspect ed of being at risk of inf ect ive
endocardit is it is advisable t o seek medical advice, pref erably f rom a
cardiologist . I f t he risk is conf irmed t hen ort hodont ic t reat ment can be
considered provided t he pat ient is able t o maint ain good gingival healt h and
accept s t he risk involved. I nvasive procedures, f or example, ext ract ions and
band placement and removal (how ever, some aut horit ies suggest bonds
should be used in pref erence f or bands in suscept ible pat ient s), should be
covered w it h t he recommended ant ibiot ic cover regime. A chlorhexidine rinse
prior t o adjust ment of a f ixed appliance is a usef ul adjunct , alt hough daily
long-t erm use of chlorhexidine may lead t o bact erial resist ance. I f t he
pat ient 's oral hygiene det eriorat es during t reat ment it may be advisable t o
discont inue appliance t reat ment .
Epilepsy. Because of t he risk of damage t o t he mout h caused by a broken
appliance during an epilept ic at t ack, it is prudent t o delay t reat ment in t his
group of pat ient s unt il t he condit ion is w ell cont rolled.
Recurrent apt hous ulcerat ion (RAU). This condit ion of (much) debat ed
aet iology is know n t o be exacerbat ed by t rauma t o t he mucosa. Cribs or
springs on

a removable appliance, or t he component s of a f ixed appliance, may be


suff icient t o set off an at t ack in a suscept ible individual. I n pat ient s w it h a
hist ory of RAU, it may be prudent t o carry out a t horough invest igat ion f irst ,
including ref erral f or blood t est s if indicat ed, and t o det ermine t he eff ect of
appliances bef ore any irreversible st eps, f or example ext ract ions, are t aken.
Hay f ever. At opic children may experience problems w it h a f unct ional
appliance during t he summer mont hs.

O f course, t here are many more esot eric condit ions t hat w ill modif y t reat ment in
aff ect ed individuals. How ever, t here is only space here t o comment t hat w hen in
doubt a specialist opinion should be sought .

5.6. EXTRA-ORAL EXAM INATION


The posit ion of t he t eet h is det ermined largely by a pat ient 's underlying skelet al
pat t ern and t he sof t t issue environment . The purpose of t his aspect of t he
examinat ion is t o evaluat e t heir relat ive inf luence in t he aet iology of a part icular
malocclusion and also t he degree t o w hich t hey can be modif ied or correct ed by
t reat ment .

5.6.1. Skeletal pattern


The pat ient should be comf ort ably seat ed upright . Tilt ing of t he head upw ards
increases t he prominence of t he chin, and conversely t ilt ing t he head dow nw ards
has t he opposit e eff ect . Theref ore it is import ant t o ensure t hat t he pat ient is
posit ioned so t hat his or her Frankf ort plane (uppermost aspect of t he ext ernal
audit ory canal t o t he low ermost aspect of t he orbit al margin) is horizont al. The
t eet h should be t oget her in maximum int erdigit at ion it is w ise t o check t his, as
of t en a pat ient w ill post ure t he mandible f orw ards w it h only t he incisors in
cont act .
The skelet al pat t ern should be asesssed in all t hree planes of space.

Anteroposterior
The pat ient should be view ed f rom t he side and t he relat ive posit ion of t he
maxilla and mandible assessed (Fig. 5. 2). I t is import ant t o look at t he region of
t he dent al base rat her t han t he lips, as t heir posit ion w ill be inf luenced by
proclinat ion or ret roclinat ion of t he incisors. The f ollow ing classif icat ion of
skelet al pat t ern is universally recognized:

Class I t he mandible is 2 3 mm post erior t o maxilla.


Class I I t he mandible is ret ruded relat ive t o t he maxilla.
Class I I I t he mandible is prot ruded relat ive t o t he maxilla.

I t is import ant t o not e t hat t his classif icat ion only gives t he posit ion of t he
mandible and t he maxilla relat ive t o each ot her and does not indicat e w here t he
discrepancy lies. A lat eral cephalomet ric radiograph is required f or f urt her
assessment of t he aet iology of t he skelet al pat t ern. I f a skelet al discrepancy is
present , an assessment of it s severit y should be made.

Vertical
Again, t he pat ient is view ed f rom t he side. The vert ical assessment comprises
t w o separat e evaluat ions:

Fig. 5.2. Assessment of anteroposterior skeletal


pattern: (a) Class I; (b) Class II; (c) Class III.

(a)
(b)

(c)
Low er f acial height (Fig. 5. 3): t he dist ance f rom t he eyebrow t o t he base of
t he nose should equal t he dist ance f rom t he base of t he nose t o t he
low ermost point on t he chin. I f t he lat t er dist ance is increased, t he low er
f acial height is described as being increased, and vice versa.
Frankf ort mandibular planes angle (FMPA) (Fig. 5. 4): assessment of t he
FMPA clinically by eye comes w it h experience, but t he neophyt e ort hodont ist
may f ind it helpf ul t o assess t his angle by placing one hand level w it h t he
Frankf ort plane (ext ernal audit ory meat us t o t he low er border of t he orbit al
margin) and t he ot her hand level w it h t he low er border of t he mandible. Then
in t he m ind's eye ext rapolat e t he planes and assess w here t hey w ould cross.
I f t he angle bet w een t hese t w o planes is around t he average of 28°, t hen t he
lines w ould int ersect approximat ely at t he back of t he head. I f t he FMPA is
increased t he lines w ould meet bef ore t he back of t he head, and if it is
reduced t hey w ould cross beyond.

Transverse
I t is import ant t o remember t hat all f aces are asymmet ric t o a small degree.
How ever, any marked discrepancies should be not ed. For t his assessment t he
pat ient should be view ed ant eriorly and, if an asymmet ry is not ed, also examined
by looking dow n on t he f ace f rom above. The ext ent of t he asymmet ry and
w het her only t he low er f acial t hird or t he maxilla or orbit s are involved should be
recorded. Whet her t he occlusal plane f ollow s t he asymmet ry and r uns dow n t o
one side should be est ablished by asking t he pat ient t o bit e ont o a t ongue
spat ula (Fig. 5. 5).
Fig. 5. 5. Use of a t ongue spat ula t o highlight a r un in t he occlusal plane in
addit ion t o a small degree of f acial asymmet ry.

5.6.2. Soft tissues


Assessment of t he sof t t issues should commence as soon as t he pat ient ent ers
t he surgery and cont inue during t he preliminary st ages of t he assessment in
order t o be able t o observe normal f unct ion.

Fig. 5.3. (a) Assessment of lower facial height: in an


averagely proportioned face the distance x from a point
between the eyebrows to the base of the nose is
equivalent to the distance y from the base of the nose
to the chin. (b) A patient with a reduced lower facial
height.
(a)

(b)

Fig. 5.4. (a) Assessment of the FMPA; (b) a patient


with a reduced FMPA; (c) a patient with an increased
FMPA.
(a)

(b)

(c)

Lips
The f ollow ing should be considered:
The f orm, t onicit y, and f ullness of t he lips (Fig. 5. 6). For example, are t hey
f ull or t hin, hyperact ive, or w it h lit t le t one?
Lip compet ence. Compet ent lips meet t oget her at rest w it hout any muscular
act ivit y (Fig. 5. 7). I f a pat ient 's lips are incompet ent , t he met hod by w hich
t hey achieve an ant erior oral seal should be evaluat ed. This is usually eit her
by t ongue t o low er lip cont act , w it h t he low er lip being draw n up behind t he
upper incisors, or by t he pat ient bringing t he lips t oget her. An assessment
should also be made as t o w het her t he lips are pot ent ially compet ent (Fig.
5. 8). This is most relevant in Class I I division 1 malocclusions w here it is
import ant t o assess w het her t he low er lip w ill act in f ront of t he upper
incisors t o ret ain t heir correct ed posit ion f ollow ing overjet reduct ion (see
Chapt er 9).

Low er lip posit ion relat ive t o t he upper incisors. A high low er lip line (Fig.
5. 9) is of t en one of t he aet iological f act ors in Class I I division 2
malocclusions.
The lengt h of t he upper lip and amount of upper incisor show n. The normal
upper incisor show, at rest , is 2 3 mm in f emales and less in males (Fig.
5. 10).

Fig. 5.6. (a) Full lips with little muscle tone; (b) thin
lips with obvious muscular tone.
(a)

(b)

Fig. 5.7. (a) Competent lips which meet together at


rest; (b) incompetent lips as they require muscular
effort to achieve contact.

(a)

(b)
Fig. 5. 8. Pot ent ially compet ent lips.

Fig. 5. 9. High low er lip line relat ive t o t he upper cent ral incisors w hich has
result ed in t heir ret roclinat ion. The short er lat eral incisors have not been
aff ect ed by t he lip.

Tongue
Tongue t hrust s are usually adapt ive, i. e. t he t ongue is placed f orw ard bet w een
t he t eet h t o help achieve an ant erior oral seal during sw allow ing. Rarely, pat ient s
are encount ered w ho appear t o have a habit of pushing t heir t ongue bet w een t he
upper and low er incisors w hen sw allow ing; t his is described as an endogenous
or primary t ongue t hrust . The signif icant diff erence bet w een t he t w o is t hat an
adapt ive t ongue t hrust w ill cease f ollow ing t reat ment w hen a lip-t o-lip cont act
can be achieved, w hereas an endogenous t ongue t hrust w ill not and t his of t en
leads t o relapse (t his is discussed in great er det ail in Chapt er 12, Sect ion
12. 2. 2).

5.6.3. Temporomandibular joints


Bef ore any examinat ion of t he t emporomandibular joint s is carried out t he pat ient
should be asked about sympt oms. The joint s should be palpat ed simult aneously
by placing t he middle f inger over t he condylar head w hilst t he pat ient is
inst ruct ed t o open and close and t o move lat erally. Any clicks, crepit us, and
locking should be recorded. I t is probably prudent t o record any negat ive
f indings

as w ell. I f def init ive sympt oms exist , t he muscles of mast icat ion should also be
examined f or areas of t enderness.

Fig. 5.10. Excessive amount of upper incisor show (a)


at rest and (b) when smiling.

(a)
(b)

5.6.4. Habits
Enquire about any habit s, w hilst observing t he pat ient 's hands f or any signs of
digit sucking or nail-bit ing (t he lat t er has been associat ed w it h a increased
incidence of root resorpt ion).
Wit h a lit t le experience it can be easy t o spot t he occlusal f eat ures of a f ingeror
t humb-sucking habit (Fig. 5. 11). Some pat ient s develop a lip-sucking habit , w hich
can lead t o a eczemat ous appearance of t he skin below t he low er lip in addit ion
t o ret roclinat ion of t he low er labial segment .

Fig. 5. 11. I ncisor posit ion of a child w it h a persist ent t humb-sucking habit .
The eff ect s of any habit upon t he dent it ion should be brought t o t he at t ent ion of
t he child and t heir parent s.

5.7. INTRA-ORAL EXAM INATION


5.7.1. Dental examination
This should include t he f ollow ing:

Chart ing all t he erupt ed t eet h.


Not ing any permanent t eet h of poor prognosis, unt reat ed caries, and t he
pat ient 's caries rat e.
O ral hygiene and gingival condit ion. Any gingival recession, and any areas
w it h a reduced w idt h of at t ached gingiva, should also be not ed.
Any t eet h w it h an abnormal morphology or size.
Ant erior t eet h w hich have suff ered t rauma.

5.7.2. Path of closure


The pat ient 's posit ion of maximum int erdigit at ion (int ercuspal or cent ric posit ion)
should be examined t oget her w it h t heir pat h of closure f rom t he rest posit ion.
This can of t en be diff icult at an init ial consult at ion w hen t he pat ient is a lit t le
apprehensive, and is occasionally impossible in t he younger child. Theref ore care
is required t o ensure t hat t he pat ient 's t rue int ercuspal posit ion is recorded,
part icularly in Class I I division 1 malocclusions w here t he pat ient may t end t o
post ure f orw ards. Asking t he subject t o curl t he t ongue up t o t ouch t he back of
t he palat e, w hilst closing t he t eet h t oget her, can be helpf ul.

Displacement on closure
A premat ure cont act encount ered on closure f rom t he rest posit ion is
uncomf ort able and t he pat ient soon learns t o displace t he mandible f orw ards or
lat erally t o avoid t he off ending t oot h or t eet h (Fig. 5. 12). This displaced posit ion
quickly becomes learned and so can be diff icult t o det ect . I t is advisable t o
assume t hat any unilat eral crossbit e is associat ed w it h a displacement unt il
proved ot herw ise, and t o examine caref ully t he pat h of closure and cent relines.
Where a displacement exist s, t he occlusion should be assessed in maximum
int erdigit at ion and t he direct ion and amount of displacement recorded.
(a)

(b)

Fig. 5.12. Diagram to illustrate the displacement of the


mandible laterally into a unilateral cross bite: (a) initial
contact on hinge axis closure; (b) displacement into
maximum interdigitation (note shift of lower centre line
relative to upper arch).

Deviation on closure
This is most commonly seen in associat ion w it h Class I I division 1 malocclusions
w here t he pat ient has a t endency t o hold t he mandible f orw ard t o mask t he
underlying problem. This used t o be rat her apt ly described as a S unday bit e . O n

closure f rom t he rest int o t he int ercuspal posit ion, t he mandible can be seen t o
t ranslat e backw ards and upw ards.

5.7.3. Labial segments


Labial segment alignment
First t he low er and t hen t he upper labial segment should be examined in t urn and
t he f ollow ing recorded:
Angulat ion relat ive t o mandibular/ maxillary base.
G eneral alignment and t he presence of crow ding and spacing.
Any rot at ed t eet h and t hose displaced f rom t he line of t he arch.
The inclinat ion of t he canines if t hey are erupt ed or, if not , w het her t hey can
be palpat ed buccally in a f avourable posit ion.

Labial segment relationship


The pat ient should be guided int o maximum int erdigit at ion and t he f ollow ing
recorded:

I ncisor relat ionship (see Chapt er 2, Sect ion 2. 3. 2).


O verjet f rom t he mesial aspect of t he upper cent ral incisors t o t he low er
incisors in millimet res (Fig. 5. 13).
O verbit e in t erms of overlap of t he low er incisors by t he upper incisors (Fig.
5. 13). Normal overbit e is a half t o a t hird of t he low er incisor crow n height .
How ever, it is usually suff icient t o record overbit e as increased, reduced, or
normal. Whet her t he overbit e is incomplet e or complet e ont o t oot h or t he
palat e should also be not ed, and if an ant erior open bit e is present , it s
ext ent should be recorded in millimet res. A t raumat ic overbit e is said t o be
present if obvious ulcerat ion is evident w here t he low er incisors make
cont act w it h t he palat al t issues (Fig. 5. 14).
Presence of any ant erior crossbit es.
Check w het her t he cent relines of each arch are coincident w it h t he cent re of
t he f ace and w it h each ot her. Measure and record any discrepancies in
millimet res.
Fig. 5. 13. Measurement of overjet and overbit e.

Fig. 5. 14. A t raumat ic overbit e.

Fig. 5. 15. Not e how t he upper buccal segment t eet h are t ilt ed palat ally in
t his phot ograph.

5.7.4. Buccal segments


Buccal segment alignment
Again, f irst t he low er and t hen t he upper buccal segment s should be examined in
t urn and t he f ollow ing recorded:
G eneral alignment and t he presence of crow ding or spacing.
Any rot at ed t eet h and t hose displaced f rom t he line of t he arch.
Angulat ion relat ive t o t heir respect ive bases (Fig. 5. 15). This is of most
relevance w here a post erior crossbit e exist s.

Buccal segment relationship


The pat ient should be guided int o maximum int erdigit at ion and t he f ollow ing
recorded:

Molar relat ionship (if a corresponding molar is present in each arch).


Canine relat ionship (Fig. 5. 16).
Presence of any crossbit es.

Fig. 5. 16. Class I canine and molar relat ionship.

5.8. RADIOGRAPHIC EXAM INATION


Bef ore radiographs can be prescribed a t horough examinat ion of t he pat ient
should be carried out so t hat t he view s indicat ed on clinical grounds can be
t aken at t he same visit . The commonly used view s include t he f ollow ing:

A panoramic view an ort hopant omographic (DPT) radiograph, or lef t and


right lat eral obliques.
A lat eral cephalomet ric radiograph indicat ed f or skelet al discrepancies
and/ or w here ant eropost erior movement of t he incisors is required (see
Chapt er 6).
A view of t he upper incisors eit her a periapical or an upper ant erior
occlusal. There has been some cont roversy as t o t he eff icacy of t his aspect
of t he radiographic examinat ion in t he light of radiographic dosage. I t has
been argued t hat only rarely does t his view reveal a unexpect ed abnormal
f inding t hat is not indicat ed on t he panoramic view (Fig. 5. 17). O bviously
w here t here is reason t o suspect pat hology (f or example f ailure of erupt ion
or a hist ory of t rauma) an int ra-oral radiograph of t his area is indicat ed. Also
a panoramic view may need t o be supplement ed w it h an int ra-oral view t o

check t he upper incisors radiographically prior t o st art ing t reat ment t o check
f or evidence of root resorpt ion, root f ract ure, or supernumerary t eet h.

Fig. 5.17. (a) DPT and (b) peri-apical radiographs of


the same patient. The intra-oral radiograph revealed a
supernumerary tooth which was not evident on the OPG
radiograph.

(a)
(b)

The radiographs t aken should be examined as f ollow s:

Check t he clinical chart ing and t o record t he presence of any unerupt ed


t eet h.
Any missing t eet h (congenit ally absent or previously ext ract ed) should be
not ed.
Assess t he posit ion and degree of development of any unerupt ed t eet h w hich
should also be st udied f or any abnormalit ies.
Not e any t eet h w it h large rest orat ions or unt reat ed caries.
Look f or evidence of root resorpt ion and apical pat hology.
Cephalomet ric t racing described in Chapt er 6.

Fig. 5.18. These photographs are of a patient called


Claire. The following summary of her malocclusion was
compiled after a thorough assessment which included
radiographs (not shown):Claire is aged 12 years and
has a Class I incisor relationship on a mild Class III
skeletal pattern with slightly increased vertical
proportions. She has a mildly crowded lower arch and a
moderately crowded upper arch with rotated upper
lateral incisors and a buccally displaced 3/.
(a)

(b)

(c)
(d)

(e)

(f)

(g)
(h)

5.9. SUM M ARY


Follow ing a t horough ort hodont ic examinat ion a summary of t he salient f eat ures
of t he malocclusion should be recorded. This usually involves t he f ollow ing:

The pat ient 's name and age.


A descript ion of t he incisor relat ionship, by classif ying as Class I , Class I I
division 1, Class I I division 2, or Class I I I (see Sect ion 2. 3. 2) w here
possible. How ever, if t here is any doubt it is of t en bet t er t o describe t he
overjet and overbit e in w ords.
Skelet al pat t ern.
The presence of crow ding or spacing.
Any ot her f eat ures of not e, f or example absent t eet h, displaced t eet h, cross-
bit es, or displacement on closure.

An example is given in Fig. 5. 18. This approach helps t o highlight t he import ant
f eat ures of a malocclusion and provides a problem list , t hus f acilit at ing t reat ment
planning (Chapt er 7).

PRINCIPAL SOURCES AND FURTHER READING


Brit ish O rt hodont ic Societ y Development and St andards Commit t ee. (1999).
O rthodonti c records: col l ecti on and management.

I saacson, K. G . and Jones, M. L. (ed. ) (1994). O rthodonti c radi ography:


gui del i nes. Brit ish O rt hodont ic Societ y, 291 G rays I nn Road London.

This pamphlet gives t he recommendat ions of t he Brit ish O rt hodont ic St andards


Working Part y on w hich radiographs t o t ake and t heir t iming t o achieve
maximum diagnost ic inf ormat ion w it h minimum X-ray dosage.
Khurana, M. and Mart in, M. V. (1999). O rt hodont ics and I nf ect ive
endocardit is. Bri ti sh Journal of O rthodonti cs, 26, 295 8 .

McDonald, F. and I reland, A. J. (1998). Di agnosi s of the orthodonti c pati ent.


O xf ord Universit y Press, O xf ord.

St ephens, C. D. , and I saacson, K. (1990). Practi cal orthodonti c assessment.


Heinemann Medical Books, O xf ord.
This excellent book cont ains a very good résumé of diagnosis and t reat ment
planning, but consist s mainly of clinical cases f or t he reader t o pract ise upon
and learn f rom.

Taylor, N. G . and Jones, A. G . (1995). Are ant erior occlusal radiographs


indicat ed t o supplement panoramic radiography during an ort hodont ic
assessment ? Bri ti sh Dental Journal, 179, 377 8 1.
Authors: Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> Table of C ontents > 6 - C ephalom etr ic s

6
Cephalometrics

Cephalomet ry is t he analysis and int erpret at ion of st andardized radiographs of


t he f acial bones. I n pract ice, cephalomet rics has come t o be associat ed w it h a
t rue lat eral view (Fig. 6. 1). An ant eropost erior radiograph can also be t aken in
t he cephalost at , but t his view is diff icult t o int erpret and is usually only employed
in cases w it h a skelet al asymmet ry.

6.1. THE CEPHALOSTAT


I n order t o be able t o compare t he cephalomet ric radiographs of one pat ient
t aken on diff erent occasions, or t hose of diff erent individuals, some
st andardizat ion is necessary. To achieve t his aim t he cephalost at w as developed
by B. Holly Broadbent in t he period af t er t he First World War (Fig. 6. 2). The
cephalost at consist s of an X-ray machine w hich is at a f ixed dist ance f rom a set
of ear post s designed t o f it int o t he pat ient 's ext ernal audit ory meat us. Thus t he
cent ral beam of t he machine is direct ed t ow ards t he ear post s, w hich also serve
t o st abilize t he pat ient 's head. The posit ion of t he head in t he vert ical axis is
st andardized by ensuring t hat t he pat ient 's Frankf ort plane (f or def init ion see
below ) is horizont al. This can be done by manually posit ioning t he subject or,
alt ernat ively, by placing a mirror some dist ance aw ay level w it h t he pat ient 's
head and asking him or her t o look int o t heir ow n eyes. This is t ermed t he
nat ural head posit ion, and some ort hodont ist s claim t hat it is more consist ent
t han a manual approach. I t is normal pract ice t o cone dow n t he area exposed so
t hat t he skull vault is not rout inely included in t he X-ray beam.
Fig. 6. 1. A lat eral cephalomet ric radiograph. Not e t he scale on t he upper
right -hand side.

Unf ort unat ely, at t empt s t o st andardize t he dist ances f rom t he t ube t o t he pat ient
(usually bet w een 5 and 6 f eet (1. 5 t o 1. 8 m)) and f rom t he pat ient t o t he f ilm
(usually around 1 f oot (around 30 cm)) have not been ent irely successf ul as t he
values in parent hesis w ould suggest . Some magnif icat ion, usually of t he order of
7 8 per cent , is inevit able w it h a lat eral cephalomet ric f ilm. I n order t o be able t o
check t he magnif icat ion and t hus t he comparabilit y of diff erent f ilms, it is helpf ul
if a scale is included in t he view (see Fig. 6. 1).
To give a bet t er def init ion of t he sof t t issue out line of t he f ace, eit her a t hin layer
of barium past e can be placed dow n t he cent ral axis of t he f ace or an aluminium
w edge posit ioned so as t o at t enuat e t he beam in t hat area.

6.2. INDICATIONS FOR CEPHALOM ETRIC EVALUATION


An increasing aw areness of t he risks associat ed w it h X-rays has led clinicians t o
re-evaluat e t he indicat ions f or t aking a cephalomet ric radiograph. The f ollow ing
are considered valid.
Fig. 6. 2. A cephalost at .

6.2.1. An aid to diagnosis


I t is possible t o carry out successf ul ort hodont ic t reat ment w it hout t aking a
cephalomet ric radiograph, part icularly in Class I malocclusions. How ever, t he
inf ormat ion t hat cephalomet ric analysis yields is helpf ul in assessing t he
probable aet iology of a malocclusion and in planning t reat ment . The benef it t o
t he pat ient in t erms of t he addit ional inf ormat ion gained must be w eighed against
t he X-ray dosage. Theref ore a lat eral cephalomet ric radiograph is best limit ed t o
pat ient s w it h a skelet al discrepancy and/ or w here ant eropost erior movement of
t he incisors is planned. I n a small proport ion of pat ient s it may be helpf ul t o
monit or grow t h t o aid t he planning and t iming of t reat ment by t aking serial
cephalomet ric radiographs, alt hough again t he dosage t o t he pat ient must be
just if iable.
I n addit ion, a lat eral view is of t en helpf ul in t he accurat e localizat ion of
unerupt ed displaced t eet h and ot her pat hology.

6.2.2. A pretreatment record


A lat eral cephalomet ric radiograph is usef ul in providing a baseline record prior
t o t he placement of appliances, part icularly w here movement of t he upper and
low er incisors is planned.

6.2.3. Monitoring the progress of treatment


I n t he management of severe malocclusions, w here t oot h movement is occurring
in all t hree planes of space (f or example t reat ment s involving f unct ional
appliances, or upper and low er f ixed appliances), it is common pract ice t o t ake a
lat eral cephalomet ric radiograph during t reat ment t o monit or anchorage
requirement s and incisor inclinat ions. A lat eral cephalomet ric radiograph may
also be usef ul in monit oring t he movement of unerupt ed t eet h and is t he most
accurat e view f or assessing upper incisor root resorpt ion if t his occurs during
t reat ment .

6.2.4. Research purposes


A great deal of inf ormat ion has been obt ained about grow t h and development by
longit udinal st udies w hich involved t aking serial cephalomet ric radiographs f rom
birt h t o t he lat e t eens or beyond. While t he dat a provided by previous
invest igat ions are st ill used f or ref erence purposes, it is no longer et hically
possible t o repeat t his t ype of st udy. How ever, t hose view s t aken rout inely
during t he course of ort hodont ic diagnosis and t reat ment can be used t o st udy
t he eff ect s of grow t h and t reat ment .

6.3. TRACING A CEPHALOM ETRIC RADIOGRAPH


Bef ore st art ing a t racing it is import ant t o examine t he radiograph f or any
abnormalit ies or pat hology. For example, a pit uit ary t umour could result in an
increase in t he size of t he sella t urcica. Short ening of t he root s of t he incisors is
of t en seen more clearly on a lat eral cephalomet ric radiograph. This view is also
helpf ul in assessing t he pat ency of t he airw ay, as enlarged adenoids can be
easily seen.
I n order t o be able t o derive meaningf ul inf ormat ion f rom a lat eral cephalo-met ric
t racing, an accurat e and syst emat ic approach is required w hich also involves
select ing t he right condit ions and equipment f or t he t ask.

The t racing should be carried out in a darkened room on a light view ing box.
All but t he area being t raced should be shielded t o block out any ext raneous
light .
Alt hough it is possible t o use t racing paper, propriet ary acet at e sheet s are
more t ransparent and give a more prof essional result .
A sharp pencil should be used. The aut hor recommends a 0. 3 mm leaded
propelling pencil (as t his saves hours searching f or pencil sharpeners). Some
ort hodont ist s w it h very st eady hands use a f ine ink st ylus, but t his is not
advocat ed f or t he novice.
The t racing paper or acet at e sheet should be secured ont o t he f ilm w it h
masking t ape, w hich does not leave a st icky residue w hen removed. The
t racing should be orient ed in t he same posit ion as t he pat ient w as w hen t he
radiograph w as t aken, i. e. w it h t he Frankf ort plane horizont al.
Some ort hodont ist s use st encils t o obt ain a neat out line of t he incisor and
molar t eet h. How ever, t oo much art ist ic licence can lead t o inaccuracies,
part icularly if t he crow n root angle of a t oot h is not a verage .
For landmarks w hich are bilat eral (unless t hey are direct ly superimposed) an
average of t he t w o should be t aken.
Wit h a caref ul t echnique t racing errors should be of t he order of + 0. 5 mm
f or linear measurement s and + 0. 5° f or angular measurement s.
I t is a valuable l earning experience t o t race t he same radiograph on t w o
separat e occasions and compare t he t racings. This helps t o reduce t he
t empt at ion t o place undue emphasis upon small variat ions f rom normal
cephalomet ric values.

An example of a t racing is show n in Fig. 6. 3 (see also Fig. 6. 4). Def init ions of
t he various point s and ref erence planes are given in Sect ion 6. 5.

Fig. 6. 3. A cephalomet ric t racing: pat ient LH (male) aged 14 years.

6.3.1. Digitizers
A digit izer comprises an illuminat ed radiographic view ing screen w hich is
connect ed t o a comput er. I nf ormat ion f rom a lat eral cephalomet ric radiograph is
ent ered int o t he comput er by means of a cursor w hich records t he horizont al and
vert ical (x, y) co-ordinat es of cephalomet ric point s or bony or sof t t issue
out lines. Specialized sof t w are can t hen be employed t o ut ilize t he inf ormat ion
ent ered t o produce a t racing and/ or t he analysis of choice. St udies have show n
digit izers t o be as accurat e as t racing a radiograph by hand. Cert ainly, t his
approach is part icularly usef ul f or research as any number of radiographs can be
ent ered, superimposed, and/ or compared st at ist ically.

6.4. CEPHALOM ETRIC ANALYSIS G ENERAL POINTS


The ort hodont ic lit erat ure is replet e w it h diff erent cephalomet ric analyses, w hich
in it self suggest s t hat no single met hod is suff icient f or all purposes and t hat all
have t heir draw backs. I n a book of t his size it is more appropriat e t o consider
one analysis in dept h. Theref ore one of t he approaches used commonly in t he UK
w ill be considered (Table 6. 1). For det ails of ot her analyses t he reader is
ref erred t o t he publicat ions cit ed in t he sect ion on f urt her reading.

Table 6. 1 Cephalometric norms for Caucasians (Eastman Standard).


Measurem ent Mean value Standard Deviation

SNA 81° 3°

SNB 78° 3°

ANB 3° 2°

UInc to MxPl 109° 6°

LInc to MnPl 93°* 6°

Inter-incisal angle 135° 10°

MMPA 27° 4°

Facial Proportion 55% 2%

LInc to APog line +1 mm 2 mm

SN to MxPl 8° 3°

For definitions see Section 6.5.


*Or 120° MMPA (see Section 6.8).

Cephalomet ric analyses are of t en based upon comparing t he values obt ained f or
cert ain measurement s f or a part icular individual (or group of individuals) w it h t he
average values f or t heir populat ion (e. g. Caucasians). An indicat ion of t he
signif icance of any diff erence bet w een t he act ual measurement f or an individual
and t he a verage value can be obt ained f rom t he st andard deviat ion. The range
given by one st andard deviat ion around t he mean w ill include 66 per cent of t he
populat ion and t w o st andard deviat ions w ill include 97 per cent .
Cephalomet ric analysis is also of value in ident if ying t he component part s of a
malocclusion and probable aet iological f act ors it is usef ul w hen a t racing is
f inished t o ref lect w hy t hat individual has t hat part icular malocclusion. How ever,
it is import ant not t o f all int o t he t rap of giving more credence t o cephalomet ric
analysis t han it act ually merit s; it should alw ays be remembered t hat it is an
adjunct ive t ool t o clinical diagnosis, and diff erences of cephalomet ric values f rom
t he average are not in t hemselves an indicat ion f or t reat ment , part icularly as
variat ions f rom normal in a specif ic value may be compensat ed f or elsew here in

t he f acial skelet on or cranial base. I n addit ion, cephalomet ric errors can occur
ow ing t o incorrect posit ioning of t he pat ient and incorrect ident if icat ion of
landmarks.
A lat eral cephalomet ric radiograph is a slight ly magnif ied, t w o-dimensional
represent at ion of a t hree-dimensional object (t he pat ient ). For t his reason
angular measurement s are generally t o be pref erred t o linear measurement s as
t he element of magnif icat ion is less import ant .

6.5. COM M ONLY USED CEPHALOM ETRIC POINTS AND


REFERENCE LINES
The point s and ref erence lines are show n in Fig. 6. 4.
A point (A) t his is t he point of deepest concavit y on t he ant erior prof ile of t he
maxilla. I t is also called subspinale. This point is t aken t o represent t he ant erior
limit of t he maxilla and is of t en t ricky t o locat e accurat ely. How ever, t racing t he
out line of t he root of t he upper cent ral incisor f irst and shielding all ext raneous
light of t en aids ident if icat ion. The A point is locat ed on alveolar bone and is
liable t o changes in posit ion w it h t oot h movement and grow t h.
Anterior nasal spine (ANS) t his is t he t ip of t he ant erior process of t he maxilla
and is sit uat ed at t he low er margin of t he nasal apert ure.
B point (B) t he point of deepest concavit y on t he ant erior surf ace of t he
mandibular symphysis. The B point is also sit ed on alveolar bone and can alt er
w it h t oot h movement and grow t h.
G onion (G o) t he most post erior inf erior point on t he angle of t he symphysis.
This point can be g uesst imat ed , or det ermined more accurat ely by bisect ing t he
angle f ormed by t he t angent s f rom t he post erior border of t he ramus and t he
inf erior border of t he mandible (Fig. 6. 5).
Menton (Me) t he low est point on t he mandibular symphysis.
Nasion (N) t he most ant erior point on t he f ront onasal sut ure. When diff icult y is
experienced locat ing nasion, t he point of deepest concavit y at t he int ersect ion of
t he f ront al and nasal bones can be used inst ead.
O rbitale (O r) t he most inf erior ant erior point on t he margin of t he orbit . By
def init ion, t he lef t orbit al margin should be used t o locat e t his point . How ever,
t his can be a lit t le t ricky t o det ermine radiographically, and so an average of t he
t w o images of lef t and right is usually t aken.
Pogonion (Pog) t he most ant erior point on t he mandibular symphysis.
Porion (Po) t he uppermost out ermost point on t he bony ext ernal audit ory
meat us. This landmark can be obscured by t he ear post s of t he cephalost at , and
some advocat e t racing t hese inst ead. How ever, t his is not recommended as t hey
do not approximat e t o t he posit ion of t he ext ernal audit ory meat us. The
uppermost surf ace of t he condylar head is at t he same level, and t his can be
used as a guide w here diff icult y is experienced in det ermining porion.
Posterior nasal spine (PNS) t his is t he t ip of t he post erior nasal spine of t he
maxilla. This point is of t en obscured by t he developing t hird molars, but lies
direct ly below t he pt erygomaxillary f issure.
Sella (S) t he midpoint of t he sella t urcica.
SN line t his line, connect ing t he midpoint of sella t urcica w it h nasion, is t aken t o
represent t he cranial base.
Frankfort plane t his is t he line joining porion and orbit ale. This plane is diff icult
t o def ine accurat ely because of t he problems inherent in det ermining orbit ale and
porion.
Mandibular plane The line joining gonion and ment on. This is only one of
several def init ions of t he mandibular plane, but is probably t he most w idely used.
O t her def init ions can be f ound in t he publicat ions list ed in t he sect ion on f urt her
reading.
Maxillary plane t he line joining ant erior nasal spine w it h post erior nasal spine.
Where it is diff icult t o det ermine ANS and PNS accurat ely, a line parallel t o t he
nasal f loor can be used inst ead.
Functional occlusal plane a line draw n bet w een t he cusp t ips of t he permanent
molars and premolars (or deciduous molars in mixed dent it ion). I t can be diff icult
t o decide w here t o draw t his line, part icularly if t here is an increased curve of
Spee, or only t he f irst permanent molars are in occlusion during t he t ransit ion
f rom mixed t o permanent dent it ion. The f unct ional plane can change orient at ion
w it h grow t h and/ or t reat ment , and so is not part icularly reliable f or longit udinal
comparisons.
Fig. 6. 4. Commmonly used cephalomet ric point s and planes.

Fig. 6.5. Construction of Gonion (Go): (a) draw


tangents to posterior and inferior borders; (b) bisect
the angle formed by the tangents and mark where it
crosses the angle of the mandible; (c) repeat for the
other outline (if one is visible). Go is located midway
between the two points.

(a)
(b)

(c)

6.6. ANTEROPOSTERIOR SKELETAL PATTERN


6.6.1. Angle ANB (Fig. 6.6)
I n order t o be able t o compare t he posit ion of t he maxilla and mandible, it is
necessary t o have a f ixed point or plane. The skelet al pat t ern is of t en
det ermined cephalomet rically by comparing t he relat ionship of t he maxilla and
mandible w it h t he cranial base by means of angles SNA and SNB. The diff erence
bet w een t hese t w o measurement s, angle ANB, is classif ied broadly as f ollow s:

Fig. 6.6. Assessment of skeletal pattern using angles


SNA and SNB: patient LH (male) aged 14 years.
ANB < 2° Class III

2° < ANB < 4° Class I

ANB > 4° Class II


How ever, t his approach assumes (incorrect ly in some cases) t hat t he cranial
base, as indicat ed by t he line SN, is a reliable basis f or comparison and t hat
point s A and B are indicat ive of maxillary and mandibular basal bone. Variat ions
in t he posit ion of nasion can also aff ect angles SNA and SNB and t hus t he
diff erence ANB (Fig. 6. 7); how ever, variat ions in t he posit ion of sella do not . I f
SNA is increased or reduced f rom t he average value, t his could be due t o eit her
a discrepancy in t he posit ion of t he maxilla (as indicat ed by point A) or nasion.
The

f ollow ing (rat her crude) modif icat ion is of t en used in order t o make allow ance f or
t his:
Provided t he angle bet w een t he maxillary plane and t he sella nasion line is w it hin
5° 11°:

if SNA is increased, f or every degree t hat SNA is great er t han 81°, subt ract
0. 5° f rom ANB;
if SNA is reduced, f or every degree t hat SNA is less t han 81°, add 0. 5° t o
ANB.

I f t he angle bet w een t he maxillary plane and t he sella nasion line is not w it hin
5° 11°, t his correct ion is not applicable.
Alt ernat ively, an approach w hich avoids t he cranial base (e. g. t he Ballard
conversion or t he Wit s analysis) can be used t o supplement t he above analysis,
part icularly w here t he cephalomet ric f indings are at variance w it h t he clinical
assessment .

Fig. 6.7. Effect of variations in the position of nasion on


angles SNA, SNB, and ANB:
6.6.2. Ballard conversion (Fig. 6.8)
This analysis uses t he incisors as indicat ors of t he relat ive posit ion of t he maxilla
and mandible. I t is easy t o conf use a Ballard conversion and a prognosis t racing
(see Fig. 6. 12), but in t he f ormer t he aim is t o t ilt t he t eet h t o t heir normal
angles (t hus eliminat ing any dent o-alveolar compensat ion) w it h t he result t hat t he
residual overjet w ill indicat e t he relat ionship of t he maxilla t o t he mandible.
Fig. 6. 8. Ballard conversion: average upper incisor angle t o maxillary plane,
109°; low er incisor angle t o mandibular plane, 120° 3 1. 5° = 88. 5°.
The met hod is as f ollow s.
1. Trace on a separat e piece of t racing paper t he out line of t he maxilla, t he
mandibular symphysis, t he incisors, and t he maxillary and mandibular planes.
2. Mark t he r ot at ion point s of t he incisors one-t hird of t he root lengt h aw ay
f rom t he root apex.
3. By rot at ing around t he point marked, reposit ion t he upper incisor at an
angle of 109° t o t he maxillary plane. Repeat f or t he low er incisor (allow ing
f or t he maxillary mandibular planes angle of 31. 5° in t his case).
4. The residual overjet ref lect s t he underlying skelet al pat t ern. I n t his case
t he Ballard conversion indicat es a mild Class I I I skelet al pat t ern as t he
reposit ioned incisors are nearly edge t o edge.

6.6.3. Wits analysis (Fig. 6.9)


This analysis compares t he relat ionships of t he maxilla and mandible w it h t he
occlusal plane. There are several def init ions of t he occlusal plane, but f or t he
purposes of t he Wit s analysis it is t aken t o be a line draw n bet w een t he cusp
t ips

of t he molars and premolars (or deciduous molars), w hich is know n as t he


f unct ional occlusal plane. Perpendicular lines f rom bot h point A and point B are
dropped t o t he f unct ional occlusal plane t o give point s AO and BO . The dist ance
bet w een AO and BO is t hen measured. The mean values are 1 mm (SD + 1. 9
mm) f or males and 0 mm (SD + 1. 77 mm) f or f emales.

Fig. 6. 9. Wit s analysis: LH (male) aged 14 years. The met hod is as f ollow s.
1. Draw in t he f unct ional occlusal plane (FO P).
2. Drop perpendiculars f rom point A and point B t o t he FO P t o give point s AO
and BO .
3. Measure t he dist ance bet w een AO and BO .
The average value is +1 mm (ą 1. 9 mm) f or males and 0 mm (ą 1. 77 mm) f or
f emales. The dist ance f rom AO t o BO f or LH (male) is +2 mm, suggest ing a
mild Class I I I skelet al pat t ern.

The draw back t o t his approach is t hat t he f unct ional occlusal plane is not easy t o
locat e, w hich obviously aff ect s t he accuracy and reproducibilit y of t he Wit s
analysis. A slight diff erence in t he angulat ion of t he f unct ional occlusal plane can
have a marked eff ect on t he relat ive posit ions of AO and BO .

6.7. VERTICAL SKELETAL PATTERN


Again t here are many diff erent w ays of assessing vert ical skelet al proport ions.
The more commonly used include t he f ollow ing.

The Maxillary M andibular Planes Angle (Fig. 6. 10). The average angle
bet w een t he maxillary plane and t he mandibular plane (MMPA) is 27° + 4°.
Some analyses measure t he angle bet w een t he Frankf ort and t he mandibular
planes (average 28° + 4°). How ever, t he maxillary plane is easier t o locat e
accurat ely and t heref ore t he MMPA is pref erred.
The Facial Proport ion (Fig. 6. 11). This is t he rat io of t he low er f acial height
t o t he t ot al ant erior f acial height measured perpendicularly f rom t he maxillary
plane, calculat ed as a percent age:

I f t here appears t o be a discrepancy bet w een t he result s f or t hese t w o


measurement s of vert ical relat ionship, it should be remembered t hat t he MMPA
ref lect s bot h post erior low er f acial height and ant erior low er f acial height .
Theref ore in

t he case of pat ient LH w ho has an increased MMPA but an average f acial


proport ion it w ould appear t hat t he post erior low er f acial height is reduced (as
opposed t o an increased ant erior low er f acial height ).

Fig. 6.10. Assessment of vertical skeletal pattern using


the MMPA and FMPA: LH (male) aged 14 years.
Both the MMPA and the Frankfort mandibular planes
angle are increased. This may be due to either an
increased lower anterior face height or a reduced lower
posterior face height.

Fig. 6.11. Calculating the facial proportion: LH (male)


aged 14 years.
6.8. INCISOR POSITION
The average value f or t he angle f ormed bet w een t he upper incisor and t he
maxillary plane is 109°. The normal value f or low er incisor angle given in Table
6. 1 is f or an individual w it h an average MMPA of 27°. How ever, t here is a
relat ionship bet w een t he MMPA and t he low er incisor angle: as t he MMPA
increases, t he low er incisors become more ret roclined. As t he sum of t he
average MMPA (27°) and t he average low er incisor angle (93°) equals 120°, an
alt ernat ive w ay of deriving t he a verage low er incisor angulat ion f or an individual
is t o subt ract t he MMPA f rom 120°:
low er incisor angle = 120° MMPA.

6.8.1. Prognosis tracing


Somet imes it is helpf ul t o be able t o det ermine t he t ype and amount of incisor
movement required t o correct an increased or reverse overjet . Alt hough t he
skelet al pat t ern w ill give an indicat ion, on occasion compensat ory proclinat ion or
ret roclinat ion (know n as dent o-alveolar compensat ion) of t he incisors can
conf use t he issue. When planning t reat ment in such a case it may be helpf ul t o
carry out a prognosis t racing. This involves m oving t he incisor(s) t o mimic t he
movement s achievable w it h diff erent t ypes of appliance t herapy t o help
det ermine t he best course of act ion f or t hat pat ient . An example is show n in Fig.
6. 12, w here it can be seen t hat bodily ret ract ion of t he upper incisors w ould
result in t heir being ret ract ed out of t he palat al bone obviously not a pract ical
t reat ment proposit ion.
A quick met hod of calculat ing t he f inal upper incisor angle f ollow ing t ipping
movement s is t o assume t hat f or 2. 5° of angular movement (about a point of
rot at ion one-t hird of t he w ay dow n t he root f rom t he apex) t he upper incisor
edge w ill t ranslat e approximat ely 1 mm. How ever, it should be st ressed t hat bot h
met hods provide only a rough guide t o t he t oot h movement s required.

Fig. 6. 12. Prognosis t racing: CP (f emale) aged 18 years. From t his diagram
it can be seen t hat bodily movement of t he upper incisors t o reduce t his
pat ient 's overjet w ould not be f easible. Theref ore a surgical aproach w as
recommended.

6.8.2. A-Pogonion line (APog)


Raleigh Williams not ed w hen he analysed t he lat eral cephalomet ric radiographs
of individuals w it h pleasing f acial appearances t hat one f eat ure w hich t hey all
had in common w as t hat t he t ip of t heir low er incisor lay on or just in f ront of t he
line connect ing point A w it h pogonion. He advocat ed using t his posit ion of t he
low er incisor as a t reat ment goal t o help ensure a good f acial prof ile. While t his
line may be usef ul w hen planning ort hodont ic t reat ment , it must be remembered
t hat it is only a guideline t o good f acial aest het ics, and not an indicat or of
st abilit y. I f t he low er incisors are moved f rom t heir pret reat ment posit ion of
labiolingual balance, w hat ever t he rat ionale, t here is a likelihood of relapse
f ollow ing removal of appliances. This t opic is discussed in more det ail in
Chapt ers 7 and 10.
6.9. SOFT TISSUE ANALYSIS
The major role of analysis of t he sof t t issues is in diagnosis and planning prior t o
ort hognat hic surgery (Chapt er 20). As w it h ot her element s of cephalomet ric
analysis, t here are a large number of diff erent analyses of varying complexit y.
The f ollow ing are some of t he more commonly used:

The Holdaway line


This is a line f rom sof t t issue chin t o t he upper lip. I n a w ell-proport ioned f ace
t his line, if ext ended, should bisect t he nose (Fig. 6. 13).

Fig. 6. 13. Sof t t issue analysis.

Rickett's E-plane
This line joins sof t t issue chin and t he t ip of t he nose. I n a balanced f ace t he
low er lip should lie 2 mm (ą 2 mm) ant erior t o t his line w it h t he upper lip
posit ioned a lit t le f urt her post eriorly t o t he line (Fig. 6. 13).
Facial plane
The f acial plane is a line bet w een t he sof t t issue nasion and t he sof t t issue chin.
I n a w ell-balanced f ace t he Frankf ort plane should bisect t he f acial plane at an
angle of about 86° and point A should lie on it (Fig. 6. 13).
As w it h ot her aspect s of cephalomet rics, but perhaps more pert inent ly, t hese
analyses should be supplement ary t o a clinical examinat ion, and it should also be
remembered t hat beaut y is in t he eye of t he beholder.

6.10. ASSESSING GROWTH AND TREATM ENT CHANGES


The advant age of st andardizing lat eral cephalomet ric radiographs is t hat it is
t hen possible t o compare radiographs eit her of groups of pat ient s f or research
purposes or of t he same pat ient over t ime t o evaluat e grow t h and t reat ment
changes. I n some cases it may be helpf ul t o monit or grow t h of a pat ient over
t ime bef ore deciding upon a t reat ment plan, part icularly if unf avourable grow t h
w ould result in a malocclusion t hat could not be t reat ed by ort hodont ics alone.
During t reat ment it can be helpf ul t o det ermine t he cont ribut ions t hat t oot h
movement s and/ or grow t h have made t o t he correct ion and t o help ensure t hat ,
w here possible, a st able result is achieved. For example, in a Class I I division 1
malocclusion, correct ion of an increased overjet can occur by ret roclinat ion of
t he upper incisors and/ or proclinat ion of t he low er incisors and/ or f orw ard
grow t h of t he mandible and/ or rest raint of f orw ard grow t h of t he maxilla. I f t he
major part of t he correct ion is due t o proclinat ion of t he low er incisors t here is
an increased likelihood of relapse of t he overjet f ollow ing cessat ion of appliance
t herapy ow ing t o sof t t issue pressures. I f t his is det ermined bef ore appliances
are removed, it may be possible t o t ake st eps t o rect if y t he sit uat ion.
How ever, in order t o be able t o compare radiographs accurat ely it is necessary
t o have a f ixed point or ref erence line w hich does not change w it h t ime or
grow t h. Unf ort unat ely t his poses a dilemma, as t here are no nat ural f ixed point s
or planes w it hin t he f ace and skull. This should be borne in mind w hen
int erpret ing t he diff erences seen using any of t he superimposit ions discussed
below.

6.10.1 Cranial base


The SN line is t aken in cephalomet rics as approximat ing t o t he cranial base.
How ever, grow t h does occur at nasion, and t heref ore superimposit ions on t his
line f or t he purpose of evaluat ing changes over t ime should be based at sella.
Unf ort unat ely, grow t h at nasion does not alw ays convenient ly occur along t he SN
line if nasion moves upw ards or dow nw ards w it h grow t h, t his w ill of course
int roduce a rot at ional error in comparisons of t racings superimposed on SN. I t is
more accurat e t o use t he out line of t he cranial base (called de Cost er's line) as
lit t le change occurs in t he ant erior cranial base af t er 7 years of age (see
Chapt er 4). How ever, a clear radiograph and a good know ledge of anat omy is
required t o do t his reliably.

6.10.2. The maxilla


G row t h of t he maxilla occurs on all surf aces by periost eal remodelling. For t he
purpose of int erpret at ion of grow t h and/ or t reat ment changes t he least aff ect ed
surf ace is t he ant erior surf ace of t he palat al vault , alt hough t he maxilla is
commonly superimposed on t he maxillary plane at PNS.

6.10.3. The mandible


I t w as not ed above t hat t here are no nat ural st able ref erence point s w it hin t he
f ace and skull. Bjork overcame t his problem by insert ing met al markers in t he
f acial skelet on. Whilst t his approach is obviously not applicable in t he
management of pat ient s, it did provide considerable inf ormat ion on pat t erns of
f acial grow t h, indicat ing t hat in t he mandible t he landmarks w hich change least
w it h grow t h are as f ollow s (in order of usef ulness):

t he innermost surf ace of t he cort ical bone of t he symphysis;


t he t ip of t he chin;
t he out line of t he inf erior dent al canal;
t he crypt of t he developing t hird permanent molars f rom t he t ime of
commencement of mineralizat ion unt il root f ormat ion begins.

PRINCIPAL SOURCES AND FURTHER READING


Brow n, M. (1981). Eight met hods of analysing a cephalogram t o est ablish
ant eropost erior skelet al discrepancy. Bri ti sh Journal of O rthodonti cs, 8,
139 4 6.
This paper admirably illust rat es t he pit f alls and problems w it h cephalomet ric
analysis, w hilst also brief ly present ing some alt ernat ive analyses.

Ferguson, J. W. , Evans, R. I . W. , and Cheng, L. H. H. (1992). Diagnost ic


accuracy and observer perf ormance in t he diagnosis of abnormalit ies in t he
ant erior maxilla: a comparison of panoramic w it h int ra-oral radiography.
Bri ti sh Dental Journal, 173, 265 7 1.

G ravely, J. F. and Murray Benzies, P. (1974). The clinical signif icance of


t racing error in cephalomet ry. Bri ti sh Journal of O rthodonti cs, 1, 95 1 01.
A classical paper on t racing errors.
G ui del i nes f or the use of radi ographs i n cl i ni cal orthodonti cs. Brit ish
O rt hodont ic Societ y, London, 1994.

Houst on, W. J. B. (1979). The current st at us of f acial grow t h predict ion.


Bri ti sh Journal of O rthodonti cs, 6, 11 1 7.

Houst on, W. J. B. (1986). Sources of error in measurement s f rom


cephalomet ric radiographs. European Journal of O rthodonti cs, 8, 149 5 1.

Jacobson, A. (1995). Radi ographi c cephal ometry: f rom basi cs to


vi deoi magi ng. Q uint essence Publishing, USA.
An aut horat at ive book. I ncludes a very good sect ion on how t o t race a
cephalomet ric radiograph w it h act ual copy f ilms and overlays t o aid landmark
ident if icat ion.

Lew is, D. H. (1981). Basic t racing f or lat eral skull radiographs. Dental
Update, 8, 45 5 1.

Lew is, D. H. (1981). Lat eral skull radiographs: grow t h and t reat ment
changes. Dental Update, 8, 193 9 9.

These t w o papers by Lew is give an int roduct ion t o cephalomet rics w hich is
easy t o f ollow.

Sandham, A. (1988). Repeat abilit y of head post ure recordings f rom lat eral
cephalomet ric radiographs. Bri ti sh Journal of O rthodonti cs, 15, 157 6 2.
Authors: Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> Table of C ontents > 7 - Tr eatm ent planning

7
Treatment planning

7.1. INTRODUCTION
Wit hout doubt , t reat ment planning is t he most diff icult , but also t he most
import ant , element of ort hodont ics. A know ledge of dent al development , f acial
grow t h, psychology, and appliance mechanics are all prerequisit es f or success.
Whilst much can be learnt f rom t ext books t here is no subst it ut e f or clinical
experience gained over t ime. Theref ore, w hen in doubt , t he less experienced
should ref er t he pat ient t o a specialist f or advice.
Prior t o planning t reat ment a t horough examinat ion of t he pat ient and t heir
malocclusion should be carried out (Chapt er 5). As soon as pract icable af t er t his
assessment , t he pat ient 's records, including st udy models and radiographs,
should be st udied, pref erably during a quiet period aw ay f rom t he clinical
environment .

7.2. PATIENT M OTIVATION


I n order f or ort hodont ic t reat ment t o be successf ul t he pat ient 's w illing
part icipat ion and cooperat ion are essent ial. Theref ore t ime spent on assessing a
pat ient 's concerns regarding t he alignment of t heir t eet h and t heir mot ivat ion
t ow ards appliance t reat ment is never w ast ed. I t may be w iser t o achieve a
compromise result successf ully t han t o f ail t o complet e an ideal t reat ment plan.
I n t his respect it is import ant t o counsel t he pat ient regarding t heir role in t he
success of t reat ment . I f mot ivat ion is at all in doubt , it is w iser not t o proceed or
at least t o t est t he w at er w it h a simple appliance bef ore any irreversible st eps,
f or example ext ract ions, are undert aken. O n occasion, a pat ient w ill seek
perf ect ion but w ill be unw illing t o cooperat e f ully w it h t he t ype of appliance
necessary t o achieve t his. Faced w it h t his sit uat ion, t he w ise clinician w ill not
proceed.

7.3. LIM ITATIONS OF ORTHODONTIC TREATM ENT


When planning t reat ment t he limit at ions of ort hodont ic appliances should be
borne in mind. Wit h an ent husiast ic pat ient and f avourable grow t h (w hich is more
likely in children and in Class I I rat her t han Class I I I malocclusions)
compensat ion of moderat ely severe skelet al pat t erns can be achieved w it h
f unct ional and/ or f ixed appliances. How ever, w here grow t h is likely t o be
unf avourable and/ or t he underlying skelet al pat t ern is severe, considerat ion
should be given t o using a combined surgical and ort hodont ic approach (see
Chapt er 20).
Convent ional removable appliances (Chapt er 16) are only suit able f or
malocclusions w here t ipping movement s w ill suff ice. Funct ional appliances
(Chapt er 18)

are part icularly usef ul in t he management of Class I I malocclusions in a grow ing


pat ient .

7.4. TIM ING OF TREATM ENT


I n t he vast majorit y of cases def init ive ort hodont ic t reat ment is best carried out
in t he early permanent dent it ion. The reasons f or t his include t he f ollow ing:

G row t h can be ut ilized t o f acilit at e ant eropost erior arch correct ion and
overbit e reduct ion.
The t endency f or spont aneous t oot h movement is great est during and short ly
af t er t oot h erupt ion, and w hile t he pat ient is st ill grow ing.
Act ive t oot h movement cannot begin unt il af t er erupt ion.
Pat ient cooperat ion reaches a peak in t he early t eens, but diminishes rapidly
f rom around 14 1 5 years.
Cellular react ions and bone remodelling in response t o ort hodont ic f orces are
more rapid in children.

O rt hodont ic t reat ment is possible in adult hood but t he range of malocclusions


t hat can be t ackled by ort hodont ics alone is diminished because of a lack of
grow t h. I n addit ion, t oot h movement is init ially slow er t han in children. Root
resorpt ion during t reat ment has been f ound t o occur t o a great er ext ent in
adult s. Nevert heless, once t hey have made t he decision t o go ahead w it h
ort hodont ic t reat ment , adult s usually make conscient ious and cooperat ive
pat ient s.

7.5. AIM S OF TREATM ENT


The f irst st ep in t he planning process is t o decide w het her or not t reat ment is
indicat ed. This issue has been discussed in det ail in Chapt er 1. I n summary,
appliances and/ or ext ract ions should only be embarked upon w hen a signif icant
improvement in dent al healt h or aest het ics can be achieved. I t is bet t er not t o
proceed t han t o run t he risk of w orsening a pat ient 's occlusion or appearance.
O nce it has been decided t hat t reat ment is indicat ed, considerat ion should be
given t o t he aims of t reat ment . This involves visualizing t he f inished result and
t hen evaluat ing w hat occlusal changes are required t o achieve t his. I t is
advisable t o decide w hat t he ideal aims should be and t hen, if necessary, t o
modif y t hem in t he light of ot her considerat ions such as pat ient cooperat ion.
How ever, it is import ant t o not e in t he pat ient 's records any t reat ment plans
discussed and w hy a part icular set of t reat ment aims w as f inally select ed.
When deciding upon t he aims of t reat ment t he less experienced operat or may
f ind it helpf ul t o const ruct a brief summary of t he pat ient 's malocclusion (see
Chapt er 5, Sect ion 5. 9). This gives a p roblem list f rom w hich t hose f act ors t hat
are t o be correct ed can be select ed. How ever, a logical approach is required.
For example, of t he t w o plans below, plan B is pref erable as t his is t he sequence
w hich pract ical t reat ment w ould t ake.

Plan A
1. Reduct ion of overjet .
2. Correct ion of crossbit e 5.
3. Relief of crow ding.
4. Reduct ion of overbit e.

Fig. 7.1. Patient HW aged 12 years: (a) ( e)


pretreatment; (f) ( j) post-treatment. HW had a Class II
division 1 malocclusion on a Class II skeletal pattern
with crowding. As proclination of the lower labial
segment had helped to compensate for the Class II
skeletal pattern, this malocclusion was treated by
extraction of all four first premolars and upper
removable appliances. Anchorage was reinforced with
extra-oral anchorage.
(a)

(b)

(c)
(d)

(e)

(f)
(g)

(h)

(i)

(j)
Plan B
1. Relief of crow ding.
2. Reduct ion of overbit e.
3. Correct ion of crossbit e 5.
4. Reduct ion of overjet .

I t is import ant t o remember t hat t he planning process is f lexible and t hat t he


init ial aims select ed may have t o be re-evaluat ed and revised.

7.6. PRINCIPLES OF TREATM ENT PLANNING


The approach t o t reat ment planning out lined below w ill provide a logical basis f or
t he management of most malocclusions (Fig. 7. 1). How ever, t his sect ion should
be read in conjunct ion w it h Chapt ers 8, 9, 10, 11, 12, 13, 14, 15 f or a f uller
appreciat ion of management .
Mixed dent it ion problems are covered separat ely in Chapt er 3.

7.6.1. The lower arch (Fig. 7.2)


I t is accept ed t hat in t he majorit y of pat ient s t he low er labial segment lies in a
zone of balance bet w een t he t ongue and t he cheeks. There are except ions t o
t his rule (see Chapt er 10), but t he management of such cases is t he domain of
t he specialist and it is advisable f or t he inexperienced operat or t o consider t he
labiolingual posit ion of t he low er incisors as immut able. This precept has t he
advant age of providing a st art ing point around w hich t reat ment planning can be
based.

Fig. 7. 2. Low er arch of HW show ing proclinat ion of low er labial segment w it h
moderat e crow ding. Ext ract ion of bot h low er f irst premolars w as planned.
The f irst st ep is t o assess t he alignment , including t he presence of crow ding or
spacing, of t he low er arch. I f alignment is good or accept able, t hen at t ent ion can
be t urned t o t he upper arch (Sect ion 7. 6. 2). I f t he low er labial segment is eit her
act ually crow ded, or crow ding is expect ed f ollow ing erupt ion of t he canines
(pot ent ial crow ding), bot h t he degree of crow ding and t he likelihood of it s
increasing signif icant ly need t o be considered. O nce int ercanine grow t h has
slow ed, at around 9 years of age, crow ding of t he low er labial segment is likely
t o increase, part icularly if t hird permanent molars are developing and/ or t he
pat ient is st ill act ively grow ing. Wit h pract ice t he degree of crow ding can of t en
be assessed by eye. The less experienced may f ind it helpf ul t o measure t he
arch circumf erence (f rom t he mesial surf ace of t he f irst permanent molars
around t he arch t hrough t he cont act point s) and compare t his w it h t he act ual
w idt hs of t he permanent t eet h (Fig. 7. 3).

Fig. 7.3. (a) Arch circumference measured from the


mesial aspect of the first permanent molars by means
of the best fit through the contact points around the
arch. A flexible piece of wire (for example copper or
fuse wire) should be used. (b) The widths of each
individual tooth (anterior to the first molars) are
measured using dividers. Each dimension is indented
onto a ruled line on a piece of paper to give the space
required to accommodate all the teeth anterior to the
first permanent molars in alignment. (c) Comparison of
the sum total of the combined widths with the actual
space available (the arch circumference) gives an exact
measurement of the crowding present.

(a)
(b)

(c)

I f t he crow ding is very mild it may be w iser t o accept t his. I f mid-arch


ext ract ions are carried out , residual spacing may remain or if if f ixed appliances
are used t o t ry and close any residual space, some lingual ret ract ion of t he
incisors may occur w hich is generally undesirable.
I f t he overbit e is increased, account must also be t aken of t he space required t o
level t he curve of Spee. An averagely increased curve of Spee w ill require
approximat ely a quart er unit of space f or leveling.
Planning space requirement s is discussed in great er det ail in Sect ion 7. 7. I n
summary, space can be provided by t he f ollow ing manoeuvres:

dist al movement of t he molars, w hich is commonly considered f or t he upper


arch but very rarely in t he low er arch;
expansion;
ext ract ions (see Sect ion 7. 7. 1), w hich is t he most commonly used approach.

O nce relief of crow ding, if indicat ed, has been decided upon, t he next st ep in t he
t reat ment planning process is t o consider w hat t oot h movement s are required t o
align t he low er arch. Spont aneous t oot h movement s are great est as t he t eet h
are erupt ing in grow ing pat ient s but cannot be relied upon t o produce complet e
alignment . Changes are great est f or t he f irst 6 mont hs f ollow ing relief of
crow ding.
Mesially inclined canines and lingually inclined low er premolars w ill usually
become upright if space is made available provided t hat t here are no occlusal
int erf erences, alt hough t his occurs less readily in an older pat ient w ho is not
grow ing. I f t he canines are dist ally inclined or any t eet h are rot at ed, f ixed
appliances are usually required t o achieve sat isf act ory alignment . Also, if
ext ract ion of t he second premolars or f irst molars is indicat ed, f ixed appliances
are usually necessary t o achieve alignment and t o close space by bodily
movement (Sect ion 7. 7. 1).
I f t here is a cent reline discrepancy in a crow ded low er arch, some spont aneous
correct ion may be achieved by st aggering t he ext ract ions. How ever, if t he
discrepancy is great er t han half a t oot h w idt h, complet e correct ion is unlikely
and f ixed appliances w ill be required if t he cent relines are t o be coordinat ed.

Fig. 7. 4. Upper arch of HW show ing mild crow ding. I t w as decided t o ext ract
bot h upper f irst premolars t o provide space f or ret ract ion of upper canines
int o Class I relat ionship w it h t he correct ed posit ion of low er canines.

7.6.2. The upper arch (Fig. 7.4)


O nce alignment of t he low er arch has been planned, it is of t en helpf ul t o
envisage t he ant icipat ed posit ion of t he low er canine bef ore f ocusing on building
t he upper arch around t he low er arch. The f irst st ep in t his process is ment ally
t o reposit ion t he maxillary canine int o a Class I relat ionship w it h t he low er
canine. This w ill not only give an indicat ion of w het her space has t o be creat ed,
but w ill also indicat e t he amount and t ype of movement required. Allow ance
should be made f or spacing of t he low er labial segment , if present , and f or
t oot h-size discrepancies, f or example peg-shaped lat eral incisors.
I f t he aim of t he t reat ment is t o produce a Class I incisor and molar relat ionship,
t hen in most cases w it h crow ding it is usual t o plan t o ext ract t he same t oot h in
t he upper arch as is planned in t he mandibular arch. This makes coordinat ion of
space closure and appliance mechanics bet w een t he arches considerably easier.
The major except ions t o t his rule occur w hen ext ract ions are planned t o aid
dent o-alveolar compensat ion in malocclusions w it h a skelet al component . For
example, in Class I I malocclusions ext ract ions in t he upper arch alone leading t o
a Class I I buccal segment relat ionship may be indicat ed if t he low er arch is w ell
aligned, or ext ract ion of t he f irst premolars in t he upper arch may be

mat ched by t he ext ract ion of t he second premolars in t he low er arch t o alt er t he
anchorage balance (see Chapt ers 9 and 10).
The t oot h movement s needed t o align t he upper labial segment , and t heref ore
t he t ype of appliance required, should be considered in conjunct ion w it h
correct ion of t he incisor relat ionship.

Fig. 7. 5. Correct ion of HW's incisor relat ionship required reduct ion of t he
overbit e and t hen t he overjet . As proclinat ion of t he low er incisors had
helped t o compensat e f or t he mild Class I I skelet al pat t ern, reduct ion of t he
overjet by t ipping t he upper incisors palat ally w as f easible. An upper
removable appliance w it h a f lat ant erior bit e plane and canine ret ract ion
springs w as prescribed. A second appliance w as used f or overjet reduct ion
once t he overbit e had been reduced and t he upper canines ret ract ed int o a
Class I relat ionship w it h t he low er arch.

7.6.3. Correction of the incisor relationship (Fig. 7.5)


Correct ion of Class I I divisions 1 and 2, and Class I I I incisor relat ionships are
discussed in great er det ail in Chapt ers 9, 10, and 11. Funct ional appliances are
most usef ul in t he correct ion of Class I I malocclusions in t he grow ing pat ient . I f
bodily, de-rot at ion, int rusion, or ext rusion movement s are required, f ixed
appliances are indicat ed.
I t is also import ant t o consider t he incisor relat ionship in t he vert ical dimension,
i. e. overbit e. This is part icularly pert inent in Class I I malocclusions, w here t he
overbit e is increased, and in Class I I I malocclusions w here proclinat ion of t he
upper incisors alone w ill reduce t he overbit e and t he chances of st abilit y of t he
correct ed incisor relat ionship.
7.6.4. The buccal segments (Fig. 7.6)
O nce t he labial segment s have been planned, at t ent ion should be f ocused on t he
buccal segment s and t he molar relat ionship. I f no ext ract ions are planned, no
t eet h are congenit ally absent , or mat ched ext ract ions in bot h arches are
indicat ed, t he molar relat ionship at t he end of t reat ment should be Class I . I f
ext ract ions are carried out in t he upper arch only, t he buccal segment s should be
Class I I ; conversely, if only low er arch ext ract ions are planned, a Class I I I molar
relat ionship should result .

Fig. 7. 6. HW's molar relat ionship w as Class I t heref ore no correct ion of t he
buccal segment s w as required.

I t is import ant t o consider how t he desired molar relat ionship w ill be achieved.
Follow ing loss of t he low er second deciduous molar, t he f irst permanent molar
w ill drif t mesially int o t he leew ay space, but apart f rom t his lit t le spont aneous
change can be ant icipat ed. Theref ore if correct ion of t he buccal segment
relat ionship is desirable, act ive change using appliances is necessary. Met hods
of changing t he molar relat ionship include t he f ollow ing:

int ramaxillary f orces (f or example space closure w it h a f ixed appliance);


int ermaxillary f orces (f or example Class I I elast ic t ract ion or a f unct ional
appliance);
ext ra-oral t ract ion;
anchorage loss, alt hough by def init ion t his is molar movement in an
undesirable direct ion.

7.6.5. Anchorage
This t opic is considered in more det ail in Chapt er 15. How ever, during t reat ment
planning it may be helpf ul t o view it in t erms of t he balance bet w een t he
available space and t he desired t oot h movement s. Considerat ion of t he amount
of space and t he t ype of movement required t o achieve alignment and/ or
correct ion of t he incisor relat ionship in t he st eps above w ill give an indicat ion of
t he anchorage requirement s of a part icular malocclusion. O bviously, if most or all
of t he space creat ed by ext ract ions is needed t o ret ract t he canines and align
t he incisors, no f orw ard movement of t he buccal segment t eet h can be permit t ed
and

anchorage w ill have t o be reinf orced (see Chapt er 15). I n addit ion, t he eff ect of
t he t ype of t oot h movement required on anchorage must be t aken int o
considerat ion. For example, bodily ret ract ion of t he upper incisors t o reduce an
increased overjet w ill place a great er st rain on anchorage t han t ipping
movement s (i. e. t he f ormer w ill t end t o drag t he molars mesially).
I t has been observed t hat space closure occurs more rapidly in pat ient s w it h
increased vert ical skelet al proport ions t han in t hose w it h reduced vert ical
proport ions. I n pract ice t his means t hat anchorage loss f ollow ing ext ract ions is
more likely t o be a problem in t he pat ient w it h a t endency t o a vert ical grow t h
pat t ern.
The eff ect of any planned t oot h movement upon t he pat ient 's f acial prof ile also
needs t o be est imat ed. Closure of spacing (eit her present bef ore t reat ment or
creat ed by ext ract ions) w ill have t he eff ect of ret ract ing t he ant erior t eet h and
moving t he buccal segment t eet h f orw ards. The ext ent t o w hich one of t hese
predominat es w it hin each arch should be det ermined during t reat ment planning,
as should t he act ual mechanics of appliance t herapy necessary. Where ret ract ion
of t he ant erior t eet h w ould be det riment al t o t he prof ile, specialist advice should
be sought bef ore ext ract ions are carried out .

7.6.6. Retention
I t is imperat ive t hat ret ent ion is considered at t he t reat ment planning st age and
present ed t o t he pat ient as a vit al part of t he overall t reat ment package.
Treat ment should alw ays aim t o leave t he t eet h in a st able posit ion on
complet ion, but a period of ret ent ion is necessary t o allow consolidat ion of new ly
f ormed bone, remodelling of t he periodont al f ibres, and sof t t issue adapt at ion.
Permanent ret ent ion is occasionally required, but such cases should be t he
province of t he specialist .
Ret ent ion is discussed in more det ail in Chapt er 15 and also in Chapt ers 8, 9,
10, 11, 12, 13 in relat ion t o t he correct ion of each t ype of malocclusion. I n
general, a regime of at least 3 mont hs f ull-t ime w ear and t hen 3 mont hs night s-
only w ear is advisable f ollow ing t reat ment w it h removable appliances. Most
operat ors double t he t ime period f ollow ing t reat ment w it h f ixed appliances.

7.6.7. Potential pitfalls


Considerat ion should be given t o ref erring a pat ient f or specialist advice w here
any doubt exist s or if any of t he f ollow ing f eat ures are not ed:

marked skelet al discrepancies in t he ant eropost erior, vert ical, or t ransverse


dimension;
deep overbit e associat ed w it h reduced vert ical skelet al proport ions;
t he molar relat ionship is a f ull unit Class I I and t he low er arch is crow ded;
Class I I division 1 malocclusions w here t he overjet is great er t han 10 mm
and/ or t he overjet is increased and t he upper incisors are upright ;
f irst permanent molars of poor prognosis and a Class I I or Class I I I incisor
relat ionship;
asymmet rical crow ding;
generalized spacing w hich concerns t he pat ient .

7.7. CREATING SPACE


Space t o relieve crow ding and/ or t o compensat e f or a skelet al discrepancy can
be gained by t he f ollow ing procedures:

ext ract ions


expansion
dist al movement of t he buccal segment t eet h
reduct ion of t oot h w idt h
a combinat ion of any or all of t he above.

7.7.1. Extractions
Bef ore planning t he ext ract ion of any permanent t eet h it is import ant t o ensure
t hat all remaining t eet h are present and developing in a sat isf act ory posit ion.
The f act ors governing t he choice of t eet h f or ext ract ion include t he f ollow ing:
Prognosis.
Posit ion.
Amount of space required and w here. Provided t hat relief of crow ding only is
indicat ed, t he f ollow ing is a general guide: 1 2 mm per quadrant , f irst pre-
molar ext ract ions should be avoided and a specialist opinion sought ; 3 5 mm
per quadrant , of t en indicat es premolar ext ract ions; more t han 5 mm per
quadrant , ext ract ions and space maint enance, or even t he ext ract ion of more
t han one t oot h per quadrant , may be necessary.
The incisor relat ionship (see Chapt ers 8, 9, 10, 11).
Anchorage requirement s and desired buccal segment relat ionship at t he end
of t reat ment .
Appliances t o be used.
Pat ient 's prof ile.

I f ext ract ions are required in bot h arches, f orw ard movement of t he buccal
segment s t o close space spont aneously w ill be f acilit at ed if t he same t oot h is
removed in bot h t he maxilla and t he mandible. This is less import ant if f ixed
appliances are t o be used, and indeed ext ract ing f urt her f orw ard in t he upper
arch in Class I I and in t he low er arch of Class I I I malocclusions may aid in t he
correct ion of skelet al discrepancies.
The posit ion of t he t oot h being ext ract ed w it hin t he arch w ill aff ect t he
anchorage balance bet w een t he t eet h ant erior and post erior t o t he ext ract ion
sit e. This means t hat ext ract ion of f irst premolars w ill give great er space f or
alignment and/ or ret ract ion of t he incisors t han ext ract ion of second pre-molars,
w hich in t urn provides more space t han ext ract ion of f irst molars, and so on.

Fig. 7. 7. Sect ional f ixed appliance t o align low er labial segment .


Incisors
Ext ract ion of a low er incisor t ends t o result in lingual t ilt ing of t he remaining
low er labial segment t eet h and a reduct ion in int ercanine w idt h, w hich w ill
produce an increase in overbit e and of t en an increase in crow ding, part icularly in
a grow ing child. O ccasionally, if t he low er canines are dist ally inclined and t he
low er labial segment crow ded in a child w ho ref uses f ixed appliance t reat ment ,
an accept able compromise can be reached by ext ract ion of one or t w o low er
incisors. I f a low er incisor is excluded f rom t he arch, it s ext ract ion may result in
sat isf act ory alignment , but of t en a sect ional low er f ixed appliance is indicat ed t o
achieve good root paralleling.
I n t he adult , removal of a low er incisor may be helpf ul if t he incisor and buccal
segment relat ionship is Class I and t he low er labial segment is crow ded.
How ever, a sect ional f ixed appliance is usually necessary t o achieve sat isf act ory
alignment and t o close space by bodily movement (Fig. 7. 7), alt hough it is w ise
t o def er t his approach unt il af t er t he t hird permanent molars have erupt ed or
been removed.

Upper incisors are rarely t he t eet h of choice f or ext ract ion, but w here t rauma or
morphology have reduced t heir prognosis, or an incisor is grossly displaced,
t here may be no alt ernat ive. Management of missing/ enf orced ext ract ion of
upper incisors is discussed in great er det ail in Chapt er 8, Sect ion 8. 3. 2.

Fig. 7.8. (a) Result following removal of displaced


lower canine; (b) patient who had both upper palatally
displaced canines extracted.

(a)
(b)

Canines
Because of t heir posit ion as t he cornerst one of t he arch, canines are usually only
considered f or ext ract ion if t hey are severely displaced and/ or crow ded out of
t he arch. O ccasionally, in cases w it h severe crow ding, t he f irst premolar erupt s
int o cont act w it h t he lat eral incisor. This can be aest het ically accept able (Fig.
7. 8), w hich is a great bonus, part icularly in t he upper arch, as t he canine is
broader t han t he f irst premolar and ext ract ion of t he lat t er alone w ould not
provide suff icient space f or alignment of t he f ormer. How ever, t he occlusion
should be checked t o ensure t hat no displacing cont act s are present on lat eral
excursions. O t herw ise, f ixed appliance t herapy is usually required f ollow ing
removal of a canine t o achieve a sat isf act ory cont act bet w een t he lat eral incisor
and t he f irst premolar. Canines are discussed f urt her in Chapt er 14.

First premolars
First premolars are t he t eet h of choice f or relief of moderat e t o severe crow ding
in eit her arch. By virt ue of t heir posit ion w it hin t he arch, ext ract ion of t he f irst
premolars provides space f or alignment and ret ract ion of t he labial segment s, as
w ell as relief of buccal segment crow ding. Ext ract ion of a f irst premolar in eit her
arch usually gives t he best chance of spont aneous occurrence of accept able
alignment (Fig. 7. 9). Also, if space closure is complet e, a good cont act bet w een
t he canine and f irst premolar can of t en be achieved. This is of part icular value in
t he low er arch w here, provided t hat t he canine is mesially inclined, spont aneous
alignment of t he low er labial segment may occur. This is most rapid w it hin t he

init ial 6 mont hs f ollow ing ext ract ion. I f t he canines are dist ally inclined, t hey w ill
not upright spont aneously int o t he ext ract ion space and f ixed appliances w ill be
required f or t heir ret ract ion.

Fig. 7.9. (a) ( c) Class I malocclusion with moderate


upper and lower crowding, treated by extraction of all
four first premolars; (d) ( f) occlusion a year after
extractions.

(a)

(b)

(c)

(d)
(e)

(f)

Fig. 7. 10. Residual spacing in a pat ient w it h mild crow ding w ho had all f our
f irst premolars removed.

I n t he upper arch t he f irst premolars usually erupt prior t o t he maxillary canine


and maximum spont aneous improvement in t he posit ion of t his t oot h can be
achieved if t he f irst premolar is ext ract ed just bef ore it s emergence. How ever, if
space is at a premium, a space maint ainer should be f it t ed f irst .
I f t he crow ding is mild, ext ract ion of f irst premolars may result in residual
spacing. I f f ixed appliances are t hen used t o close t he remaining space, t here is
a danger of over-ret ract ing t he labial segment s, w hich may have delet erious
eff ect s upon t he prof ile. I n cases w it h mild crow ding, considerat ion should be
given t o ext ract ing t eet h f urt her dist al in t he arch (Fig. 7. 10).

Second premolars
The indicat ions f or ext ract ion of second premolars include t he f ollow ing:

congenit al absence of t he second premolars and crow ding of t he arch;


hypoplasia of t he second premolars and crow ding of t he arch;
severe displacement of t he second premolar;
mild t o moderat e crow ding (2 4 mm per quadrant );
w here space closure by f orw ard movement of t he molars rat her t han
ret ract ion of t he labial segment s is indicat ed.

Ext ract ion of t he second premolars is pref erable t o ext ract ion of t he f irst
premolars in cases w it h mild t o moderat e crow ding as t heir ext ract ion alt ers t he
anchorage balance, f avouring space closure by f orw ard movement of t he molars.
I n order t o f acilit at e t his and t o ensure a sat isf act ory cont act bet w een t he f irst
premolar and t he f irst molar, f ixed appliances are required, part icularly in t he
low er arch.
Early loss of t he second deciduous molars can result in crow ding of t he second
premolars palat ally in t he upper arch and lingually in t he low er arch (Fig. 7. 11).
I n t he upper arch ext ract ion of t he displaced second premolars on erupt ion is
of t en indicat ed. Conversely, in t he low er arch ext ract ion of t he f irst premolars is
usually easier and in most cases upright ing of t he second premolars occurs
spont aneously f ollow ing relief of crow ding.
Fig. 7. 11. The model on t he lef t (pat ient HW) show s lingual crow ding of t he
low er second premolars. The model on t he right illust rat es t he improvement
t hat occurred in t he posit ion of t he low er second premolars f ollow ing
ext ract ion of t he f irst premolars (see also Fig. 7. 2).

First permanent molars


First permanent molars are never an ort hodont ist 's f irst choice. How ever, t heir
ext ract ion may be indicat ed if t heir prognosis is compromised t o such an ext ent
t hat t hey are unlikely t o last f or a reasonable t ime. Ext ract ion of t he f irst
permanent molars is discussed in great er det ail in Chapt er 3.

Second permanent molars


Ext ract ion of second permanent molars has become more popular in recent
years. Concern raised by some pract it ioners about t he d elet erious eff ect upon
t he prof ile of premolar ext ract ions (see Sect ion 7. 8) has led t o a f ashionable
revival of non-ext ract ion t reat ment . This t erm is conf using because in many such
cases second permanent molars are ext ract ed as part of t he t reat ment .
I ndicat ions f or ext ract ion of second permanent molars include t he f ollow ing:

f acilit at ion of dist al movement of t he upper buccal segment s;


relief of mild low er premolar crow ding;

provision of addit ional space f or t he t hird permanent molars and t hus


reduct ion of t he likelihood of t heir impact ion;
prevent ion of low er labial segment crow ding.

Fig. 7.12. Patient with mild lower arch crowding who


had both lower second molars removed in an attempt to
prevent a further increase in crowding: (a) DPT
radiograph prior to extraction of both lower second
molars (the upper second molars were not extracted
because of concerns over the prognosis for the upper
first molars); (b) DPT radiograph two years after the
extractions showing eruption of both lower third molars.
(a)

(b)

Because of t he great er t endency f or mesial drif t in t he upper arch, ext ract ion of
second permanent molars w ill not provide space f or t he relief of premolar or
labial segment crow ding w it hout using appliances. Timing of t he ext ract ion of
second molars in t he upper arch is less crit ical t han in t he low er arch, and
generally t he upper t hird molar w ill erupt int o a good posit ion. I n t he low er arch
removal of a second permanent molar w ill yield, on average, around 1 2 mm of
space in t he premolar region and w ill provide addit ional space f or erupt ion of
t hird permanent molar. How ever, space alone w ill not ensure t hat t he
(unpredict able) low er t hird permanent molar w ill erupt int o a sat isf act ory
posit ion. The likelihood t hat t he low er t hird permanent molar w ill erupt int o
occlusion is increased if t he f ollow ing f act ors (as seen on an
ort hopant omographic (DPT), or lat eral oblique radiograph) are sat isf ied (Fig.
7. 12):
t he angle bet w een t he t hird permanent molar t oot h germ and t he long axis of
t he second molar is bet w een 10° and 30°;

t he crypt of t he developing t hird molar overlaps t he root of t he second molar;


t he t hird permanent molar is developed t o t he bif urcat ion.

Even if t hese crit eria are sat isf ied, erupt ion of t he low er t hird molar int o
occlusion cannot be guarant eed, and it should be made clear t o t he pat ient t hat
a course of f ixed appliance t reat ment t o upright or align t he t hird molar may be
necessary.

Third permanent molars


Early ext ract ion of t hese t eet h has been advocat ed in t he past t o prevent low er
labial segment crow ding. How ever, most oral surgeons are now unw illing t o
remove sympt omless w isdom t eet h. Research int o t he role of t he t hird
permanent molar in low er labial segment crow ding has not demonst rat ed a clear-
cut case of cause and eff ect . St udies have show n t hat pat ient s w it h absent t hird
molars are less likely t o exhibit crow ding, but are also likely t o have smaller
t eet h t han average. This t opic is discussed in more det ail in Chapt er 8.

7.7.2. Expansion
Space can be creat ed by expanding an arch lat erally, but t his is only an opt ion in
malocclusions w here a unilat eral crossbit e exist s; ot herw ise t he expansion is
likely t o be unst able. Expansion of a narrow upper arch t o correct a unilat eral
crossbit e w it h displacement is st raight f orw ard. I f t he upper arch is crow ded, it is
prudent t o complet e t he expansion f irst bef ore assessing w het her ext ract ions are
also indicat ed. Expansion of t he low er arch may be indicat ed if a lingual
crossbit e of t he low er premolars and/ or molars exist s, but management of t his
t ype of malocclusion is t he province of t he specialist . Crossbit es are discussed
in more det ail in Chapt er 13.

7.7.3. Distal movement of molars


Dist al movement of t he f irst permanent molar in t he low er arch is at t empt ed very
rarely, but can be considered if ext ract ion of t he low er second permanent molar
is planned ow ing t o displacement or space considerat ions. This can be achieved
w it h a removable screw appliance, or a lip bumper; how ever, f ixed appliances
are more commonly used.
Dist al movement of t he molars in t he upper arch may be indicat ed in t he
f ollow ing sit uat ions:
Class I w it h mild upper arch crow ding, or mild Class I I division 1 w it h a w ell-
aligned low er arch and molar relat ionship less t han half a unit Class I I (Fig.
7. 13).
Where ext ract ion of bot h upper f irst premolars does not give suff icient space
t o complet e alignment and/ or overjet reduct ion in t he upper arch (Fig. 7. 14).
Where early unilat eral loss of a deciduous molar has result ed in mesial drif t
of t he f irst permanent molar.
Where t he upper arch is crow ded but a median diast ema is present (Fig.
7. 13). Ext ract ion of premolars in t his sit uat ion may result in a w orsening of
t he diast ema.
Where t he prognosis f or st abilit y of overjet reduct ion is doubt f ul, it may be
w iser t o creat e space f or ret ract ion of t he upper labial segment by DMUBS
rat her t han ext ract ions.

Fig. 7.13. Because of the presence of an upper midline


diastema it was decided to gain space to align the
upper arch by distal movement of the upper buccal
segments: (a), (b) pretreatment; (c) upper fixed
appliance in situ. In these cases it is wise to take the
molar further distally than required; (d) post-treatment.

(a)
(b)

(c)

(d)

Dist al movement of t he upper buccal segment t eet h usually involves headgear as


t he mot ive f orce. A screw appliance can be used f or unilat eral movement , but ,
except in Class I I I cases, care is required t o ensure t hat anchorage is not lost
and it is w ise t o include ext ra-oral anchorage in t he appliance design.

7.7.4. Enamel stripping


Removal of a small amount of enamel f rom t he mesial and dist al surf aces of t he
low er incisor t eet h is know n as enamel st ripping or reproximat ion. I t is really a
l ast dit ch met hod and should only be considered in adult s w here t he low er labial
segment is mildly crow ded. No more t han 1 2 mm of space in t ot al should be
gained in t his w ay, and t he t eet h should be t reat ed t opically w it h f luoride
f ollow ing reduct ion of t he enamel.

7.8. STABILITY VERSUS PROFILE


Wide smiles, w it h a t endency t ow ards bimaxillary proclinat ion, are f ashionable in
t he USA, w here t here is a t rend f or alignment t o be achieved by expansion
and/ or proclinat ion. The draw back t o t his approach is t hat movement of t he t eet h
out side t heir zone of labiolingual balance increases t he likelihood of relapse.
I t has been suggest ed by some ort hodont ist s t hat ext ract ions have a delet erious
eff ect upon t he prof ile. This view is more prevalent in t he USA, and as a result ,
an enormous amount of research t o invest igat e t hese claims has been carried
out . This w ork suggest s t hat t he eff ect of ext ract ions upon t he prof ile is minimal.
For example, in one st udy (see sect ion on f urt her reading) it w as f ound t hat t he
lips of pat ient s w ho had undergone premolar ext ract ions f ollow ed by f ixed
appliance t reat ment w ere ret ract ed only 1 2 mm f urt her on average t han t hose of
pat ient s managed by removal of second molars and f ixed appliances. I ndividual
variat ion in sof t t issue t hickness and grow t h pat t ern w as not ed t o be of great er
signif icance.

7.9. PRESENTATION OF THE TREATM ENT PLAN TO THE


PATIENT
The last st ep of t reat ment planning is t o present t he proposed t reat ment t o t he
pat ient and, if appropriat e, t heir parent or guardian. O f t en t here is more t han
one possible opt ion and each should be present ed t o t he pat ient w it h an
explanat ion of t he relat ive merit s. I t is helpf ul if t his explanat ion can be
accompanied by colour pict ures of t he appliances t o be used.
The nat ure of t he pat ient 's role in ort hodont ic t reat ment should be explained
caref ully at t his st age, part icularly t he increased likelihood of decalcif icat ion and

periodont al damage if t oot hbrushing and diet ary advice is not f ollow ed. I f t he
t reat ment involves headgear or elast ic t ract ion, t his should also be discussed. I t
is w ise t o overest imat e t reat ment t imes, even t aking int o account appliance
breakages, holidays, et c. I f t reat ment is complet ed more quickly t he pat ient w ill
be impressed w it h your skill. How ever, in t he unlikely event t hat unf oreseen
circumst ances prolong t reat ment t here w ill be t ime t o recover.

Fig. 7.14. Patient NM aged 13 years. Class II skeletal


pattern (ANB=7°). Upper and lower arch crowding.
Buccal segment relationship a full unit Class II left and
right. Therefore, this was a maximum anchorage case:
(a) ( d) pretreatment. Because the extraction of one
premolar in each quadrant would not give enough
space to relieve the crowding and reduce the overjet,
distal movement of the buccal segments with headgear
was indicated. A nudger appliance (see section 16.4.6)
was used to aid distal movement (e). Once the upper
molars had been moved into a Class I relationship with
the lower arch fixed appliances were used to complete
alignment and reduction of the overbite and overjet (f);
(g) ( i) post-treatment. (NB: The patient still had a Class
II skeletal pattern at the end of treatment dental
camouflage was used to compensate for this.)

(a)

(b)

(c)
(d)

(e)

(f)

(g)
(h)

(i)

As in all branches of medicine and dent ist ry, ort hodont ic t reat ment has pot ent ial
risks. These should be explained t o t he pat ient so t hat t heir inf ormed consent t o
t he t reat ment is obt ained. How ever, it is import ant not t o be alarmist and any
risks should be put in cont ext . This t opic is discussed in great er det ail in Chapt er
1.
I t may be helpf ul if some w rit t en mat erial is provided t o back up t he inf ormat ion
t hat is given at t he consult at ion, and t he pat ient is allow ed some t ime t o ref lect
upon t he proposed t reat ment at home bef ore reaching a decision on w het her or
not t o go ahead.

PRINCIPAL SOURCES AND FURTHER READING


Bishara, S. E. and Burkey, P. S. (1986). Second molar ext ract ions: a review.
Ameri can Journal of O rthodonti cs, 89, 415 2 4.

An inf ormat ive review.

Brit ish O rt hodont ic Societ y (1996). Young practi ti oner's gui de to


O rthodonti cs. BO S O ff ice, 291 G rays I nn Road, London.

This is a w ell-illust rat ed simple int roduct ion t o ort hodont ics.

Dacre, J. T. (1985). The long-t erm eff ect s of one low er incisor ext ract ion.
European Journal of O rthodonti cs, 7, 136 4 4.
Dacre J. T. (1987). The crit eria f or low er second molar ext ract ion. Bri ti sh
Journal of O rthodonti cs, 14, 1 9 .

Drysdale, C. et al . (1996). O rt hodont ic management of root -f illed t eet h.


Bri ti sh Journal of O rthodonti cs, 23, 255 6 0.

Lee, R. T. (1999). Arch w idt h and f orm: A review. Ameri can Journal of
O rthodonti cs and Dentof aci al O rthopedi cs, 115, 305 1 3.

Morse, P. H. and Webb, W. G . (1973). The indicat ion f or dist al movement of


upper buccal segment s. Bri ti sh Journal of O rthodonti cs, 1, 18 2 6.

NHS Cent re f or Review s and Disseminat ion, York (1998). Prophylact ic


removal of impact ed t hird molars: is it just if ied? Bri ti sh Journal of
O rthodonti cs, 26, 149 5 1.

Recommended reading f or all dent ist s and ort hodont ist s.

Richardson, M. E. and Richardson, A. (1993). Low er t hird molar development


subsequent t o second molar ext ract ion. Ameri can Journal of O rthodonti cs
and Dentof aci al O rthopedi cs, 104, 566 7 4.

This art icle suggest s t hat t he crit eria f or second molar ext ract ion do not need
t o be as st rict as previously t hought . How ever, t he aut hor advises t he
inexperienced ort hodont ist t o limit ext ract ion of low er second molars t o t hose
cases sat isf ying t he crit eria out lined in Sect ion 7. 7. 1.

St aggers J. A. (1990) A comparison of second molar and f irst premolar


ext ract ion t reat ment . Ameri can Journal of O rthodonti cs and Dentof aci al
O rthopedi cs, 98, 430 6 .
The aut hor report s t hat t he f acial prof ile result ing af t er ext ract ion of second
molars w as not st at ist ically diff erent f rom t hat result ing af t er ext ract ion of f irst
premolars, despit e f urt her ret ract ion of t he incisors in t he lat t er group. Well
w ort h reading.

Sw essi, D. M. and St ephens, C. D. (1993). The spont aneous eff ect of low er
f irst premolar ext ract ion on t he mesio-dist al angulat ion of adjacent t eet h and
t he relat ionship of t his t o ext ract ion space closure in t he long-t erm. European
Journal of O rthodonti cs, 15, 503 11.
The t it le is f airly self -explanat ory regarding t he aims of t his st udy. The aut hors
f ound t hat excessive t ipping of t he canine and second premolar w as t he
except ion rat her t han t he rule w hen low er f irst premolars w ere ext ract ed and no
appliances used.

Tulloch, J. F. C. (1978). Treat ment f ollow ing loss of second premolars. Bri ti sh
Journal of O rthodonti cs, 5, 29 3 4.

Young, T. M. and Smit h, R. J. (1993) Eff ect s of ort hodont ics on t he f acial
prof ile: a comparison of changes during non-ext ract ion and premolar
ext ract ion t reat ment . Ameri can Journal of O rthodonti cs and Dentof aci al
O rthopedi cs, 103, 452 8 .

t he result s provide addit ional evidence t hat it is simplist ic and incorrect t o


blame undesirable f acial aest het ics af t er ort hodont ic t reat ment on t he ext ract ion
of premolars .
Authors: Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> Table of C ontents > 8 - C las s I

8
Class I

A Class I incisor relat ionship is def ined by t he Brit ish St andards incisor
classif icat ion as f ollow s: t he low er incisor edges occlude w it h or lie immediat ely
below t he cingulum plat eau of t he upper cent ral incisors . Theref ore Class I
malocclusions include t hose w here t he ant eropost erior occlusal relat ionship is
normal and t here is a discrepancy eit her w it hin t he arches and/ or in t he
t ransverse or vert ical relat ionship bet w een t he arches.

8.1. AETIOLOGY
8.1.1. Skeletal
I n Class I malocclusions t he skelet al pat t ern is usually Class I , but it can also be
Class I I or Class I I I w it h t he inclinat ion of t he incisors compensat ing f or t he
underlying skelet al discrepancy (Fig. 8. 1), i. e. dent o-alveolar compensat ion.
Marked t ransverse skelet al discrepancies bet w een t he arches are more
commonly associat ed w it h Class I I or Class I I I occlusions, but milder t ransverse
discrepancies are of t en seen in Class I cases. I ncreased vert ical skelet al
proport ions and ant erior open bit e can also occur w here t he ant eropost erior
incisor relat ionship is Class I .

8.1.2. Soft tissues


I n most Class I cases t he sof t t issue environment is f avourable (f or example
result ing in dent o-alveolar compensat ion) and is not an aet iological f act or. The
major except ion t o t his is bimaxillary proclinat ion, w here t he upper and low er
incisors are proclined. This may be racial in origin and can also occur because
lack of lip t onicit y result s in t he incisors being moulded f orw ards under t ongue
pressure.

Fig. 8.1. (a) Class I incisor relationship on Class I


skeletal pattern; (b) Class I incisor relationship on a
Class II skeletal pattern; (c) Class I incisor relationship
on a Class III skeletal pattern.

(a)

(b)

(c)

8.1.3. Dental factors


Dent al f act ors are t he main aet iological agent in Class I malocclusions. The most
common are t oot h/ arch size discrepancies, leading t o crow ding or, less
f requent ly, spacing.
The size of t he t eet h is genet ically det ermined and so, t o a great ext ent , is t he
size of t he jaw s. Environment al f act ors can also cont ribut e t o crow ding or
spacing. For example, premat ure loss of a deciduous t oot h can lead t o a
localizat ion of any pre-exist ing crow ding.
Local f act ors also include displaced or impact ed t eet h, and anomalies in t he
size, number, and f orm of t he t eet h, all of w hich can lead t o a localized
malocclusion. How ever, it is import ant t o remember t hat t hese f act ors can also
be f ound in associat ion w it h Class I I or Class I I I malocclusions.

8.2. CROWDING
Crow ding occurs w here t here is a discrepancy bet w een t he size of t he t eet h and
t he size of t he arches. Approximat ely 60 per cent of Caucasian children exhibit
crow ding t o some degree. I n a crow ded arch loss of a permanent or deciduous
t oot h w ill result in t he remaining t eet h t ilt ing or drif t ing int o t he space creat ed.
This t endency is great est w hen t he adjacent t eet h are erupt ing.
Crow ding can eit her be accept ed or relieved. Bef ore deciding bet w een t hese
alt ernat ives t he f ollow ing should be considered:

t he posit ion, presence, and prognosis of remaining permanent t eet h;


t he degree of crow ding w hich is usually calculat ed in millimet res per arch or
quadrant ;
t he pat ient 's malocclusion and any ort hodont ic t reat ment planned, including
anchorage requirement s;
t he pat ient 's age and t he likelihood of t he crow ding increasing or reducing
w it h grow t h;
t he pat ient 's prof ile.

These aspect s of t reat ment planning are considered in more det ail in Chapt er 7,
Sect ions 7. 6 and 7. 7.
I n a Class I case w it h mild crow ding (1 2 mm per quadrant ) accept ance, or
perhaps ext ract ion of second molars, should be considered unless a signif icant
increase in crow ding is ant icipat ed. I n cases w it h moderat e crow ding (3 5 mm
per quadrant ) ext ract ion of premolars is usually indicat ed. Where t he crow ding is
severe (more t han 5 mm per quadrant ) space maint enance is def init ely indicat ed
prior t o t he ext ract ion of , probably, t he f irst premolars. O ccasionally t he
ext ract ion of t w o t eet h per quadrant is indicat ed, but t his severit y of crow ding is
t he province of t he specialist .
Af t er relief of crow ding a degree of nat ural spont aneous movement w ill t ake
place. I n general, t his is great er under t he f ollow ing condit ions:

in a grow ing child;


if t he ext ract ions are carried out just prior t o erupt ion of t he adjacent t eet h;
w here t he adjacent t eet h are f avourably posit ioned t o upright if space is
made available (f or example considerable improvement w ill of t en occur in a
crow ded low er labial segment provided t hat t he mandibular canines are
mesially inclined);
t here are no occlusal int erf erences w it h t he ant icipat ed t oot h movement .

Fig. 8.2. Class I malocclusion treated by extraction of


all four first premolars and no appliances: (a) ( c) prior to
extractions; (d) ( f) 3 years after extractions.

(a)

(b)
(c)

(d)

(e)

(f)

Fig. 8.3. Class I malocclusion with upper arch


crowding, treated by extraction of upper first premolars
and use of fixed appliances: (a) pretreatment; (b)
during treatment; (c) 1 year after the end of retention.

(a)

(b)

(c)

Most spont aneous improvement occurs in t he f irst 6 mont hs af t er t he ext ract ions.
I f alignment is not complet e af t er 1 year, t hen f urt her improvement w ill require
act ive t oot h movement w it h appliances. Figure 8. 2 show s a case w hich w as
t reat ed by ext ract ion of all f our f irst premolars w it hout appliances, and Fig. 8. 3
show s a pat ient w hose management required t he ext ract ion of upper f irst
premolars and t he use of f ixed appliances.

8.2.1. Late lower incisor crowding


I n most individuals int ercanine w idt h increases up t o around 12 t o 13 years of
age, and t his is f ollow ed by a very gradual diminut ion t hroughout adult lif e. The
rat e of decrease is most not iceable during t he mid t o lat e t eens. This reduct ion
in int ercanine w idt h result s in an increase of any pre-exist ing low er labial
crow ding, or t he emergence of crow ding in arches w hich w ere w ell aligned or
even

spaced in t he early t eens. Theref ore, t o some ext ent , low er incisor crow ding can
be considered as an age change. Cert ainly, pat ient s w ho have undergone
ort hodont ic t reat ment (including ext ract ions) are not immune f rom low er labial
segment crow ding unless st eps are t aken t o ret ain alignment subsequent ly; f or
example w it h a bonded lingual ret ainer.
The aet iology of lat e low er incisor crow ding is not f ully underst ood, and
considerable cont roversy st ill exist s as t o t he role of t he t hird permanent molar.
Most aut hors acknow ledge t hat t he aet iology is mult if act orial. Nevert heless t he
f ollow ing have all been proposed as major inf luences in t he development of t his
phenomenon:

Forw ard grow t h of t he mandible (eit her horizont ally or manif est ing as a
grow t h rot at ion) w hen maxillary grow t h has ceased, t oget her w it h sof t t issue
pressures, w hich result in a reduct ion in low er arch perimet er and labial
segment crow ding.
Mesial migrat ion of t he post erior t eet h ow ing t o f orces f rom t he int ersept al
f ibres and/ or f rom t he ant erior component of t he f orces of occlusion.
The presence of an erupt ing t hird molar pushes t he dent it ion ant eriorly, i. e.
t he t hird molar plays an act ive role.
The presence of a t hird molar prevent s pressure developed ant eriorly (due t o
eit her mandibular grow t h or sof t t issue pressures) f rom being dissipat ed
dist ally around t he arch, i. e. t he t hird molar plays a passive role.

Review s of t he many st udies t hat have been carried out indicat e t hat t he t hird
permanent molar has a st at ist ically w eak associat ion w it h lat e low er incisor
crow ding.
Removal of symt omless low er t hird molars has been advocat ed in t he past in
order t o prevent low er labial segment crow ding. A recent prospect ive st udy
f ound t hat t here w as a (non-signif icant ) reduct ion in t he presence of crow ding in
pat ient s w ho had had t he low er w isdom t eet h ext ract ed, but concluded t hat
removing t he low er t hird molar t o reduce t he degree of low er labial segment
crow ding could not be just if ied. Management of low er labial segment crow ding
should be considered t oget her w it h ot her aspect s of t he malocclusion (see
Chapt er 7), bearing in mind t he propensit y of t his problem t o w orsen w it h age.
How ever, low er labial segment crow ding is occasionally seen in arches, w hich
are ot herw ise w ell aligned w it h a good Class I buccal segment int erdigit at ion and
a slight ly increased overbit e (Fig. 8. 4). These cases are best kept under
observat ion unt il t he lat e t eens w hen t he f at e of t he t hird permanent molars, if
present , has been det ermined. At t hat st age mild low er labial segment crow ding
can be accept ed. I f t he crow ding is more marked and upper ext ract ions are
cont raindicat ed, it may be bet t er t o consider ext ract ion of t he most displaced
low er incisor and use of a sect ional f ixed appliance t o align and upright t he
remaining low er labial segment t eet h (Fig. 8. 5). How ever, pat ient s should be
w arned t hat t his may result in t he labial segment s dropping lingually, t o t he
det riment of alignment in t he upper arch.

Fig. 8. 4. Class I occlusion w it h accept able mild low er labial segment


crow ding.

Fig. 8.5. Adult with severe


lower labial segment
crowding despite the
previous loss of a lower
incisor. Management involved
the extraction of the most
displaced incisor and a lower
sectional fixed appliance: (a), (a)
(b) pretreatment; (c), (d)
post-treatment.
(b)

(c)

(d)

8.3. SPACING
G eneralized spacing is rare and is due t o eit her hypodont ia or small t eet h in
w ell-developed arches. I nt erest ingly, an associat ion bet w een small t eet h and
hypodont ia has been demonst rat ed. O rt hodont ic management of generalized
spacing is f requent ly diff icult as t here is usually a t endency f or t he spaces t o
reopen unless permanent ly ret ained. I n milder cases it may be w iser t o
encourage t he pat ient t o accept t he spacing, or if t he t eet h are narrow er t han
average, acid-et ch composit e addit ions or porcelain veneers can be used t o
w iden t hem and t hus improve aest het ics. I n severe cases of hypodont ia a
combined ort hodont ic r est orat ive approach t o localize space f or t he provision of
prost heses, or perhaps implant s, may be required (Fig. 8. 6).
Localized spacing may be due t o hypodont ia or loss of a t oot h as a result of
t rauma, or because ext ract ion w as indicat ed because of displacement ,
morphology, or pat hology. This problem is most not iceable if an upper incisor is
missing as t he symmet ry of t he smile is aff ect ed, a f eat ure w hich is usually
not iced more by t he lay public t han ot her aspect s of a malocclusion.

Fig. 8.6. Patient with hypodontia (the upper right


second premolar and all four lateral incisors were
absent) treated with fixed appliances to localize space
for prosthetic replacement of the lateral incisors: (a)
pretreatment; (b) fixed appliance; (c) post-treatment,
before replacement of the lateral incisors by dentures
cum retainers.

(a)

(b)

(c)
8.3.1. Median diastema
A median diast ema is a space bet w een t he cent ral incisors, w hich is more
common in t he upper arch (Fig. 8. 7). A diast ema is a normal physiological st age
in t he early mixed dent it ion w hen t he f raenal at t achment passes bet w een t he
upper cent ral incisors t o at t ach t o t he incisive papilla. I n normal development , as
t he lat eral incisors and canines erupt t his gap closes and t he f raenal at t achment
migrat es labially t o t he labial at t ached mucosa. I f t he upper arch is spaced or
t he lat eral incisors are dimunit ive or absent , t here is less pressure f orcing t he
upper cent ral incisors t oget her and t he diast ema w ill t end t o persist . Rarely, t he
f raenal at t achment appears t o prevent t he cent ral incisors f rom moving t oget her.
I n t hese cases, blanching of t he incisive papilla can be observed if t ension is
applied t o t he f raenum, and on radiographic examinat ion a V-shaped not ch of t he
int erdent al bone can be seen bet w een t he incisors indicat ing t he at t achment of
t he f raenum (see Chapt er 3, Fig. 3. 26).

Fig. 8. 7. Upper midline diast ema.

M anagement (see also Chapter 3, Section 3.3.9)


I t is import ant t o t ake a periapical radiograph t o exclude t he presence of a
super-numerary t oot h w hich, if present , should be removed bef ore closure of t he
diast ema is undert aken. As median diast emas t end t o reduce or close w it h t he
erupt ion of t he canines, management can be subdivided as f ollow s.

Bef ore erupt ion of t he permanent canines int ervent ion is only necessary if
t he diast ema is great er t han 3 mm and t here is a lack of space f or t he
lat eral incisors t o erupt . Care is required not t o cause resorpt ion of t he
incisor root s against t he unerupt ed canines.
Af t er erupt ion of t he permanent canines space closure is usually
st raight f orw ard. Eit her f ixed or removable appliances are used as indicat ed
by t he angulat ion of t he incisors. Prolonged ret ent ion is usually necessary as
diast emas exhibit a great t endency t o reopen, part icularly if t here is a
f amilial t endency; t he upper arch is spaced or t he init ial diast ema w as
great er t han 2 mm. I n view of t his it may be bet t er t o accept a minimal
diast ema, part icularly if no ot her ort hodont ic t reat ment is required.
Alt ernat ively, if t he cent ral incisors are narrow a rest orat ive solut ion, f or
example veneers, can be considered (Fig. 8. 8).

I f it is t hought t hat t he f raenum is an cont ribut ory f act or, t hen f raenect omy is
best carried out during space closure as scar t issue cont ract ion w ill aid space
closure.

Fig. 8.8. Adult with narrow proclined upper central


incisors with a midline diastema. An upper removable
appliance was used to reduce the overbite, and then to
retract and move 1/1 a little closer together: (a)
pretreatment; (b) at the completion of active appliance
therapy, following veneering of 21/1.

(a)

(b)

8.3.2. Management of missing upper incisors


Upper cent ral incisors are rarely congenit ally absent . They can be lost as a
result of t rauma, or occasionally t heir ext ract ion may be indicat ed because of
dilacerat ion. Upper lat eral incisors are congenit ally absent in approximat ely 2
per cent of a Caucasian populat ion, but can also be lost f ollow ing t rauma. Bot h
can occur unilat erally, bilat erally, or t oget her. What ever t he reason f or t heir
absence, t here are t w o t reat ment opt ions:

closure of t he space
opening of t he space and placement of a dent ure or a bridge.

The choice f or a part icular pat ient w ill depend upon a number of f act ors, w hich
are list ed below. How ever, t his is a diff icult area of t reat ment planning and
specialist advice should be sought .

Skelet al relat ionship: if t he skelet al pat t ern is Class I I I , space closure in t he


upper labial segment may compromise t he incisor relat ionship; conversely,

f or a Class I I division 1 pat t ern space closure may be pref erable as it w ill
aid overjet reduct ion.
Presence of crow ding or spacing.
Colour and f orm of adjacent t eet h: if t he permanent canines are much darker
t han t he incisors and/ or part icularly caninif orm in shape, modif icat ion t o
make t hem resemble lat eral incisors w ill be diff icult ; also, if a lat eral incisor
is t o be brought f orw ard t o replace a missing single upper cent ral incisor, an
aest het ically pleasing result w ill only be possible if t he lat eral is f airly large
and has a good gingival circumf erence.
The inclinat ion of adjacent t eet h, as t his w ill inf luence w het her it is easier t o
open or close t he space.
The desired buccal segment occlusion at t he end of t reat ment ; f or example if
t he low er arch is w ell aligned and t he buccal segment relat ionship is Class I ,
space opening is pref erable.
The pat ient 's w ishes and abilit y t o cooperat e w it h complex t reat ment : some
pat ient s have def init e ideas about w het her t hey are w illing t o proceed w it h
appliance t reat ment , and w het her t hey w ish t o have t he space closed or
opened f or a prost het ic replacement .
Fig. 8. 9. Trial (Kesling's) set -up.

Trial (Kesling's) set-up


To invest igat e t he f easibilit y of diff erent opt ions a t rial set -up can be carried out
using duplicat e models. The t eet h t o be moved are cut off t he model and
reposit ioned in t he desired place using w ax (Fig. 8. 9). This allow s any number of
opt ions t o be t est ed and also gives an opport unit y t o evaluat e in more det ail t he
amount and nat ure of any ort hodont ic and rest orat ive t reat ment required by a
part icular opt ion. This exercise is of t en helpf ul in describing t he out come of
diff erent opt ions t o t he pat ient .
Af t er assessment of t he above f act ors a provisional plan can be discussed w it h
t he pat ient . I t is of t en possible t o draw up more t han one plan and t hese should
all be t horoughly discussed, including t he advant ages and disadvant ages, and
t he long-t erm maint enance of any prost het ic replacement s.

Space closure
This can be f acilit at ed by early ext ract ion of any deciduous t eet h t o allow
f orw ard movement of t he f irst permanent molars in t hat quadrant (s). I n crow ded
mout hs, if t his st ep is carried out early it may be possible t o achieve a
sat isf act ory result w it hout appliances, but usually f ixed appliances are necessary
t o correct t he axial inclinat ions. I f any masking procedures (f or example
cont ouring a canine incisally, palat ally, and int erproximally t o resemble a lat eral
incisor) or acid-et ch composit e addit ions are required, t hese should be carried
out prior t o t he placement of appliances t o f acilit at e f inal t oot h alignment .
Placement of a bonded ret ainer post -t reat ment is advisable in t he majorit y of
cases (Fig. 8. 10).

Fig. 8.10. (a) Patient with missing lateral incisors


treated by space closure and modification of the upper
canines. (b) Occlusal view of same patient to show
bonded retainer.
(a)

(b)

Space maintenance or opening


I f an incisor is ext ract ed elect ively or a pat ient seen soon af t er loss has
occurred, ideally a space maint enance should be f it t ed f ort hw it h. I n cases w here
space closure has occurred as a result eit her of early t oot h loss or congenit al
absence, appliances w ill be required t o open t he space. The angulat ion of t he
adjacent t eet h w ill det ermine w het her f ixed or removable appliances are required

(Fig. 8. 11). Whenever space is opened prior t o bridgew ork, it is import ant t o
ret ain w it h a part ial dent ure f or at least 3 t o 6 mont hs (Fig. 8. 12), part icularly if
an adhesive acid-et ch ret ained bridge is t o be used. Research has show n t hat
acid-et ch bridges placed immediat ely af t er t he complet ion of t oot h movement
have a great er incidence of f ailure t han t hose placed f ollow ing a period of
ret ent ion w it h a removable ret ainer.

Fig. 8.11. Class I incisor relationship on a Class III


skeletal pattern with congenital absence of all four
lateral incisors. Since space closure would run the risk
of retracting the upper incisors into a Class III
relationship, it was decided to open space for
prosthetic replacement of 2/2 and to accept the spacing
in the lower arch. Because of the axial inclination of the
central incisors and canines, an upper fixed appliance
was used in conjunction with a clip-over bite plane
(using plint clips engaging the bands on 6/6). (a)
Pretreatment lateral view showing mild Class III
skeletal pattern; (b) ( d) pretreatment intra-oral
photographs; (e) post-treatment intra-oral photographs
(a partial denture cum retainer was fitted replacing
2/2).

(a)

(b)

(c)
(d)

(e)

Fig. 8.12. (a) Patient with early traumatic loss of 1/ and


partial space closure. Space for prosthetic replacement
of 1/ was gained using a fixed appliance. (b) Result on
completion of active treatment. (c) Partial denture cum
retainer (NB: Stops were placed mesial to both 2/ and
/1 to help prevent relapse).

(a)
(b)

(c)

I mplant t echnology is improving rapidly and it is hoped t hat it w ill become


cheaper in t he f ut ure, allow ing t his opt ion t o be more readily available.

8.4. DISPLACED TEETH


Teet h can be displaced f or a variet y of reasons including t he f ollow ing:

Abnormal posit ion of t he t oot h germ: canines (Chapt er 14) and second
premolars are t he most commonly aff ect ed t eet h. Management depends upon
t he degree of displacement . I f t his is mild, ext ract ion of t he associat ed
primary t oot h plus space maint enance, if indicat ed, may result in an
improvement in posit ion in some cases. Alt ernat ively, exposure and t he
applicat ion of ort hodont ic t ract ion may be used t o bring t he mildly displaced
t oot h int o t he arch. I f t he displacement is severe, ext ract ion is usually
necessary.
Crow ding: lack of space f or a permanent t oot h t o erupt w it hin t he arch can
lead t o or cont ribut e t o displacement . Those t eet h t hat erupt last in a
segment , f or example upper lat eral incisors, upper canines (Fig. 8. 13),
second premolars, and t hird molars, are most commonly aff ect ed.
Management involves relief of crow ding, f ollow ed by act ive t oot h movement
w here necessary. How ever, if t he displacement is severe it may be prudent
t o ext ract t he displaced t oot h (Fig. 8. 14).
Ret ent ion of a deciduous predecessor: ext ract ion of t he ret ained primary
t oot h should be carried out as soon as possible provided t hat t he permanent
successor is not displaced.
Secondary t o t he presence of a supernumerary t oot h or t eet h (see Chapt er
3): management involves ext ract ion of t he supernumerary f ollow ed by t oot h
alignment , usually w it h f ixed appliances. Displacement s due t o
supernumeraries have a t endency t o relapse and prolonged ret ent ion is
required.
Caused by a habit (see Chapt er 9).
Secondary t o pat hology, f or example a dent igerous cyst . This is t he rarest
cause.

Fig. 8. 13. Class I malocclusion w it h mild low er and marked upper arch
crow ding. I n crow ded arches t he last t eet h in a segment t o erupt , in t his
case t he upper canines, are t he most likely t o be short of space. The
maxillary second premolars are also crow ded, probably ow ing t o early loss
of t he upper second deciduous molars.

Fig. 8.14. Occasionally it may be prudent to extract the


most displaced tooth. In this case all four canines were
extracted: (a) prior to extractions; (b) after extractions.
(NB: Patient is posturing forwards to show lower arch
alignment.)
(a)

(b)

8.5. VERTICAL DISCREPANCIES


Variat ions in t he vert ical dimension can occur in associat ion w it h any
ant eropost erior skelet al relat ionship. I ncreased vert ical skelet al proport ions are
discussed in Chapt er 9 in relat ion t o Class I I division 1; in Chapt er 11 in relat ion
t o Class I I I , and in Chapt er 12 on ant erior open bit e.

8.6. TRANSVERSE DISCREPANCIES


A t ransverse discrepancy bet w een t he arches result s in a crossbit e and can
occur in associat ion w it h Class I , Class I I , and Class I I I malocclusions.
Classif icat ion and management of crossbit e is discussed in Chapt er 13.

8.7. BIM AXILLARY PROCLINATION


As t he name suggest s, bimaxillary proclinat ion is t he t erm used t o describe
occlusions w here bot h t he upper and low er incisors are proclined. Bimaxillary
proclinat ion is seen more commonly in some racial groups (f or example Af ro-
Caribbean)), and so w hen an assessment is carried out t he pat ient should be
assessed bearing in mind w hat is normal f or t heir et hnic background. This is
part icularly pert inent in cephalomet ric analysis.

When bimaxillary proclinat ion occurs in a Class I malocclusion t he overjet is


increased because of t he angulat ion of t he incisors (Fig. 8. 15). Management is
diff icult because bot h upper and low er incisors need t o be ret roclined t o reduce
t he overjet . Ret roclinat ion of t he low er labial segment w ill encroach on t ongue
space and t heref ore has a high likelihood of relapse f ollow ing removal of
appliances. For t hese reasons, t reat ment of bimaxillary proclinat ion should be
approached w it h caut ion and considerat ion should be given t o accept ing t he
incisor relat ionship. I f t he lips are incompet ent , but have a good muscle t one and
are likely t o achieve a lip-t o-lip seal if t he incisors are ret ract ed, t he chances of
a st able result are increased. How ever, t he pat ient should st ill be w arned t hat
t he prognosis f or st abilit y is guarded. Where bimaxillary proclinat ion is
associat ed w it h compet ent lips, or w it h grossly incompet ent lips w hich are
unlikely t o ret ain t he correct ed incisor posit ion, it may be w iser not t o proceed.
How ever, if , t reat ment is decided upon, permanent ret ent ion is advisable.

Fig. 8. 15. (a) Class I incisor relat ionship w it h normal axial inclinat ion (int er-
incisal angle is 137°); (b) Class I incisor relat ionship w it h bimaxillary
inclinat ion show ing increased overjet (int er-incisal angle is 107°).

Bimaxillary proclinat ion can also occur in associat ion w it h Class I I division 1 and
Class I I I malocclusions.

PRINCIPAL SOURCES AND FURTHER READING


Bishara, S. E. (1999). Third molars: a dilemma: O r is it ? Ameri can Journal of
O rthodonti cs and Dentof aci al O rthopedi cs, 115, 628 3 3.

Harradine, N. W. T. , Pearson, M. H. , and Tot h, B. (1998). The eff ect of


ext ract ion of t hird molars on lat e low er incisor crow ding: A randomised
cont rolled t rial. Bri ti sh Journal of O rthodonti cs, 25, 117 2 2.
This excellent st udy is essent ial reading.
Lit t le, R. M. , Reidel, R. A. , and Art un, J. (1981). An evaluat ion of changes in
mandibular ant erior alignment f rom 10 2 0 years post ret ent ion. Ameri can
Journal of O rthodonti cs and Dentof aci al O rthopedi cs, 93, 423 8 .

Classic paper. The aut hors f ound t hat low er labial segment crow ding t ends t o
increase even f ollow ing ext ract ions and appliance t herapy.

Richardson, M. E. (1989). The role of t he t hird molar in t he cause of lat e


low er arch crow ding: a review. Ameri can Journal of O rthodonti cs and
Dentof aci al O rthopedi cs, 95, 79 8 3.

The evidence in support of t he t heory t hat t he presence of a t hird molar is one


of t he aet iological f act ors in lat e low er incisor crow ding is review ed in t his
paper.

Shashua, D. and Art un, J. (1999). Relapse af t er ort hodont ic correct ion of
maxillary median diast ema: a f ollow -up evaluat ion of consecut ive cases. The
Angl e O rthodonti st, 69, 257 6 3.

St ephens, C. D. (1989). The use of nat ural spont aneous t oot h movement in
t he t reat ment of malocclusion. Dental Update, 16, 337 4 2.

An int erest ing paper in w hich t he role of int ercept ive ext ract ions in Class I
malocclusions is discussed.

Vasir, N. S. , and Robinson, R. J. (1991). The mandibular t hird molar and lat e
crow ding of t he mandibular incisors a review. Bri ti sh Journal of
O rthodonti cs, 18, 59 6 6.

An unbiased review of t he lit erat ure regarding t he role of t hird molars in lat e
low er incisor crow ding. The aut hors conclude t hat t he w isdom t oot h has a small,
but variable, eff ect .
Authors: Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> Table of C ontents > 9 - C las s II divis ion 1

9
Class II division 1

The Brit ish St andards classif icat ion def ines a Class I I division 1 incisor
relat ionship as f ollow s: t he low er incisor edges lie post erior t o t he cingulum
plat eau of t he upper incisors, t here is an increase in overjet and t he upper
cent ral incisors are usually proclined . I n a Caucasian populat ion t he incidence of
Class I I division 1 incisor relat ionship is approximat ely 15 2 0 per cent .
Prominent upper incisors, part icularly w hen t he lips are incompet ent , are at
increased risk of being t raumat ized. I t has been show n t hat children w it h an
overjet great er t han 9 mm are t w ice as likely t o have suff ered t rauma involving
t heir upper incisor t eet h as are t hose w it h normal or reduced overjet s.

9.1. AETIOLOGY
9.1.1. Skeletal pattern
A Class I I division 1 incisor relat ionship is usually associat ed w it h a Class I I
skelet al pat t ern, commonly due t o a ret rognat hic mandible (Fig. 9. 1). How ever,
proclinat ion of t he upper incisors and/ or ret roclinat ion of t he low er incisors by a
habit or t he sof t t issues can result in an increased overjet on a Class I (Fig.
9. 2), or even a Class I I I skelet al pat t ern.

Fig. 9. 1. A Class I I division 1 incisor relat ionship on a Class I I skelet al


pat t ern w it h a ret rognat hic mandible.
Fig. 9. 2. A Class I I division 1 incisor relat ionship on a Class I skelet al
pat t ern.

A Class I I division 1 incisor relat ionship is f ound in associat ion w it h a range of


vert ical skelet al pat t erns. Management of t hose pat ient s w it h signif icant ly
increased or signif icant ly reduced vert ical proport ions is usually diff icult and is
t he province of t he specialist .

Fig. 9. 3. Marked circumoral muscular act ivit y is visible as t his pat ient
at t empt s t o achieve an ant erior oral seal by a lip-t o-lip seal.

9.1.2. Soft tissues


The inf luence of t he sof t t issues on a Class I I division 1 malocclusion is mainly
mediat ed by t he skelet al pat t ern, bot h ant eropost eriorly and vert ically, and also
by t he pat ient 's eff ort s t o achieve an ant erior oral seal.
I n a Class I I division 1 malocclusion t he lips are t ypically incompet ent ow ing t o
t he prominence of t he upper incisors and/ or t he underlying skelet al pat t ern. I f
t he lips are incompet ent , t he pat ient w ill t ry t o achieve an ant erior oral seal in
one of t he f ollow ing w ays:

circumoral muscular act ivit y t o achieve a lip-t o-lip seal (Fig. 9. 3);
t he mandible is post ured f orw ards t o allow t he lips t o meet at rest ;
t he low er lip is draw n up behind t he upper incisors (Fig. 9. 4);
t he t ongue is placed f orw ards bet w een t he incisors t o cont act t he low er lip,
of t en cont ribut ing t o t he development of an incomplet e overbit e;
a combinat ion of t hese.

Fig. 9. 4. I n t his pat ient w it h a Class I I division 1 malocclusion t he low er lip


f unct ions behind t he upper cent ral incisors, w hich have been proclined, and
in f ront of t he lat eral incisors, w hich have been ret roclined as a result .

Where t he pat ient can achieve lip-t o-lip cont act by circumoral muscle act ivit y or
t he mandible is post ured f orw ards, t he inf luence of t he sof t t issues is of t en t o
moderat e t he eff ect of t he underlying skelet al pat t ern by dent o-alveolar
compensat ion. More commonly a seal is achieved by t he low er lip being draw n
up behind t he upper incisors, w hich leads t o ret roclinat ion of t he low er labial
segment and/ or proclinat ion of t he upper incisors w it h t he result t hat t he incisor
relat ionship is more severe t han t he underlying skelet al pat t ern.
How ever, if t he t ongue comes f orw ard t o cont act t he low er lip during sw allow ing,
proclinat ion of t he low er incisors may occur, helping t o compensat e f or t he
underlying skelet al pat t ern. This t ype of sof t t issue behaviour is of t en associat ed
w it h increased vert ical skelet al proport ions and/ or grossly incompet ent lips, or a
habit w hich has result ed in an increase in overjet and an ant erior open bit e. I n
pract ice, it is of t en diff icult t o det ermine t he degree t o w hich t his is adapt ive
t ongue behaviour, or w het her a rarer endogenous t ongue t hrust exist s (see
Chapt er 12).
I nf requent ly, a Class I I division 1 incisor relat ionship occurs ow ing t o
ret roclinat ion of t he low er incisors by a very act ive low er lip (Fig. 9. 5).

Fig. 9.5. A Class II division 1 malocclusion due mainly


to retroclination of the lower labial segment by an
active lower lip. This patient achieved an anterior oral
seal by contact between the tongue and the lower lip.
(a) ( c) pretreatment; (d), (e) post-treatment.

(a)

(b)

(c)
(d)

(e)

9.1.3. Dental factors


A Class I I division 1 incisor relat ionship may occur in t he presence of crow ding
or spacing. Where t he arches are crow ded, lack of space may result in t he
upper incisors being crow ded out of t he arch labially and t hus t o exacerbat ion of
t he overjet . Conversely, crow ding of t he low er labial segment may help t o
compensat e f or an increased overjet in t he same manner. I n such cases,
ext ract ions ant erior t o t he second premolars in t he low er arch may result in t he
low er labial segment dropping lingually w it h a concomit ant w orsening of t he
incisor relat ionship.

9.1.4. Habits
A persist ent digit -sucking habit w ill act like an ort hodont ic f orce upon t he t eet h if
indulged in f or more t han a f ew hours per day. The severit y of t he eff ect s
produced w ill depend upon t he durat ion and t he int ensit y, but t he f ollow ing are
commonly associat ed w it h a det ermined habit (Fig. 9. 6):

proclinat ion of t he upper incisors;


ret roclinat ion of t he low er labial segment ;
an incomplet e overbit e or a localized ant erior open bit e;
narrow ing of t he upper arch t hought t o be mediat ed by t he t ongue t aking up
a low er posit ion in t he mout h and t he negat ive pressure generat ed during
sucking of t he digit .

Fig. 9.6. The effects of a persistent digit sucking habit


upon the occlusion: the upper incisors have been
proclined and the lower incisors retroclined.

(a)

(b)

The f irst t w o eff ect s w ill cont ribut e t o an increase in overjet .


The eff ect s of a habit w ill be superimposed upon t he child's exist ing skelet al
pat t ern and incisor relat ionship, and t hus can lead t o an increased overjet in a
child w it h a Class I or Class I I I skelet al pat t ern, or can exacerbat e a pre-
exist ing Class I I malocclusion. The eff ect s may be asymmet ric if a single f inger
or t humb is sucked (Fig. 9. 7).

9.2. OCCLUSAL FEATURES


The overjet is increased, and t he upper incisors may be proclined, perhaps as
t he result of a habit or an adapt ive sw allow ; or upright , w it h t he increased
overjet ref lect ing t he skelet al pat t ern. The overbit e is of t en increased, but may
be incomplet e as a result of an adapt ive t ongue-f orw ard sw allow, a habit , or
increased vert ical skelet al proport ions. I f t he lat t er t w o f act ors are marked, an
ant erior open bit e may result . I f t he lips are grossly incompet ent and are
habit ually apart at rest , drying of t he gingivae may lead t o an exacerbat ion of
any pre-exist ing gingivit is.
The molar relat ionship usually ref lect s t he skelet al pat t ern unless early
deciduous t oot h loss has result ed in mesial drif t of t he f irst permanent molars.

Fig. 9. 7. An asymmet rical increase in overjet in a pat ient w it h a habit of


sucking one f inger.

9.3. ASSESSM ENT OF, AND TREATM ENT PLANNING IN,


CLASS II DIVISION 1 M ALOCCLUSIONS
Bef ore deciding upon a def init ive t reat ment plan t he f ollow ing f act ors should be
considered:

The patient's age


This is of import ance in relat ion t o f acial grow t h: f irst w het her f urt her f acial
grow t h is t o be expect ed, and second, if f urt her grow t h is ant icipat ed, w het her
t his is likely t o be f avourable or unf avourable. I n t he a verage grow ing child,
f orw ard grow t h of t he mandible occurs during t he pubert al grow t h spurt and t he
early t eens. This is advant ageous in t he management of Class I I malocclusions.
How ever, correct ion of t he incisor relat ionship in a child w it h increased vert ical
skelet al proport ions and a backw ard-opening rot at ional pat t ern of grow t h has a
poorer prognosis f or st abilit y. This is because t he ant eropost erior discrepancy
w ill w orsen w it h grow t h, and in addit ion an increase in t he low er f ace height may
reduce t he likelihood of lip compet ence at t he end of t reat ment .
I n t he adult pat ient , a lack of grow t h w ill reduce t he range of skelet al Class I I
malocclusions t hat can be t reat ed by ort hodont ic means alone and w ill also make
overbit e reduct ion more diff icult .
The difficulty of treatment
The skelet al pat t ern is t he major det erminant of t he diff icult y of t reat ment . Those
cases w it h a marked ant eropost erior discrepancy and/ or signif icant ly increased
or reduced vert ical skelet al proport ions w ill require caref ul evaluat ion, an
experienced ort hodont ist , and possibly surgery f or a successf ul result .
The result s of a recent ret rospect ive st udy of over 1200 consecut ively t reat ed
Class I I division 1 malocclusions f ound t hat pat ient s w it h large overjet s and more
upright incisors w ere less likely t o achieve an excellent out come.

The likely stability of overjet reduction


The sof t t issues are t he major det erminant of st abilit y f ollow ing overjet
reduct ion. Bef ore planning t reat ment it is of t en helpf ul t o t ry t o det ermine t hose
f act ors t hat have cont ribut ed t o t he development of t hat part icular Class I I
division 1 maloccusion and t he degree t o w hich t hey can be modif ied or
correct ed by t reat ment . For example, t he pat ient show n in Fig. 9. 8 has an
increased overjet on a Class I skelet al pat t ern w it h a low er lip t rap. I n t he
absence of a habit , it is probable t hat t he upper incisors w ere def lect ed labially
as t hey erupt ed, and it is likely t hat

ret ract ion of t he upper incisors w it hin t he cont rol of t he low er lip w ould be st able
as t he lips w ould t hen be compet ent . I n cont rast , t he pat ient show n in Fig. 9. 9
has a Class I I skelet al pat t ern w it h increased vert ical skelet al proport ions and
markedly incompet ent lips. An ant erior oral seal w as achieved by cont act
bet w een t he t ongue and low er lip. I n t his case overjet reduct ion is unlikely t o be
st able as, f ollow ing ret ract ion, t he upper labial segment w ould not be cont rolled
by t he low er lip and t he f orw ard t ongue sw allow w ould probably cont inue.
Fig. 9. 8. Follow ing overjet reduct ion, t his pat ient 's lips w ill probably be
compet ent . Theref ore t he prognosis f or st abilit y is good.

I deally, at t he end of overjet reduct ion t he low er lip should act on t he incisal one-
t hird of t he upper incisors and be able t o achieve a compet ent lip seal. I f t his is
not possible, it should be considered w het her t reat ment is necessary and, if
indicat ed, w het her prolonged ret ent ion or even surgery is required.

The patient's facial appearance


I n some cases a considerat ion of t he prof ile may help t o make t he decision
bet w een t w o alt ernat ive modes of t reat ment . For example, in a case w it h a
Class I I skelet al pat t ern due t o a ret rusive mandible, a f unct ional appliance may
be pref erable t o dist al movement of t he upper buccal segment s w it h headgear.
The prof ile may also inf luence t he decision w het her or not t o relieve mild
crow ding by ext ract ions.
O ccasionally, alt hough management by ort hodont ics alone is f easible, t his w ill be
t o t he det riment of t he f acial appearance and accept ance of t he increased
overjet or a surgical approach may be pref erred. Feat ures w hich may lead t o
t his scenario include an obt use nasolabial angle or excessive upper incisor show
(Fig. 9. 10).

9.3.1. Practical treatment planning


Treat ment planning in general is discussed in Chapt er 7. Class I I division 1
malocclusions are commonly associat ed w it h increased overbit e, w hich must be
reduced bef ore t he overjet can be reduced. O verbit e reduct ion requires space
(about 1 2 mm f or an averagely increased overbit e) and allow ance f or t his must
be made w hen planning space requirement s in t he low er arch. Signif icant ly
increased overbit es w ill require more space and f ixed appliances, or even
surgery. O verbit e reduct ion is also considered in more det ail in Chapt er 10,
Sect ion 10. 3. 1.
I f ext ract ions are required in t he low er arch, bot h spont aneous and act ive t oot h
movement are f acilit at ed by removal of t he corresponding t oot h in t he upper
arch. The act ual choice of ext ract ion sit e w ill depend upon t he presence of
crow ding, t he t oot h movement s planned, and t heir anchorage requirement s.
How ever, in t he t reat ment of moderat ely severe Class I I division 1 malocclusions
w it h f ixed appliances, low er second premolars and upper f irst premolars may be
chosen. This ext ract ion pat t ern f avours f orw ard movement of t he low er molar t o
aid correct ion of t he molar relat ionship and ret ract ion of t he upper labial
segment .

Fig. 9. 9. Class I I division 1 malocclusion w it h a poor prognosis f or overjet


reduct ion ow ing t o t he markedly incompet ent lips and increased vert ical
proport ions.

Where t he low er arch is w ell aligned and t he molar relat ionship is Class I I ,
space f or overjet reduct ion can be gained by dist al movement of t he upper
buccal segment s or by ext ract ions. Where possible, a Class I buccal segment
relat ionship is pref erable. I f ext ract ions are carried out in t he upper arch only,
t he molar relat ionship at t he end of t reat ment w ill be Class I I . This is f unct ionally
sat isf act ory, but as half a molar w idt h is narrow er t han a premolar, some
residual space of t en remains in t he upper arch. I f f ixed appliances are used, t he
upper f irst molar can be rot at ed mesiopalat ally t o t ake up t his space by virt ue of
it s rhomboid shape.
Dist al movement is discussed in more det ail in Chapt er 7, Sect ion 7. 7. 3, and is
usually considered if t he molar relat ionship is half a unit Class I I or less,
alt hough a f ull unit of space can be gained in a cooperat ive, grow ing pat ient . I f
t he prognosis f or overjet reduct ion is guarded, it may be advisable t o gain space

in t he upper arch by dist al movement of t he upper buccal segment s rat her t han
by ext ract ions. Then should relapse occur t his w ill not result in a reopening of
t he ext ract ion space.

Fig. 9. 10. Pat ient w it h an obt use nasolabial angle and incompet ent lips. This
pat ient also show ed an excessive amount of upper incisor show at rest and
w hen smiling.

Treat ment in t he f ollow ing sit uat ions is diff icult and is best managed by a
specialist :

The molar relat ionship is Class I I and t he low er arch is crow ded as t he
ext ract ion of one unit in each quadrant in t he upper arch w ill not give
suff icient space f or relief of crow ding and overjet reduct ion (see Fig. 7. 14).
The molar relat ionship is great er t han one unit Class I I .

Management of t hese cases may involve t he ext ract ion of f our t eet h f rom t he
upper arch; dist al movement of t he upper buccal segment s; or a f unct ional
appliance used init ially t o gain a degree of ant eropost erior correct ion. Upper and
low er f ixed appliances are t hen usually required t o complet e alignment .

9.4. EARLY TREATM ENT


G iven t he suscept ibilit y of prominent incisors t o t rauma, early t reat ment is a
t empt ing proposit ion. I n addit ion, t he child's parent s are of t en concerned and are
keen f or early t reat ment . How ever, t here are a number of f act ors t hat need t o be
considered:

I n younger children t he lips are of t en incompet ent , t hus reducing t he chances


of st abilit y f ollow ing overjet reduct ion. Theref ore, if t reat ment is carried out
in t he early mixed dent it ion, very prolonged ret ent ion may be required unt il
t he permanent dent it ion is est ablished, w it h obvious implicat ions f or dent al
healt h.
Because of space considerat ions it may not be possible t o reduce t he
overjet f ully, t hus increasing t he chances of relapse.
I f t he upper incisors are ret ract ed bef ore t he maxillary permanent canines
have erupt ed, t here is a risk of root resorpt ion or def lect ion of t he canines.
I n pract ice, if overjet reduct ion is carried out in t he early mixed dent it ion,
f urt her t reat ment is of t en required once t he permanent dent it ion is
est ablished, by w hich t ime t he pat ient 's co-operat ion is f lagging.

I n America a large, randomized, cont rolled clincial t rial has been set up t o look
at t he t iming of t reat ment f or Class I I malocclusions. Pre-adolescent children
w ere randomized t o eit her observat ion or t o early t reat ment w it h eit her a
f unct ional appliance or headgear. Follow ing t his phase pat ient s in all t hree
groups

underw ent comprehensive t reat ment w it h f ixed appliances in t he permanent


dent it ion. The preliminary dat a f rom t his st udy indicat es t hat t he early skelet al
eff ect s f rom f unct ional or headgear appliance t reat ment are not maint ained long-
t erm and t hat f ollow ing complet ion of f ixed appliance t herapy in t he permanent
dent it ion, lit t le diff erence, if any, remained bet w een t he early t reat ment and
cont rol (observat ion) groups. Alt hough, on average, t he t ime in f ixed appliances
w as reduced f or children w ho underw ent early t reat ment t he overall t reat ment
t ime w as considerably longer if t he early t reat ment t ime w as included.

Fig. 9.11. Boy aged 9 years with a Class II division 1


malocclusion on a Class II skeletal pattern. As the
upper incisors were at risk of trauma, treatment was
started early with a functional appliance. Following
eruption of the permanent dentition, definitive treatment
involving the extraction of all four second premolars
and the use of fixed appliances was carried out to
correct the inter-incisal angle and alieviate the
crowding: (a) ( c) pretreatment (age 9); (d) at end of
treatment with functional appliance (note the
retroclination of the upper incisors as most of the
reduction of the overjet has been achieved by dento-
alveolar change); (e) following extraction of second
premolars fixed appliances were placed; (f) ( h) following
removal of fixed appliances (age 15).

(a)

(b)
(c)

(d)

(e)

(f)
(g)

(h)

At present many clinicians f eel t hat t reat ment is best def erred unt il t he erupt ion
of t he secondary dent it ion w here space can be gained f or relief of crow ding and
reduct ion of t he overjet by t he ext ract ion of permanent t eet h (if indicat ed), and
sof t t issue mat urit y increases t he likelihood of lip compet ence. I n t he int erim a
cust om-made mout hguard can be w orn f or sport s. How ever, if t he upper incisors
are t hought t o be at part icular risk of t rauma during t he mixed dent it ion,
t reat ment w it h a f unct ional appliance can be considered (Fig. 9. 11).

9.5. M ANAGEM ENT OF AN INCREASED OVERJET


ASSOCIATED WITH A CLASS I OR M ILD CLASS II
SKELETAL PATTERN
Fixed appliances, w it h ext ract ions if indicat ed, w ill give good result s in skilled
hands in t his group (Fig. 9. 12).
Provided t he skelet al pat t ern is Class I , t hat f ixed appliances are not indicat ed
f or ot her f eat ures of t he malocclusion, and t hat t he increased overjet can be
reduced by t ilt ing of t he upper labial segment , a removable appliance can be
considered (Fig. 9. 13). The f easibilit y of using t ilt ing movement s t o reduce an
overjet can be evaluat ed w it h a prognosis t racing f rom a lat eral cephalomet ric
radiograph (see Chapt er 6, Sect ion 6. 8).

Fig. 9.12. Class II division 1 malocclusion on a Class I


skeletal pattern with crowding treated by extraction of
first premolars and fixed appliances: (a) ( c)
pretreatment; (d) initial stages of appliance treatment;
(e) ( g) post-treatment.

(a)

(b)

(c)
(d)

(e)

(f)

(g)

Fig. 9.13. Class II division 1


malocclusion managed with
removable appliances. The patient
suffered from recurrent ulceration
due to cyclic neutropenia and
therefore the patient's medical
practitioner requested an appliance
which could be removed if the
ulceration became severe: (a), (b)
pretreatment; (c) showing
removable appliance with palatal
(a)
finger springs to retract the canines
and a flat anterior bite plane for
overbite reduction; (d) post-
treatment.

(b)

(c)
(d)

I f low er arch ext ract ions are required, t he likelihood t hat good spont aneous
alignment of t he low er arch w ill occur during t reat ment w it h an upper removable
appliance is increased if moderat e crow ding is managed by ext ract ion of t he f irst
premolars in a grow ing child. I f t he crow ding is mild, considerat ion should be
given t o eit her accept ing t he crow ding, perhaps w it h t he ext ract ion of second
molars, or ext ract ing t he second premolars and using f ixed appliances (see
Chapt er 7, Sect ion 7. 7).
A f unct ional appliance can be used t o reduce an overjet in a cooperat ive child
w it h w ell-aligned arches and a mild t o moderat e skelet al Class I I pat t ern,
provided t hat t reat ment is t imed f or t he pubert al grow t h spurt (Chapt er 18). I f
t he arches are crow ded, ant eropost erior correct ion can be achieved w it h a
f unct ional appliance f ollow ed by ext ract ions, and t hen f ixed appliances can be
used t o achieve alignment and t o det ail t he occlusion.

9.6. M ANAGEM ENT OF AN INCREASED OVERJET


ASSOCIATED WITH A M ODERATE TO SEVERE CLASS II
SKELETAL PATTERN
Management of t he more severe case is t he province of t he experienced
operat or. There are t hree possible approaches t o t reat ment :

1. G rowth modification by at t empt ing rest raint of maxillary grow t h, by


encouraging mandibular grow t h, or by a combinat ion of t he t w o (Fig. 9. 14).
I n pract ice, t he amount of change t hat can be produced is small and success
is dependent upon f avourable grow t h and an ent husiast ic pat ient . Prolonged
ret ent ion unt il grow t h is complet e is desirable. Headgear can be used t o t ry
and rest rain grow t h of t he maxilla horizont ally and/ or vert ically, depending
upon t he direct ion of f orce relat ive t o t he maxilla. Funct ional appliances

appear t o produce rest raint of maxillary grow t h w hilst encouraging


mandibular grow t h.
2. O rthodontic camouflage using f ixed appliances t o achieve bodily ret ract ion
of t he upper incisors (Fig. 9. 15). The severit y of t he case t hat can be
approached in t his w ay is limit ed by t he availabilit y of cort ical bone palat al
t o t he upper incisors and by t he pat ient 's f acial prof ile. I f headgear is used
in conjunct ion w it h t his approach, a degree of grow t h modif icat ion may also
be produced in f avourably grow ing children.
3. Surgical correction (see Chapt er 20).

Fig. 9.14. Patient treated by growth modification.


Because correction required a combination of restraint
of vertical and forward growth of the maxilla and
encouragement of forward growth of the mandible, a
functional appliance with high-pull headgear was used:
(a), (b) pretreatment aged 12 years; (c), (d) at the end
of retention aged 15 years.

(a)

(b)
(c)

(d)

As mandibular grow t h predominat es over maxillary grow t h during t he pubert al


grow t h spurt , more Class I I malocclusions t han Class I I I malocclusions can be
managed w it h ort hodont ics alone. Research indicat es t hat t he amount of grow t h
modif icat ion t hat can be achieved is limit ed, but even a small amount of skelet al
change can be helpf ul. I n pract ice, t he child w it h a moderat ely severe Class I I
skelet al pat t ern can of t en be managed by a combinat ion of approaches 1 and 2,
provided t hat grow t h is not unf avourable. This usually involves an init ial phase of
f unct ional appliance t herapy carried out during t he pubert al grow t h spurt ,
f ollow ed by a second phase of f ixed appliance t reat ment plus ext ract ions if
indicat ed.
O rt hodont ic camouf lage can also be achieved by proclinat ion of t he low er labial
segment . I n t he main t his movement is inherent ly inst able, but it can be st able in
a small number of cases w here t he low er incisors have been t rapped lingually by
an increased overbit e or pushed lingually by a habit or by a low er lip

t rap. Diagnosis of t hese cases is diff icult and t he inexperienced operat or should
avoid proclinat ion of t he low er labial segment at all cost s. O ccasionally, some
proclinat ion of t he low er labial segment and permanent ret ent ion is f elt by t he
adult pat ient and operat or t o be pref erable t o a surgical opt ion.
Unf ort unat ely, gummy smiles associat ed w it h increased vert ical skelet al
proport ions and/ or a short upper lip w ill of t en w orsen as t he incisors are
ret ract ed. Theref ore act ive st eps should be t aken t o manage t his problem.
Milder cases are best managed by eit her t he use of high-pull headgear t o a
f unct ional t ype of appliance or a f ixed appliance t o t ry and rest rain maxillary
vert ical development w hile t he rest of t he f ace grow s. I n severe cases of vert ical
maxillary excess or w here t here is an excessive amount of upper incisor show in
an adult pat ient , surgery t o impact t he maxilla is advisable.
I n cases w it h a severe Class I I skelet al pat t ern, part icularly w here t he low er
f acial height is signif icant ly increased or reduced, a combinat ion of ort hodont ics
and surgery may be required t o produce an aest het ic and st able correct ion of
t he malocclusion (see Chapt er 20). The t hreshold f or surgery is low er in adult s
because of a lack of grow t h.

Fig. 9.15. Patient with Class II division 1 malocclusion


on a moderately severe Class II skeletal pattern
treated by orthodontic camouflage in which both upper
first premolars were extracted to gain space for overjet
reduction and fixed appliances were used for bodily
retraction of the upper incisors: (a) ( c) pretreatment
(note the upright upper incisors); (d) ( f) post-retention.

(a)
(b)

(c)

(d)

(e)
(f)

9.7. RETENTION
A common mist ake is t o st op t reat ment bef ore overjet reduct ion is f ully
complet ed. I n many cases t he pat ient cont inues t o ret ract t he low er lip behind
t he

upper incisors t o achieve an ant erior oral seal, w it h a subsequent relapse in


incisor posit ion. Theref ore f ull reduct ion of t he overjet and t he achievement of lip
compet ence is advisable.
Unf ort unat ely no amount of ret ent ion w ill make an inherent ly unst able t oot h
posit ion become st able, and so ret ent ion must be considered during t reat ment
planning. Provided t hat t he upper incisors have been ret ract ed t o a posit ion of
sof t t issue balance and are cont rolled by t he low er lip, only a short period of
ret ent ion is required t o allow f or adapt at ion of t he periodont al f ibres and sof t
t issues. O ne except ion t o t his is f unct ional appliance t herapy w here ret ent ion
unt il grow t h is complet e is advisable (Chapt er 18).

PRINCIPAL SOURCES AND FURTHER READING


Aelbers, C. M. F and Dermaut , L. R. (1996). O rt hopedics in ort hodont ics:
f ict ion or realit y. A review of t he lit erat ure. Ameri can Journal of O rthodonti cs
and Dentof aci al O rthopedi cs, 110, 513 1 9 and 667 7 1.

Banks, P. A. (1986). An analysis of complet e and incomplet e overbit e in Class


I I division 1 malocclusions (an analysis of overbit e incomplet eness). Bri ti sh
Journal of O rthodonti cs, 13, 23 3 2.

Bat t agel, J. M. (1989). Prof ile changes in Class I I division 1 malocclusions: a


comparison of t he eff ect s of Edgew ise and Frankel appliance t herapy.
European Journal of O rthodonti cs, 11, 243 5 3.

Burden D. J. et al . (1999). Predict ors of out come among pat ient s w it h Class
I I division 1 malocclusion t reat ed w it h f ixed appliances in t he permanent
dent it ion. Ameri can Journal of O rthodonti cs and Dentof aci al O rthopedi cs,
116, 452 5 9.

King, G . J. , Keeling, S. D. , Hocevar, R. A. , and Wheeler, T. T. (1990). The


t iming of t reat ment f or Class I I malocclusions in children: a lit erat ure review.
Angl e O rthodonti st, 60, 87 9 7.
The argument s f or and against early t reat ment of Class I I division 1
malocclusions.

Tulloch, C. J. F. , Phillips, C. , and Proff it , W. R. (1998). Benef it of early Class


I I t reat ment : progress report of a t w o-phase randomised clinical t rial.
Ameri can Journal of O rthodonti cs and Dentof aci al O rthopedi cs, 113, 62 7 2.

The result s of t his import ant t rial are essent ial reading f or any clinician
involved in t reat ing pat ient s w it h Class I I malocclusions.
Authors: Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> Table of C ontents > 10 - C las s II divis ion 2

10
Class II division 2

A Class I I incisor relat ionship is def ined by t he Brit ish St andards classif icat ion
as being present w hen t he low er incisor edges occlude post erior t o t he cingulum
plat eau of t he upper incisors. Class I I division 2 includes t hose malocclusions
w here t he upper cent ral incisors are ret roclined. The overjet is usually minimal,
but may be increased. The prevalence of t his malocclusion in a Caucasian
populat ion is approximat ely 10 per cent .

10.1. AETIOLOGY
The majorit y of Class I I division 2 malocclusions arise as a result of a number of
int errelat ed skelet al and sof t t issue f act ors.

10.1.1. Skeletal pattern


Class I I division 2 malocclusion is commonly associat ed w it h a mild Class I I
skelet al pat t ern, but may also occur in associat ion w it h a Class I or even a Class
I I I dent al base relat ionship. Where t he skelet al pat t ern is more markedly Class I I
t he upper incisors usually lie out side t he cont rol of t he low er lip, result ing in a
Class I I division 1 relat ionship, but w here t he low er lip line is high relat ive t o t he
upper incisors a Class I I division 2 malocclusion can result .
The vert ical dimension is also import ant in t he aet iology of Class I I division 2
malocclusions, and t ypically is reduced. A reduced low er f ace height occurring in
conjunct ion w it h a Class I I jaw relat ionship of t en result s in t he absence of an
occlusal st op t o t he low er incisors, w hich t hen cont inue t o erupt leading t o an
increased overbit e (Fig. 10. 1).
Fig. 10. 1. A cross-sect ional view t hrough t he st udy models of a pat ient w it h
a very severe Class I I division 2 incisor relat ionship. Lack of an occlusal
st op allow ed t he incisors t o cont inue erupt ing, leading t o a signif icant ly
increased overbit e.

A reduced low er f acial height is associat ed w it h a f orw ard rot at ional pat t ern of
grow t h. This usually means t hat t he mandible becomes more prognat hic w it h
grow t h (Fig. 10. 2). While t his pat t ern of grow t h is helpf ul in reducing t he severit y
of a Class I I skelet al pat t ern, it also has t he eff ect of increasing overbit e unless
an occlusal st op is creat ed by t reat ment t o limit f urt her erupt ion of t he low er
incisors and t o shif t t he axis of grow t h rot at ion t o t he low er incisal edges.

Fig. 10. 2. Diagram show ing how, despit e a f orw ard pat t ern of f acial grow t h,
t he overbit e can become w orse in an unt reat ed Class I I division 2 incisor
relat ionship.

10.1.2. Soft tissues


The inf luence of t he sof t t issues in Class I I division 2 malocclusions is usually
mediat ed by t he skelet al pat t ern. I f t he low er f acial height is reduced, t he low er
lip line w ill eff ect ively be higher relat ive t o t he crow n of t he upper incisors (more
t han t he normal one-t hird coverage). A high low er lip line w ill t end t o ret rocline
t he upper incisors (Fig. 10. 3; see also Fig. 5. 9). I n some cases t he upper lat eral
incisors, w hich have a short er crow n lengt h, w ill escape t he act ion of t he low er
lip and t heref ore lie at an average inclinat ion, w hereas t he cent ral incisors are
ret roclined (Fig. 10. 4).

Fig. 10. 3. Class I I division 2 malocclusion w it h ret roclinat ion of all t he upper
incisors ow ing t o a high low er lip line w hich is evident in t he view of t he
pat ient smiling.

Fig. 10. 4. Typical Class I I division 2 malocclusion w it h ret roclinat ion of t he


upper cent ral incisors. The lat eral incisors, w hich are short er, escape t he
eff ect of t he low er lip and lie at an average inclinat ion, albeit slight ly
mesiolabially rot at ed and crow ded.
Fig. 10. 5. Pat ient w it h bimaxillary ret roclinat ion due t o t he act ion of t he lips.

Class I I division 2 incisor relat ionships may also result f rom bimaxillary
ret roclinat ion caused by act ive muscular lips (Fig. 10. 5), irrespect ive of t he
skelet al pat t ern.

10.1.3. Dental factors


As w it h ot her malocclusions, crow ding is commonly seen in conjunct ion w it h a
Class I I division 2 incisor relat ionship. I n addit ion, any pre-exist ing crow ding is
exacerbat ed because ret roclinat ion of t he upper cent ral incisors result s in t heir
being posit ioned in an arc of smaller circumf erence. I n t he upper labial segment
t his usually manif est s in a lack of space f or t he upper lat eral incisors w hich are
crow ded and are t ypically rot at ed mesiolabially out of t he arch. I n t he same
manner low er arch crow ding is of t en exacerabat ed by ret roclinat ion of t he low er
labial segment . This can occur because t he low er labial segment becomes
t rapped lingually t o t he upper labial segment by an increased overbit e (Fig.
10. 6).
Fig. 10. 6. T rapping of t he low er incisor t eet h behind t he cingulum of t he
upper incisors in a Class I I division 2 malocclusion. Not e t he space creat ed
labial t o t he low er incisor crow n by reduct ion of t he overbit e (t he dot t ed line)
w it hin t he sof t t issue environment .

Lack of an eff ect ive occlusal st op t o erupt ion of t he low er incisors may result in
t heir cont inued development , giving rise t o an increased overbit e. This may be
due t o a Class I I skelet al pat t ern or ret roclinat ion of t he incisors as a result of
t he act ion of t he lips, leading t o an increased int er-incisal angle. I n addit ion, it
has been f ound t hat in some Class I I division 2 cases t he upper cent ral incisors

exhibit a more acut e crow n and root angulat ion. How ever, rat her t han being t he
cause, t his crow n root angulat ion could it self be due t o t he act ion of a high low er
lip line causing def lect ion of t he crow n of t he t oot h relat ive t o t he root af t er
erupt ion.

10.2. OCCLUSAL FEATURES


Classically, t he upper cent ral incisors are ret roclined and t he lat eral incisors are
at an average angulat ion or are proclined, depending upon t heir posit ion relat ive
t o t he low er lip (see Fig. 10. 4). Where t he low er lip line is very high t he lat eral
incisors may be ret roclined (see Fig. 10. 3). The more severe malocclusions
occur eit her w here t he underlying skelet al pat t ern is more Class I I or w here t he
lip musculat ure is act ive, causing bimaxillary ret roclinat ion.
I n mild cases t he low er incisors occlude w it h t he upper incisors, but in pat ient s
w it h a more severe Class I I skelet al pat t ern t he overbit e may be complet e ont o
t he palat al mucosa. I n a small proport ion of cases t he low er incisors may cause
ulcerat ion of t he palat al t issues (Fig. 10. 7), and in some pat ient s ret roclinat ion
of t he upper incisors leads t o st ripping of t he labial gingivae of t he low er incisors
(Fig. 10. 8). I n t hese cases t he overbit e is described as t raumat ic, but
f ort unat ely bot h are comparat ively rare.

Fig. 10. 7. Ulcerat ion of t he palat al mucosa of 1/ 1 caused by t he occlusion of


t he low er incisor edges an example of a t raumat ic overbit e.

Fig. 10. 8. St ripping of t he labial gingivae of t he low er incisors caused by t he


severely ret roclined upper incisors an example of a t raumat ic overbit e.

Anot her f eat ure associat ed w it h a more severe underlying Class I I skelet al
pat t ern is lingual crossbit e of t he f irst and occasionally t he second premolars
(Fig. 10. 9) ow ing t o t he relat ive posit ions and w idt hs of t he arches, and possibly
t o t rapping of t he low er labial segment w it hin a ret roclined upper labial segment .
Fig. 10. 9. Part icularly severe lingual crossbit e of t he ent ire lef t buccal
segment ow ing t o a Class I I skelet al pat t ern result ing in w ider port ion of
upper arch occluding w it h narrow er sect ion of low er arch.

10.3. M ANAGEM ENT


I n t he mild Class I I division 2 malocclusion, w here t he low er incisors occlude
w it h t he upper incisors, t reat ment can be limit ed t o achievement of alignment
and t he incisor relat ionship accept ed.
St able correct ion of a Class I I division 2 incisor relat ionship is diff icult as it
requires not only reduct ion of t he increased overbit e (discussed in Sect ion
10. 3. 1), but also reduct ion of t he int er-incisal angle w hich classically is
increased (Fig. 10. 10). I f re-erupt ion of t he incisors and t heref ore an increase in
overbit e is t o be resist ed, t he int er-incisal angle needs t o be reduced, pref erably
t o bet w een 125° and 135°, so t hat an eff ect ive occlusal st op is creat ed (Fig.
10. 11).
The int er-incisal angle in a Class I I division 2 malocclusion can be reduced in a
number of w ays:

Torquing t he incisor root s palat ally/ lingually w it h a f ixed appliance (Fig.


10. 12).
Proclinat ion of t he low er labial segment (Fig. 10. 13). This approach should
only be employed by t he experienced as, alt hough it provides addit ional
space f or alignment of t he low er incisor t eet h, proclinat ion of t he low er labial
segment w ill only be st able if it has been t rapped lingually by t he upper
labial segment .
Proclinat ion of t he upper labial segment f ollow ed by use of a f unct ional
appliance t o reduce t he result ant overjet and achieve int ermaxillary
correct ion (Fig. 10. 14).
A combinat ion of t he above approaches.
Fig. 10.10. (a) A Class I incisor relationship with an
average inter-incisal angle of around 135°; (b) a Class
II division 2 relationship where the inter-incisal angle is
increased.

(a)

(b)

Fig. 10.11. If a Class II division 2 incisor relationship is


to be corrected not only the overbite but also the inter-
incisal angle must be reduced to prevent re-eruption of
the incisors post-treatment: (a) Class II division 2
incisor relationship; (b) reduction of the overbite alone
will not be stable as the incisors will re-erupt following
removal of appliances; (c) reduction of the inter-incisal
angle in conjunction with reduction of the overbite has
a greater chance of stability.
(a)

(b)

(c)

Fig. 10. 12. Correct ion of a Class I I division 2 incisor relat ionship by reducing
t he overbit e and t orquing t he incisors lingually/ palat ally. Fixed appliances are
necessary.

Fig. 10. 13. Correct ion of a Class I I division 2 incisor relat ionship by
proclinat ion of t he low er labial segment .

Fig. 10. 14. Correct ion of a Class I I division 2 incisor relat ionship by an init ial
phase involving proclinat ion of t he upper incisors, f ollow ed by reduct ion of
t he result ant overjet w it h a f unct ional appliance.

The t reat ment approach chosen f or a part icular pat ient w ill depend upon t he
aet iology of t he malocclusion, t he presence and degree of crow ding, t he
pat ient 's prof ile, and t heir probable compliance.
O nce t he decision has been made t o accept or correct t he incisor relat ionship,
considerat ion should be given as t o w het her ext ract ions are required t o relieve
crow ding and t o provide space f or incisor alignment . Some pract it ioners have
argued t hat closure of excess ext ract ion space in a Class I I division 2
malocclusion w ill result in f urt her ret roclinat ion of t he labial segment s and a
d ished-in prof ile . This claim is usually made in associat ion w it h t he present at ion
of isolat ed case report s. How ever, research using groups of caref ully mat ched
pat ient s has show n t hat t here is lit t le diff erence in t he amount of ret ract ion of
t he lips bet w een ext ract ion and non-ext ract ion t reat ment approaches (see
Chapt er 7, Sect ion 7. 8). Nevert heless, it w ould seem advisable in t he
management of Class I I division 2 malocclusions t o minimize lingual movement of
t he low er incisors in order t o avoid any possibilit y of w orsening t he pat ient 's
overbit e; indeed, it may be pref erable t o accept a degree of low er arch crow ding
rat her t han run t his risk. Cert ainly, ext ract ion of permanent t eet h in t he low er
arch in Class I I division 2 maloccclusions should be approached w it h caut ion,
and if any doubt exist s specialist advice should be sought . I n addit ion, clinical
experience suggest s t hat space closure occurs less readily in pat ient s w it h
reduced vert ical skelet al proport ions, w hich are commonly associat ed w it h Class
I I division 2 malocclusions, t han in t hose w it h increased low er f ace height s.
I n general, proclinat ion of t he low er labial segment should be considered
unst able, but it has been argued t hat in some Class I I division 2 malocclusions
t he low er labial segment is t rapped behind t he upper labial segment , result ing in
ret roclinat ion of t he low er incisors and const rict ion of t he low er int ercanine
w idt h. This means t hat a limit ed increase in int ercanine w idt h and a degree of
proclinat ion of t he low er labial segment can be st able, alt hough it is import ant t o
assess t he low er labial support ing t issues t o avoid iat rogenic gingival recession.
How ever, proclinat ion of t he low er incisors is helpf ul in reducing bot h overbit e
and t he int er-incisal angle.
I n view of t he above comment s, it is not surprising t hat Class I I division 2
malocclusions are managed more f requent ly on a non-ext ract ion basis,
part icularly in t he low er arch, t han are ot her t ypes of malocclusion.
This discussion has highlight ed some of t he diff icult ies inherent in planning
t reat ment of Class I I division 2 incisor relat ionships. Except f or t he mild case,
w here management is t o be limit ed t o alignment of t he upper arch, correct ion of
Class I I division 2 incisor relat ionships is best lef t t o t he specialist .

10.3.1. Approaches to the reduction of overbite


Intrusion of the incisors
Act ual int rusion of t he incisors is diff icult t o achieve. Fixed appliances are
necessary and t he mechanics employed pit int rusion of t he incisors against
ext rusion of t he buccal segment t eet h; as it is easier t o move t he molars
occlusally t han t o int rude t he incisors int o bone, t he f ormer t ends t o
predominat e. I n pract ice, t he eff ect s achieved are relat ive int rusion, w here t he
incisors are held st ill w hile vert ical grow t h of t he f ace occurs around t hem, plus
ext rusion of t he molars. High-pull headgear can be hooked ont o t he ant erior
segment of t he archw ire of an upper f ixed appliance t o t ry and achieve int rusion
of t he upper labial segment ; how ever, t his approach has become less popular
due t o concerns over headgear saf et y and root resorpt ion.
I ncreasing t he anchorage unit post eriorly by including second permanent molars
(or even t hird molars in adult s) w ill aid int rusion of t he incisors and help t o limit
ext rusion of t he molars. Arches w hich bypass t he canines and premolars t o pit
t he incisors against t he molars, f or example t he ut ilit y arch (Fig. 10. 15), are
employed w it h some success t o reduce overbit e by int rusion of t he incisors,
alt hough some molar ext rusion does occur.

Fig. 10. 15. Low er ut ilit y arch f or overbit e reduct ion. Not e t he diff erence in
level bet w een t he low er incisor bracket s and t he buccal segment t eet h.

Eruption of the molars


Use of a f lat ant erior bit e-plane on an upper removable appliance t o f ree t he
occlusion of t he buccal segment t eet h w ill, if w orn conscient iously, limit f urt her
occlusal movement of t he incisors and allow t he low er molars t o erupt , t hus
reducing t he overbit e. This met hod requires a grow ing pat ient t o accommodat e
t he increase in vert ical dimension t hat result s, ot herw ise t he molars w ill reint rude
under t he f orces of occlusion once t he appliance is w it hdraw n. How ever, t his
t endency can be resist ed t o a degree if t he t reat ment creat es a st able incisor
relat ionship.

Extrusion of the molars


As ment ioned above, t he major eff ect of at t empt ing int rusion of t he incisors is
of t en ext rusion of t he molars. This may be advant ageous in Class I I division 2
cases as t his t ype of malocclusion is usually associat ed w it h reduced vert ical
proport ions. Again, vert ical grow t h is required if t he overbit e reduct ion achieved
in t his w ay is t o be st able.

Proclination of the low er incisors


Advancement of t he low er labial segment ant eriorly w ill result in a reduct ion of
overbit e as t he incisors t ip labially. This approach should only be carried out by
t he experienced ort hodont ist (see Sect ion 10. 3. 2). How ever, in a f ew cases
w here t he low er incisors have been t rapped behind t he upper labial segment by
an increased overbit e, f it t ing of an upper bit e-plane appliance may allow t he
low er labial segment t o procline spont aneously (Fig. 10. 16).

Fig. 10. 16. Diagram t o show spont aneous proclinat ion of t he low er labial
segment f ollow ing placement of a f lat ant erior bit e-plane w hich has reduced
t he overbit e by erupt ion of t he low er molars.

Surgery
I n adult s w it h a markedly increased overbit e and t hose pat ient s w here t he
underlying skelet al pat t ern is more markedly Class I I , a combinat ion of
ort hodont ics and surgery is required.

10.3.2. Practical management


The incisor relationship is to be accepted
I n milder cases w here t he low er incisors occlude ont o t oot h t issue it may be
possible t o accept t he increased overbit e, limit ing t reat ment t o alignment ,
part icularly of t he upper lat eral incisors.
As discussed above, it may be pref erable t o accept mild t o moderat e low er arch
crow ding rat her t han run t he risk of ext ract ions leading t o lingual movement of
t he low er labial segment and a w orsening of t he overbit e. I f t he crow ding is
marked, ext ract ion of low er f irst premolars may be required. How ever, if low er
arch ext ract ions run t he risk t hat t he low er incisors may t ilt lingually and come t o
occlude w it h t he palat al gingivae behind t he upper incisors, it may be pref erable
t o use f ixed appliances and correct t he incisor relat ionship inst ead (see below ).
Space f or alignment of t he upper arch can be creat ed by ext ract ions (Chapt er 7,
Sect ion 7. 7. 1) or by dist al movement of t he upper buccal segment t eet h (Chapt er
7, Sect ion 7. 7. 3). Ext ract ion of t he upper f irst premolars is usually indicat ed if
t he f irst premolars have been lost in t he low er arch or t he buccal segment
relat ionship is great er t han half a unit Class I I . Ext ract ion of second premolars
w ill give less space ant eriorly and can be considered if upper arch crow ding is
mild and/ or

dist al movement of t he molars is not indicat ed or t he pat ient is unw illing t o w ear
headgear.

Fig. 10.17. A mild Class II division 2 incisor


relationship with mild upper and lower arch crowding.
The patient requested treatment to align 2/. Treatment
involved the extraction of 4/7, 4/7 to relieve the
crowding, followed by an upper removable appliance to
retract 3/ and align 2/: (a) pretreatment; (b) post-
treatment.

(a)

(b)
Dist al movement of t he upper buccal segment s can be considered w here t he
low er arch alignment is t o be accept ed and t he molar relat ionship is not great er
t han half a unit Class I I . Ext ract ion of t he upper second molars may be required
t o f acilit at e dist al movement , provided t hat upper t hird molars of a good size are
present and in a f avourable posit ion. I n some cases removable appliances can
be used t o achieve upper arch alignment . Alt hough a removable appliance cannot
be used t o de-rot at e rot at ed upper lat eral incisors, relief of crow ding and
ret ract ion of t hese t eet h int o t he line of t he arch may provide suff icient
improvement (Fig. 10. 17). The appliance should incorporat e a f lat ant erior bit e-
plane t o f ree t he occlusion of t he low er labial segment and achieve some
overbit e reduct ion.
When planning t reat ment in t hese cases it is import ant t o bear in mind t hat , if t he
upper incisors are ret roclined, t he upper canines should only be ret ract ed
suff icient ly t o provide space f or alignment of t he incisors. This is because
ret roclined upper incisors occupy less arch lengt h t han upright incisors; t heref ore
if t he maxillary canines are ret ract ed t o Class I , excess space w ill be creat ed in
t he upper labial segment . This may leave t he upper canines buccally posit ioned
relat ive t o t he arch in a half -unit Class I I relat ionship w it h t he low er canines, in
w hich case considerat ion should be given t o correct ing t he incisor relat ionship
w it h f ixed appliances.
I f use of a removable appliance w ill not produce an accept able result t hen f ixed
appliances are indicat ed.

The incisor relationship is to be corrected


Correct ion of t he incisor relat ionship is indicat ed w here t he overbit e is complet e
t o t he palat al sof t t issues, or is liable t o become so f ollow ing ext ract ions in t he
low er arch t o relieve crow ding. I n some pat ient s, reduct ion of overbit e is
necessary in order t o be able t o t reat ot her f eat ures of a malocclusion.
Cert ainly, correct ion of t he incisor relat ionship should be given priorit y if t he
overbit e is t raumat ic.
I t w ill be apparent f rom t he discussion at t he beginning of Sect ion 10. 3 t hat t here
are t hree possible t reat ment modalit ies as described below.

Fixed appliances
When f ixed appliances are used t he int er-incisal angle can be reduced by
palat al/ lingual root t orque or by proclinat ion of t he low er incisors. The relat ive
role of t hese t w o approaches in t he management of a part icular malocclusion is
a mat t er of f ine judgement .
Torquing of incisor apices is dependent upon t he presence of suff icient cort ical
bone palat ally/ lingually and places a considerable st rain on anchorage. This t ype
of movement is also more likely t o result in resorpt ion of t he root apices t han
ot her t ypes of t oot h movement .
Mild crow ding in t he low er arch may be eliminat ed by f orw ard movement of t he
low er labial segment . I f crow ding is marked, ext ract ions w ill be required and a
low er f ixed appliance used t o ensure t hat space closure occurs w it hout
movement of t he low er incisor edges lingually (Fig. 10. 18). Space f or correct ion
of t he incisor relat ionship can be gained by upper arch ext ract ions or by dist al
movement of t he upper buccal segment s. I f headgear is used f or anchorage or
dist al movement , a direct ion of pull below t he occlusal plane (cervical pull) is
usually indicat ed in Class I I division 2 malocclusions as t he vert ical f acial
proport ions are reduced. A lingual crossbit e, if present , usually aff ect s t he f irst
premolars only. I f ext ract ion of t he upper f irst premolars is not indicat ed, or if
t he second premolars

are involved, eliminat ion of t he crossbit e w ill involve a combinat ion of cont ract ion
across t he aff ect ed upper t eet h and expansion of t he low er premolar w idt h.
Follow ing t reat ment , t he prognosis f or t he correct ed posit ion is good as cuspal
int erlock w ill help t o prevent relapse.

Fig. 10.18. Patient aged 12 years with a Class II


division 2 incisor relationship on a Class I skeletal
pattern with crowded and rotated incisors. The second
premolars were extracted and fixed appliances were
used to achieve alignment and correction of the incisor
relationship: (a), (b) pretreatment; (c) during treatment;
(d), (e) at end of treatment (note favourable mandibular
growth).

(a)
(b)

(c)

(d)

(e)

O n complet ion of t reat ment it is prudent t o ret ain w it h a upper removable


appliance incorporat ing a bit e-plane. I deally, ret ent ion should be cont inued unt il
grow t h is complet e t o t ry and prevent a ret urn of t he overbit e. Whilst t his is not
alw ays pract icable, one approach is t o ret ain f or about 6 mont hs f ull t ime,
f ollow ed by 6 mont hs night s only. I f proclinat ion of t he low er labial segment is
decided upon, an assessment of t he st abilit y of t his movement needs t o be made
at t he planning st age and permanent ret ent ion inst it ut ed w here indicat ed.

Functional appliances
Funct ional appliances can be ut ilized in t he correct ion of Class I I division 2
malocclusions in grow ing pat ient s w it h a mild t o moderat e Class I I skelet al
pat t ern and a relat ively w ell-aligned low er arch (Fig. 10. 19). Reduct ion of t he
int er-incisal angle is achieved mainly by proclinat ion of t he upper incisors,
alt hough some proclinat ion of t he low er labial segment may occur as a result of
t he f unct ional appliance. I f an act ivat or t ype of f unct ional appliance is used, t hen
a pre-f unct ional phase is required t o procline any ret roclined incisors and t o
expand t he upper arch (t o ensure t he correct buccolingual arch relat ionship at
t he end of t reat ment ). This can be achieved using a removable appliance (Fig.
10. 20); t his design is know n as an ELSAA (Expansion and Labial Segment
Alignment Appliance). I f a t w in-block f unct ional is used, t hen a spring t o procline
t he

incisors can be incorporat ed int o t he upper appliance. Finally, f ixed appliances


are of t en required t o det ail t he occlusion. I f t he low er incisors have been
proclined, t he st abilit y of t heir posit ion should be assessed and, if doubt f ul,
permanent ret ent ion (or at least ret ent ion unt il grow t h is complet e) should be
inst it ut ed.

Fig. 10.19. Class II division 2 malocclusion treated


initially with a twin-block appliance, which incorporated
a double cantilever spring to procline the retroclined
upper central incisors. Then fixed appliances were used
to detail the occlusion: (a) pretreatment; (b) at end of
the functional phase; (c) fixed appliance phase; (d) end
of active treatment.
(a)

(b)

(c)

(d)
Fig. 10. 20. An upper removable appliance used t o expand t he upper arch and
procline ret roclined upper incisors prior t o f unct ional appliance t herapy.

Fig. 10. 21. Adult pat ient w it h severe Class I I division 2 malocclusion on a
marked Class I I skelet al pat t ern w it h reduced vert ical proport ions. I t w as
decided t hat a combined ort hodont ic and ort hognat hic surgery appproach
w as required t o correct t his malocclusion.

Surgery (see Chapter 20)


A st able aest het ic ort hodont ic correct ion may not be possible in pat ient s w it h an
unf avourable skelet al pat t ern ant eropost eriorly and/ or vert ically, part icularly if
grow t h is complet e (Fig. 10. 21). I n t hese cases surgery may be necessary. A
phase of presurgical ort hodont ics is required t o align t he t eet h. How ever, arch
levelling is usually not complet ed as ext rusion of t he molars is much more easily
accomplished af t er surgery. Where t he overbit e is part icularly marked, t he low er
labial segment may have t o be set dow n surgically, in w hich case space w ill have
t o be creat ed dist al t o t he low er canines f or t he surgical cut s t o be made.

PRINCIPAL SOURCES AND FURTHER READING


Burst one, C. R. (1977) Deep overbit e correct ion by int rusion. Ameri can
Journal of O rthodonti cs, 72, 1 2 2.

A usef ul paper f or t he more experienced ort hodont ist using f ixed appliances.

Lee, R. T. (1999). Arch w idt h and f orm: a review. Ameri can Journal of
O rthodonti cs and Dentof aci al O rthopedi cs, 115, 305 1 3.

Leight on, B. C. and Adams, C. P. (1986). I ncisor inclinat ion in Class I I division
2 malocclusions. European Journal of O rthodonti cs, 8, 98 1 05.

Kim, T. W. and Lit t le, R. M. (1999). Post ret ent ion assessment of deep
overbit e correct ion in Class I I division 2 malocclusion. Angl e O rthodonti st. 69,
175 8 6.

Rut t er, R. R. and Wit t , E. (1990). Correct ion of Class I I division 2


malocclusions t hrough t he use of t he Bionat or appliance. Report of t w o cases.
Ameri can Journal of O rthodonti cs and Dentof aci al O rthopedi cs, 97, 106 1 2.

Selw yn-Barnet t , B. J. (1991). Rat ionale of t reat ment f or Class I I division 2


malocclusion. Bri ti sh Journal of O rthodonti cs, 18, 173 8 1.

This paper cont ains a caref ully const ruct ed argument f or management of Class
I I division 2 malocclusion by proclinat ion of t he low er labial segment rat her t han
ext ract ions, in order t o avoid det riment al eff ect s upon t he prof ile.

Selw yn-Barnet t , B. J. (1996). Class I I division 2 malocclusion: a met hod of


planning and t reat ment . Bri ti sh Journal of O rthodonti cs, 23, 29 3 6.
Authors: Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> Table of C ontents > 11 - C las s III

11
Class III

The Brit ish St andards def init ion of Class I I I incisor relat ionship includes t hose
malocclusions w here t he low er incisor edge occludes ant erior t o t he cingulum
plat eau of t he upper incisors. Class I I I malocclusions aff ect around 3 per cent of
Caucasians.

11.1. AETIOLOGY
11.1.1. Skeletal pattern
The skelet al relat ionship is t he most import ant f act or in t he aet iology of most
Class I I I malocclusions, and t he majorit y of Class I I I incisor relat ionships are
associat ed w it h an underlying Class I I I skelet al relat ionship. Cephalomet ric
st udies have show n t hat , compared w it h Class I occlusions, Class I I I
malocclusions exhibit t he f ollow ing:

increased mandibular lengt h;


a more ant eriorly placed glenoid f ossa so t hat t he condylar head is
posit ioned more ant eriorly leading t o mandibular prognat hism;
reduced maxillary lengt h;
a more ret ruded posit ion of t he maxilla leading t o maxillary ret rusion.

The f irst t w o of t hese f act ors are t he most inf luent ial. Figure 11. 1 show s a
pat ient w it h a Class I I I malocclusion w it h mandibular prognat hism and Fig. 11. 2
illust rat es maxillary ret rognat hia (maxillary ret rusion).
Fig. 11. 1. Pat ient w it h mandibular prognat hism

Fig. 11. 2. Pat ient w it h maxillary ret rognat hia.

Class I I I malocclusions occur in associat ion w it h a range of vert ical skelet al


proport ions, ranging f rom increased t o reduced. A backw ard opening rot at ion
pat t ern of f acial grow t h w ill t end t o result in a reduct ion of overbit e; how ever, a
f orw ard rot at ing pat t ern of f acial grow t h w ill lead t o an increase in t he
prominence of t he chin.

11.1.2. Soft tissues


I n t he majorit y of Class I I I malocclusions t he sof t t issues do not play a major
aet iological role. I n f act t he reverse is of t en t he case, w it h t he sof t t issues
t ending t o t ilt t he upper and low er incisors t ow ards each ot her so t hat t he incisor
relat ionship is of t en less severe t han t he underlying skelet al pat t ern. This dent o-
alveolar compensat ion occurs in Class I I I malocclusions because an ant erior oral
seal can f requent ly be achieved by upper t o low er lip cont act . This has t he eff ect
of moulding t he upper and low er labial segment s t ow ards each ot her. The main
except ion occurs in pat ient s w it h increased vert ical skelet al proport ions w here
t he lips are more likely t o be incompet ent and an ant erior oral seal is of t en
accomplished by t ongue t o low er lip cont act .

11.1.3. Dental factors


Class I I I malocclusions are of t en associat ed w it h a narrow upper arch and a
broad low er arch, w it h t he result t hat crow ding is seen more commonly, and t o a
great er degree, in t he upper arch t han in t he low er. Frequent ly, t he low er arch is
w ell aligned or evenly spaced.

11.2. OCCLUSAL FEATURES


By def init ion Class I I I malocclusions occur w hen t he low er incisors are
posit ioned more labially relat ive t o t he upper incisors. Theref ore an ant erior
crossbit e of one or more of t he incisors is a common f eat ure of Class I I I
malocclusions. As w it h any crossbit e, it is essent ial t o check f or a displacement
of t he mandible on closure f rom a premat ure cont act int o maximal int erdigit at ion.
I n Class I I I malocclusions t his can be ascert ained by asking t he pat ient t o t ry t o
achieve an edge-t o-edge incisor posit ion. I f such a displacement is present , t he
prognosis f or correct ion of t he incisor relat ionship is more f avourable. I n t he
past it w as t hought t hat such a displacement led t o overclosure and great er
prominence of t he mandible, w it h t he condylar head displaced f orw ard. I n f act
cephalomet ric st udies suggest t hat in most cases, alt hough t here is a f orw ard
displacement of t he mandible t o disengage t he premat ure cont act of t he incisors
as closure int o occlusion occurs, t he mandible moves backw ards unt il t he
condyles regain t heir normal posit ion w it hin t he glenoid f ossa (Fig. 11. 3).
Fig. 11. 3. Diagram illust rat ing t he pat h of closure in a Class I I I malocclusion
f rom an edge-t o-edge incisor relat ionship int o maximal occlusion. Alt hough
t he mandible is displaced f orw ards f rom t he init ial cont act of t he incisors t o
achieve maximal int erdigit at ion, t he condylar head is not displaced out of t he
glenoid f ossa.

Anot her common f eat ure of Class I I I malocclusions is buccal crossbit e, w hich is
usually due t o a discrepancy in t he relat ive w idt h of t he arches. This occurs
because t he low er arch is posit ioned relat ively more ant eriorly in Class I I I
malocclusions and is of t en w ell developed, w hile t he upper arch is narrow. This
is also ref lect ed in t he relat ive crow ding w it hin t he arches, w it h t he upper arch
commonly more crow ded (Fig. 11. 4).

Fig. 11. 4. A Class I I I malocclusion w it h a narrow crow ded upper arch and a
broader less crow ded low er arch w it h associat ed buccal crossbit e.

As ment ioned above, Class I I I malocclusions of t en exhibit dent o-alveolar


compensat ion w it h t he upper incisors proclined and t he low er incisors
ret roclined, w hich reduces t he severit y of t he incisor relat ionship (Fig. 11. 5).

11.3. TREATM ENT PLANNING IN CLASS III


M ALOCCLUSIONS
A number of f act ors should be considered bef ore planning t reat ment .
The patient's opinion regarding t heir occlusion and f acial appearance must be
t aken int o account . This subject needs t o be approached w it h some t act .
The severity of the skeletal pattern bot h ant eropost eriorly and vert ically should
be assessed. This is t he major det erminant of t he diff icult y and prognosis of
ort hodont ic t reat ment .
The expected pattern of future growth bot h ant eropost eriorly and vert ically
should be considered. I t is import ant t o remember t hat average grow t h w ill t end
t o result in a w orsening of t he relat ionship bet w een t he arches, and a signif icant
det eriorat ion can be ant icipat ed if grow t h is unf avourable. When evaluat ing t he
likely direct ion and ext ent of f acial grow t h, t he pat ient 's age, sex, and f acial
pat t ern should be t aken int o considerat ion (see Chapt er 4). Children w it h
increased vert ical skelet al proport ions of t en cont inue t o exhibit a vert ical pat t ern
of grow t h, w hich w ill have t he eff ect of reducing incisor overbit e. O bviously f or
pat ient s on t he borderline bet w een diff erent management regimes it is w ise t o
err on t he side of pessimism (as grow t h w ill of t en prove t his t o be correct ).

Fig. 11. 5. Dent o-alveolar compensat ion.

I n Class I I I malocclusions a normal or increased overbite is an advant age, as a


vert ical overlap of t he upper incisors w it h t he low er incisors post -t reat ment is
vit al f or st abilit y.
If the patient can achieve an edge-to-edge incisor position, t his increases
t he prognosis f or correct ion of t he incisor relat ionship.
I n general, ort hodont ic management of Class I I I malocclusion w ill aim t o
increase dento-alveolar compensation. Theref ore, if considerable
dent oalveolar compensat ion is already present , t rying t o increase it f urt her may
not be an aest het ic or st able t reat ment opt ion.
The degree of crowding in each arch should be considered. I n Class I I I
malocclusions crow ding occurs more f requent ly, and t o a great er degree, in t he
upper arch t han in t he low er. Ext ract ions in t he upper arch only should be
resist ed as t his w ill of t en lead t o a w orsening of t he incisor relat ionship. Where
upper arch ext ract ions are necessary, it is advisable t o ext ract at least as f ar
f orw ards in t he low er arch.
O rt hodont ic correct ion of a Class I I I incisor relat ionship can be achieved by
eit her proclinat ion of t he upper incisors alone or ret roclinat ion of t he low er
incisors w it h or w it hout proclinat ion of t he upper incisors. The approach
applicable t o a part icular malocclusion is largely det ermined by t he skelet al
pat t ern and t he amount of overbit e present bef ore t reat ment , as proclinat ion of
t he upper incisors reduces t he overbit e (Fig. 11. 6) w hereas ret roclinat ion of t he
low er incisors helps t o increase overbit e (Fig. 11. 7). A prognosis t racing (see
Chapt er 6, Sect ion 6. 8) may be helpf ul in deciding bet w een t he t w o approaches
(Fig. 11. 8).

Fig. 11. 6. Diagram t o show how proclinat ion of t he upper incisors result s in a
reduct ion of overbit e.
Fig. 11. 7. Diagram t o show how ret roclinat ion of t he low er incisors result s in
an increase of overbit e.

Fig. 11. 8. A prognosis t racing w hich indicat es t hat a combinat ion of


ret roclinat ion of t he low er incisors and proclinat ion of t he upper labial
segment is required t o correct t he incisor relat ionship.

I f t he low er arch is moderat ely crow ded, considerat ion should be given t o
ext ract ing t he low er f irst premolars t o allow t he low er labial segment t o drop
lingually, t hereby aiding dent o-alveolar compensat ion. This can result in residual
space in t he low er arch if f ixed appliances are not used.
Addit ional space f or relief of crow ding in t he upper arch can of t en be gained by
expansion of t he arch ant eriorly t o correct t he incisor relat ionship and/ or
buccolingually t o correct buccal segment crossbit es. Theref ore, w here possible,
it may be prudent t o delay permanent ext ract ions unt il af t er t he crossbit e is
correct ed and t he degree of crow ding is reassessed. Expansion of t he upper
arch t o correct a crossbit e w ill have t he eff ect of reducing overbit e, w hich is a
disadvant age in Class I I I cases. This reduct ion in overbit e occurs because
expansion of t he upper arch is achieved primarily by t ilt ing t he upper premolars
and molars buccally, w hich result s in t he palat al cusps of t hese t eet h sw inging
dow n and p ropping open t he occlusion. Theref ore, if upper arch expansion is
indicat ed and t he over-bit e is reduced, f ixed appliances should be used t o t ry
and limit t ilt ing of t he upper molars buccally during t he expansion.
Dist al movement of t he upper buccal segment s w it h headgear t o gain space f or
alignment is inadvisable as t his w ill have t he eff ect of rest raining grow t h of t he
maxilla. How ever, in Class I I I cases w it h mild t o moderat e mid-arch crow ding,
space can be made by a combinat ion of f orw ard movement of t he incisors as
w ell as some dist al movement of t he remaining buccal segment t eet h. This can
be accomplished by using a removable appliance w it h a screw posit ioned at t he
sit e of crow ding or w it h f ixed appliances.
Anot her approach is t o use a f unct ional appliance, but it is diff icult f or pat ient s
t o post ure post eriorly t o achieve an act ive w orking bit e. Theref ore f unct ional
appliances are less w idely used in Class I I I malocclusions, alt hough t hey can be
usef ul in mild cases in t he mixed dent it ion w here a combinat ion of proclinat ion of
t he upper incisors t oget her w it h ret roclinat ion of t he low er incisors is required.
I n pat ient s w it h a severe Class I I I skelet al pat t ern and/ or reduced overbit e, t he
possibilit y t hat a surgical approach may ult imat ely be required must be
considered,

part icularly bef ore any permanent ext ract ions are undert aken (see Sect ion
11. 4. 4).

11.4. TREATM ENT OPTIONS


11.4.1. Accepting the incisor relationship
I n mild Class I I I malocclusions, part icularly t hose cases w here t he overbit e is
minimal, it may be pref erable t o accept t he incisor relat ionship and direct
t reat ment t ow ards achieving arch alignment (Fig. 11. 9).
Fig. 11. 9. Mild Class I I I case w here it w as decided t o accept t he incisor
relat ionship and direct t reat ment t ow ards alignment of t he arches only.

O ccasionally pat ient s w it h more severe Class I I I incisor relat ionships are
unconcerned about t heir malocclusion, part icularly if t he remainder of t he f amily
have a similar f acial appearance. I n t his sit uat ion, and also w here a pat ient is
unw illing t o undergo t he f ixed appliance t reat ment necessary t o correct t he
incisor relat ionship, t reat ment can be limit ed t o achieving alignment only.
Somet imes upper arch crow ding result s in t he lat eral incisors erupt ing palat ally
and t he canines buccally. I f t he upper lat eral incisors are markedly displaced
t hen t heir ext ract ion may make t reat ment more st raight f orw ard (Fig. 11. 10).
Some pat ient s are happy t o accept a smile w it h t he canines adjacent t o t he
cent ral incisors. How ever, veneers can be used t o make t he canines resemble
lat eral incisors more closely.

Fig. 11.10. Patient whose Class III malocclusion with


marked upper arch crowding was managed by
extraction of the palatally displaced upper lateral
incisors and the lower first premolars: (a) prior to
extractions; (b) 6 months after extractions and prior to
fixed appliance therapy.

(a)
(b)

11.4.2. Proclination of the upper labial segment


Correct ion of t he incisor relat ionship by proclinat ion of t he upper incisors only
can be considered in cases w it h t he f ollow ing f eat ures:

a Class I or mild Class I I I skelet al pat t ern


t he upper incisors are not already signif icant ly proclined
an adequat e overbit e w ill be present at t he end of t reat ment t o ret ain t he
correct ed posit ion of t he upper incisors, given t hat a reduct ion of overbit e
w ill occur as t he incisors are t ipped labially (see Sect ion 11. 3 and Fig. 11. 6).

I f indicat ed, t his approach is of t en best carried out in t he mixed dent it ion w hen
t he unerupt ed permanent canines are high above t he root s of t he upper lat eral
incisors (Fig. 11. 11). Ext ract ion of t he low er deciduous canines at t he same t ime
may allow t he low er labial segment t o move lingually slight ly, t hereby aiding
correct ion of t he incisor relat ionship. Early correct ion of a Class I I I incisor
relat ionship has t he addit ional advant age t hat f urt her f orw ard mandibular grow t h
may be count erbalanced by dent o-alveolar compensat ion (Fig. 11. 12).
Lat er in t he mixed dent it ion, w hen t he developing permanent canines drop dow n
int o a buccal posit ion relat ive t o t he lat eral incisor root , t here may be a risk of
resorpt ion if t he incisors are moved labially. I n t his sit uat ion correct ion is best
def erred unt il t he permanent canines have erupt ed.
Where t he upper labial segment is mildly crow ded, permanent ext ract ions should
be delayed unt il af t er t he incisor relat ionship is correct ed as proclinat ion of t he
upper incisors w ill provide addit ional space. I f t he low er arch is at all crow ded,
considerat ion should be given t o relieving t he crow ding by ext ract ions as t his w ill
allow some lingual movement of t he low er labial segment t eet h.
Proclinat ion of t he upper labial segment can of t en be accomplished successf ully
w it h a removable appliance, part icularly as buccal capping can be incorporat ed
t o f ree t he occlusion w it h t he low er arch. A screw t ype design is part icularly
usef ul in t he mixed dent it ion as t hen t he upper incisors can be ut ilized f or
ret ent ion of t he appliance (see Chapt er 16). Fixed appliances can also be
used t o advance t he upper labial segment and are usef ul w hen ot her f eat ures of
t he malocclusion dict at e t heir use.

Fig. 11.11. Mild Class III malocclusion that was treated


in the mixed dentition by proclination of the upper labial
segment with a removable appliance: (a) pretreatment;
(b) post-treatment.

(a)

(b)

11.4.3. Retroclination of the lower labial segment with


or without proclination of the upper labial segment
I n t hose cases w it h a mild t o moderat e Class I I I skelet al pat t ern, or w here t here
is a reduced overbit e, a combinat ion of ret roclinat ion of t he low er incisors and
proclinat ion of t he upper incisors w ill achieve correct ion of t he incisor
relat ionship (see Fig. 11. 8). Alt hough t he pit f alls of signif icant movement of t he
low er labial segment have been emphasized in earlier chapt ers, in t he correct ion
of Class I I I malocclusions t he posit ions of t he upper and low er incisors are
changed around w it hin t he zone of sof t t issue balance and, provided t hat t here is
an adequat e overbit e and f urt her grow t h is not unf avourable, t he correct ed
incisor relat ionship has a good chance of st abilit y. Alt hough removable and
f unct ional appliances can be used t o advance t he upper incisors and ret rocline
t he low er incisors, in pract ice t hese t oot h movement s are accomplished more
eff icient ly w it h f ixed appliances.

Fig. 11.12. (a) Forward growth rotation is the most


common pattern of mandibular growth. In a Class III
malocclusion this will lead to a worsening of the
skeletal pattern and the incisor relationship. (b) If a
Class III incisor relationship is corrected in the mixed
dentition, dento-alveolar compensation may help to
mask the effects of further growth provided that this is
not marked.

(a)

(b)

Space is required in t he low er arch f or ret roclinat ion of t he low er labial segment ,
and ext ract ions are required unless t he arch is spaced nat urally. Use of a round
archw ire in t he low er arch and a rect angular arch in t he upper arch along w it h
judicious space closure can be used t o help correct t he incisor relat ionship (Fig.
11. 13).
I nt ermaxillary Class I I I elast ic t ract ion (see Chapt er 15, Sect ion 15. 6. 1) f rom t he
low er labial segment t o t he upper molars (Fig. 11. 14) can also be used t o help
move t he upper arch f orw ards and t he low er arch backw ards, but care is
required t o avoid ext rusion of t he molars w hich w ill reduce overbit e.
Reverse-pull headgear, also know n as a f ace-mask (Fig. 11. 15), is used t o apply
an ant eriorly direct ed f orce, via elast ics, on t he maxillary t eet h and maxilla.
Alt hough some have claimed t hat t his appliance can change t he posit ion of t he
maxilla, a very cooperat ive pat ient is necessary in view of t he prolonged daily
w ear required, of t en over several years. Nevert heless, t his t echnique is
occasionally usef ul in t he management of Class I I I malocclusions, part icularly
t hose associat ed w it h a clef t lip and palat e anomaly, and also in cases of
hypodont ia w here f orw ard movement of t he buccal segment t eet h t o close space
is desirable.

Fig. 11.13. Correction of a Class III malocclusion by


retroclination of the lower incisors and proclination of
the upper incisors using fixed appliances with relief of
crowding by the extraction of all four first premolars: (a)
pretreatment; (b) fixed appliances in situ. (note the use
of rectangular archwire in the upper arch and a round
wire in the lower arch during space closure to help
achieve the desired movements); (c) post-treatment
result.

(a)
(b)

(c)

Fig. 11. 14. Class I I I int ermaxillary t ract ion.


Fig. 11. 15. Face-mask.

11.4.4. Surgery
I n some cases t he severit y of t he skelet al pat t ern and/ or t he presence of a
reduced overbit e or an ant erior open bit e precludes ort hodont ics alone, and
surgery is necessary t o correct t he underlying skelet al discrepancy. I t is
impossible t o produce hard and f ast guidelines as t o w hen t o choose surgery
rat her t han ort hodont ics, but it has been suggest ed t hat surgery is almost
alw ays required if t he value f or t he ANB angle is below 4° and t he inclinat ion of
t he low er incisors t o t he mandibular plane is less t han 83°. How ever, t he
cepahalomet ric f indings should be considered in conjunct ion w it h ot her f eat ures
of t he malocclusion and t he pat ient 's f acial appearance.
For t hose pat ient s w here ort hodont ic t reat ment w ill be challenging ow ing t o t he
severit y of t he skelet al pat t ern and/ or a lack of overbit e, a surgical approach
should be explored bef ore any permanent ext ract ions are carried out , and
pref erably bef ore any appliance t reat ment . The reason f or t his is t hat
management of Class I I I malocclusions by ort hodont ics alone involves dent o-
alveolar compensat ion f or t he underlying skelet al pat t ern. How ever, in order t o
achieve a sat isf act ory occlusal and f acial result w it h a surgical approach, any
dent o-alveolar compensat ion must f irst be removed or reduced (Fig. 11. 16). For
example, if

low er premolars are ext ract ed in an at t empt t o ret ract t he low er labial segment
but t his f ails and a surgical approach is subsequent ly necessary, t he presurgical
ort hodont ic phase w ill probably involve proclinat ion of t he incisors t o a more
average inclinat ion w it h reopening of t he ext ract ion spaces. This is a f rust rat ing
experience f or bot h pat ient and operat or.
Fig. 11.16. (a) Severe Class III malocclusion with
dento-alveolar compensation. (b) W ithout reduction of
the dento-alveolar compensation, surgery to produce a
Class I incisor relationship will only achieve a limited
correction of the underlying skeletal pattern, thus
constraining the overall aesthetic result. (c)
Decompensation of the incisors to bring them nearer to
their correct axial inclination allows a complete
correction of the underlying skeletal pattern.

(a)

(b)

(c)
Fig. 11.17. Patient treated with a combination of
orthodontics and bimaxillary orthognathic surgery: (a),
(b) pretreatment; (c), (d) post-treatment.

(a)

(b)

(c)
(d)

Some pat ient s w it h marked skelet al I I I malocclusions are unw illing t o w ear
appliances. Management by surgery alone is unsat isf act ory as t he result ing
occlusion is poor, and in addit ion a f ull correct ion of t he underlying skelet al
problem is not possible w it hout dent o-alveolar decompensat ion. Theref ore
pat ient s should be encouraged t o undergo t he appliance t herapy necessary f or
t he best result .
An example of a pat ient t reat ed by a combinat ion of ort hodont ics and surgery is
show n in Fig. 11. 17. Surgical approaches t o t he correct ion of Class I I I
malocclusions are considered in Chapt er 20.

PRINCIPAL SOURCES AND FURTHER READING


Bat t agel, J. M. (1993). Discriminant analysis: a model f or t he predict ion of
relapse in Class I I I children t reat ed ort hodont ically by a non-ext ract ion
t echnique. European Journal of O rthodonti cs, 15, 199 2 09.

Bat t agel, J. M. (1993). The aet iological f act ors in Class I I I malocclusion.
European Journal of O rthodonti cs, 15, 347 7 0.

Bat t agel, J. M. and O rt on, H. S. (1993). Class I I I malocclusion: t he post -


ret ent ion f indings f ollow ing a non-ext ract ion t reat ment approach. European
Journal of O rthodonti cs, 15, 45 5 5.

Bryant , P. M. F. (1981). Mandibular rot at ion and Class I I I malocclusion.


Bri ti sh Journal of O rthodonti cs, 8, 61 7 5.

This paper is w ort h reading f or t he int roduct ion alone, w hich cont ains a very
good discussion of grow t h rot at ions. The st udy it self looks at t he eff ect of
grow t h rot at ions and t reat ment upon Class I I I malocclusions.

Dibbet s, J. M. (1996). Morphological diff erences bet w een t he Angle classes.


European Journal of O rthodonti cs, 18, 111 1 8.
G ravely, J. F. (1984). A st udy of t he mandibular closure pat h in Angle Class
I I I relat ionship. Bri ti sh Journal of O rthodonti cs, 11, 85 9 1.

A very readable and clever art icle w hich examines t he displacement element of
Class I I I malocclusions.

Kerr, W. J. S. and Tenhave, T. R. (1988) A comparison of t hree appliance


syst ems in t he t reat ment of Class I I I malocclusion. European Journal of
O rthodonti cs, 10, 203 1 4.

Kerr, W. J. S. , Miller, S. , and Daw ber, J. E. (1992). Class I I I malocclusion:


surgery or ort hodont ics? Bri ti sh Journal of O rthodonti cs, 19, 21 4 .
An int erest ing st udy w hich compares t he pret reat ment lat eral cephalomet ric
radiographs of t w o groups of Class I I I cases t reat ed by eit her surgery or
ort hodont ics alone. The aut hors report t he t hresholds f or t hree cephalomet ric
values w hich w ould indicat e w hen surgery is required.

Kim, J. H. et al . (1999). The eff ect iveness of prot ract ion f ace mask t herapy: a
met aanalysis. Ameri can Journal of O rthodonti cs and Dentof aci al
O rthopedi cs, 115, 675 8 5.
Authors: Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> Table of C ontents > 12 - Anter ior open bite and pos ter ior open bite

12
Anterior open bite and posterior open bite

12.1. DEFINITIONS
Anterior open bite (AO B): t here is no vert ical overlap of t he incisors w hen
t he buccal segment t eet h are in occlusion (Fig. 12. 1).
Posterior open bite (PO B): w hen t he t eet h are in occlusion t here is a space
bet w een t he post erior t eet h (Fig. 12. 2).
Incomplete overbite: t he low er incisors do not occlude w it h t he upper
incisors or t he palat al mucosa (Fig. 12. 3). The overbit e may be decreased or
increased.

Fig. 12. 1. Ant erior open bit e.


Fig. 12. 2. Post erior open bit e.

Fig. 12. 3. I ncomplet e overbit e.

12.2. AETIOLOGY OF ANTERIOR OPEN BITE


I n common w it h ot her t ypes of malocclusion, bot h inherit ed and environment al
f act ors are implicat ed in t he aet iology of ant erior open bit e. These f act ors
include skelet al pat t ern, sof t t issues, habit s, and localized f ailure of
development . I n many cases t he aet iology is mult if act orial, and in pract ice it can
be diff icult t o det ermine t he relat ive roles of t hese inf luences as t he present ing
malocclusion is similar. How ever, a t horough hist ory and examinat ion, perhaps
w it h a period of observat ion, may be helpf ul.

12.2.1. Skeletal pattern


I ndividuals w it h a t endency t o vert ical rat her t han horizont al f acial grow t h exhibit
increased vert ical skelet al proport ions (see Chapt er 4). Where t he low er f ace
height is increased t here w ill be an increased int er-occlusal dist ance bet w een
t he maxilla and mandible. Alt hough t he labial segment t eet h appear t o be able t o
compensat e f or t his t o a limit ed ext ent by f urt her erupt ion, w here t he int er-
occlusal dist ance exceeds t his compensat ory abilit y an ant erior open bit e w ill
result . I f t he vert ical, dow nw ards, and backw ards, pat t ern of grow t h cont inues,
t he ant erior open bit e w ill become more marked.
I n t his group of pat ient s t he ant erior open bit e is usually symmet rical and in t he
more severe cases may ext end dist ally around t he arch so t hat only t he post erior
molars are in cont act w hen t he pat ient is in maximal int erdigit at ion (Fig. 12. 4).
The vert ical devlopment of t he labial segment s result s in t ypically ext ended
alveolar processes w hen view ed on a lat eral cephalomet ric radiograph (Fig.
12. 5).

Fig. 12. 4. Pat ient w it h increased vert ical skelet al proport ions and an ant erior
open bit e.
Fig. 12. 5. Lat eral cephalomet ric radiograph of a pat ient w it h a marked Class
I I division 1 malocclusion on a Class I I skelet al pat t ern w it h increased
vert ical skelet al proport ions. Not e t he t hin dent o-alveolar processes.

12.2.2. Soft tissue pattern


I n order t o be able t o sw allow it is necessary t o creat e an ant erior oral seal. I n
younger children t he lips are of t en incompet ent and a proport ion w ill achieve an
ant erior seal by posit ioning t heir t ongue f orw ard bet w een t he ant erior t eet h
during sw allow ing. I ndividuals w it h increased vert ical skelet al proport ions have
an increased likelihood of incompet ent lips and may cont inue t o achieve an
ant erior oral seal in t his manner even w hen t he sof t t issues have mat ured. This
t ype of sw allow ing pat t ern is also seen in pat ient s w it h an ant erior open bit e due
t o a digit -sucking habit (see Sect ion 12. 2. 3). I n t hese sit uat ions t he behaviour of
t he t ongue is adapt ive. An endogenous or primary t ongue t hrust is rare, but it is
diff icult t o dist inguish it f rom an adapt ive t ongue t hrust as t he occlusal f eat ures
are similar (Fig. 12. 6). How ever, it has been suggest ed t hat an endogenous
t ongue t hrust is associat ed w it h sigmat ism (lisping), and in some cases t he bot h
t he upper and low er incisors are proclined by t he act ion of t he t ongue.

Fig. 12. 6. Pat ient w it h an ant erior open bit e w hich w as believed t o be due t o
an endogenous t ongue t hrust . Despit e t he lips being compet ent , t he t ongue
w as t hrust f orw ard bet w een t he incisors during sw allow ing. Bot h upper and
low er incisors w ere proclined. The pat ient did not have a digit -sucking habit .

12.2.3. Habits
The eff ect s of a habit depend upon it s durat ion and int ensit y. I f a persist ent
digit -sucking habit cont inues int o t he mixed and permanent dent it ions, t his can
result in an ant erior open bit e due t o rest rict ion of development of t he incisors
by t he f inger or t humb (Fig. 12. 7). Charact erist ically, t he ant erior open bit e
produced is asymmet rical (unless t he pat ient sucks t w o f ingers) and it is of t en
associat ed w it h a post erior crossbit e. Const rict ion of t he upper arch is believed
t o be caused by cheek pressure and a low t ongue posit ion.
Af t er a sucking habit st ops t he open bit e t ends t o resolve, alt hough t his may
t ake several years. During t his period t he t ongue may come f orw ard during
sw allow ing t o achieve an ant erior seal. I n a small proport ion of cases w here t he
habit has cont inued unt il grow t h is complet e t he open bit e may persist .

12.2.4. Localized failure of development


This is seen in pat ient s w it h a clef t of t he lip and alveolus (Fig. 12. 8), alt hough
rarely it may occur f or no apparent reason.

12.2.5. Mouth breathing


I t has been suggest ed t hat t he open-mout h post ure adopt ed by individuals w ho
habit ually mout hbreat he, eit her due t o nasal obst ruct ion or habit , result s in

overdevelopment of t he buccal segment t eet h. This leads t o an increase in t he


height of t he low er t hird of t he f ace and consequent ly a great er incidence of
ant erior open bit e. I n support of t his it has been show n t hat pat ient s ref erred f or
t onsillect omy and adenoidect omy had signif icant ly increased low er f acial height s
compared w it h cont rols, and t hat post -operat ively t he disparit y bet w een t he t w o
groups diminished. How ever, t he diff erences demonst rat ed w ere small. O t her
w orkers have show n t hat children ref erred t o ear, nose, and t hroat clinics exhibit
t he same range of malocclusions as t he normal populat ion, and no relat ionship
has been demonst rat ed bet w een nasal airw ay resist ance and skelet al pat t ern in
normal individuals.
Fig. 12. 7. The occlusal eff ect s of a persist ent digit -sucking habit . Not e t he
ant erior open bit e and t he unilat eral post erior crossbit e.

Fig. 12. 8. A pat ient w it h a repaired clef t involving t he lip and palat e show ing
t ypical localized limit at ion of vert ical development in t he region of t he clef t
alveolus.

O n balance, it w ould appear t hat mout hbreat hing per se does not play a
signif icant role in t he development of ant erior open bit e in most pat ient s.

12.3. M ANAGEM ENT OF ANTERIOR OPEN BITE


Not w it hst anding t he diff icult ies f aced in det ermining aet iology, t reat ment of
ant erior open bit e is one of t he more challenging aspect s of ort hodont ics.
Management of an ant erior open bit e due purely t o a digit -sucking habit can be
st raight f orw ard, but w here t he skelet al pat t ern, grow t h, and/ or sof t t issue
environment are unf avourable, correct ion w it hout resort t o ort hognat hic surgery
may not be possible.
I n t he mixed dent it ion, a digit -sucking habit t hat has result ed in an ant erior open
bit e should be gent ly discouraged. I f a child is keen t o st op, a removable
appliance can be f it t ed t o act as a reminder. How ever, if t he child derives
support f rom his habit , f orcing him t o w ear an appliance t o discourage it is
unlikely t o be successf ul. Alt hough a number of barbaric designs have been
described (involving w ire project ions f or example), a simple plat e w it h a long
labial bow f or ant erior ret ent ion w ill usually suff ice if a habit -breaker is
indicat ed. Af t er f it t ing, t he acrylic behind t he upper incisors should be t rimmed t o
allow any spont aneous alignment . O nce t he permanent dent it ion is est ablished,
more act ive st eps can be t aken, alt hough t his can of t en be combined w it h
t reat ment f or ot her aspect s of t he malocclusion.
A period of observat ion may be helpf ul in t he management of pat ient s w it h an
ant erior open bit e w hich is not associat ed w it h a digit -sucking habit . I n some
cases an ant erior open bit e may reduce spont aneously, possibly because of
mat urat ion of t he sof t t issues and improved lip compet ence, or f avourable
grow t h.

Skelet al open bit es w it h increased vert ical proport ions are of t en associat ed w it h
a dow nw ard and backw ard rot at ion of t he mandible w it h grow t h. O bviously, if
grow t h is unf avourable, it is bet t er t o know t his bef ore planning t reat ment rat her
t han experiencing diff icult ies once t reat ment is under w ay.
Previously, it w as t hought t hat ext ract ing molars in cases w it h increased vert ical
skelet al proport ions w ould help t o c lose dow n t he bit e . How ever, t his w as not
based on scient if ic evidence.

12.3.1. Approaches to the management of anterior open


bite
There are t hree possible approaches t o management .

Acceptance of the anterior open bite


I n t his case t reat ment is aimed at relief of any crow ding and alignment of t he
arches. This approach can be considered in t he f ollow ing sit uat ions (part icularly
if t he AO B does not present a problem t o t he pat ient ):

mild cases;
w here t he sof t t issue environment is not f avourable, f or example w here t he
lips are markedly incompet ent and/ or an endogenous t ongue t hrust is
suspect ed;
in more marked malocclusions w here t he pat ient is not mot ivat ed t ow ards
surgery.
Orthodontic correction of the anterior open bite
I f grow t h and t he sof t t issue environment are f avourable, an ort hodont ic solut ion
t o t he ant erior open bit e can be considered. A caref ul assessment should be
carried out , including t he ant eropost erior and vert ical skelet al pat t ern, t he
f easibilit y of t he t oot h movement s required, and post -t reat ment st abilit y.
Ext rusion of t he incisors t o close an ant erior open bit e is inadvisable, as t he
condit ion w ill relapse once t he appliances are removed. Rat her, t reat ment should
aim t o t ry and int rude t he molars, or at least cont rol t heir vert ical development .
I nt rusion of t he molars can be at t empt ed w it h high-pull headgear and/ or by using
buccal capping on a removable appliance.
I n t he milder malocclusions t he use of high-pull headgear during convent ional
t reat ment may suff ice. I n cases w it h a more marked ant erior open bit e
associat ed w it h a Class I I skelet al pat t ern, a removable appliance or a f unct ional
appliance incorporat ing buccal blocks and high-pull headgear can be used t o t ry
t o rest rain vert ical maxillary grow t h. I n order t o achieve t rue grow t h modif icat ion
it is necessary t o apply an int rusive f orce t o t he maxilla f or at least 14 1 6 hours
per day during t he pubert al grow t h spurt , cont inuing unt il grow t h is complet e.
This is only achievable w it h excellent pat ient cooperat ion and f avourable grow t h.
The maxillary int rusion splint and t he buccal int rusion splint are removable
appliances w hich w ere developed by O rt on and are now w idely adopt ed. The
maxillary int rusion splint incorporat es acrylic coverage of all t he t eet h in t he
upper arch and high-pull headgear (Fig. 12. 9). The buccal int rusion splint is
similar, except t hat only t he buccal segment t eet h are capped. Funct ional
appliances used f or Class I I maloclusions w it h increased vert ical proport ions
include t he t w in-block appliance (Fig. 12. 10) and t he van Beek appliance (Fig.
12. 11). Bot h incorporat e high-pull headgear and buccal capping. I n many cases
f ixed appliances are t hen used t o complet e arch alignment , t oget her w it h
ext ract ions if indicat ed.
Fig. 12. 9. A pat ient w earing a maxillary int rusion splint and high-pull
headgear. The f ace-bow of t he headgear slot s int o t ubes embedded in t he
acrylic of t he occlusal capping, w hich ext ends t o cover all t he maxillary
t eet h.

Fig. 12. 10. Upper and low er t w in-blocks.


Fig. 12.11. (a) Intra-oral view of a van Beek appliance;
(b) extra-oral view showing the high-pull headgear; (c)
lateral cephalometric radiograph of the patient prior to
treatment; (d) lateral cephalometric radiograph of the
same patient 1 year later.

(a)

(b)

(c)
(d)

I n cases w it h bimaxillary crow ding and proclinat ion, relief of crow ding and
alignment of t he incisors can result in reduct ion of an open bit e (Fig. 12. 12).
St abilit y of t his correct ion is more likely if t he lips w ere incompet ent prior t o
t reat ment but become compet ent f ollow ing ret roclinat ion of t he incisors.
I f it is diff icult t o ascert ain t he exact aet iology of an ant erior open bit e but a
primary t ongue t hrust is suspect ed, even t hough t hese are uncommon, it is w ise
t o err on t he side of caut ion regarding t reat ment object ives and t o w arn pat ient s
of t he possibilit y of relapse.

Surgery
This opt ion can be considered once grow t h is complet e f or severe problems w it h
a skelet al aet iology and/ or w here dent al compensat ion w ill not give an aest het ic
or st able result . I n some pat ient s an ant erior open bit e is associat ed w it h a
g ummy smile w hich can be diff icult t o reduce by ort hodont ics alone necessit at ing
a surgical approach. The assessment and management of such cases is
discussed in Chapt er 20.

Fig. 12.12. Patient with an anterior open bite treated by


extraction of all four first premolars to relieve crowding
and fixed appliances: (a) pretreatment; (b) post-
retention.
(a)

(b)

12.3.2. Management of patients with increased vertical


skeletal proportions and reduced overbite
The specif ics of t reat ment of pat ient s w it h increased vert ical skelet al
proport ions w ill obviously be inf luenced by t he ot her aspect s of t heir
malocclusion (see appropriat e chapt ers), but management requires caref ul
planning t o t ry and prevent an iat rogenic det eriorat ion of t he vert ical excess. The
f ollow ing point s should be borne in mind:

Space closure appears t o occur more readily in pat ient s w it h increased


vert ical skelet al proport ions.
Avoid ext ruding t he molars as t his w ill result in an increase of t he low er
f acial height . I f headgear is required, a direct ion of pull above t he occlusal
plane is necessary, i. e. high-pull headgear. Cervical-pull headgear is
cont raindicat ed.
I f overbit e reduct ion is required, t his should be achieved by int rusion of t he
incisors rat her t han ext rusion of t he molars. For t his reason ant erior bit e-
planes should be avoided.
Avoid upper arch expansion. When t he upper arch is expanded t he upper
molars are t ilt ed buccally w hich result s in t he palat al cusps being t ipped
dow nw ards. I f arch expansion is required, t his is best achieved using a f ixed
appliance so t hat buccal root t orque can be used t o limit t ipping dow nw ards
of t he palat al cusps.
Avoid Class I I or Class I I I int ermaxillary t ract ion as t his may ext rude t he
molars.

12.4. POSTERIOR OPEN BITE


Post erior open bit e occurs more rarely t han ant erior open bit e and t he aet iology
is less w ell underst ood. I n some cases an increase in t he vert ical skelet al
proport ions is a f act or, alt hough t his is more commonly associat ed w it h an
ant erior open bit e w hich also ext ends post eriorly. A lat eral open bit e is
occasionally seen in associat ion w it h early ext ract ion of f irst permanent molars
(Fig. 12. 13), possibly occurring as a result of lat eral t ongue spread.

Fig. 12. 13. Post erior open bit e in a pat ient w ho had all f our f irst permanent
molars ext ract ed in t he mixed dent it ion.

Post erior open bit e is also seen in cases w it h submergence of buccal segment
t eet h. Submergence of deciduous molars is discussed in Chapt er 3. There are
t w o rare condit ions w hich aff ect t he erupt ion of t he permanent buccal segment
t eet h:

Primary failure of eruption: t his condit ion almost exclusively aff ect s molar
t eet h and is of unknow n aet iology. Alt hough bone resorpt ion above t he
unerupt ed t oot h proceeds normally, t he t oot h it self appears t o lack any
erupt ive pot ent ial (Fig. 12. 14). Ext ract ion is t he only t reat ment alt ernat ive.
The aet iology is not underst ood.

Arrest of eruption: t his also usually involves molar t eet h. Aff ect ed t eet h
appear t o erupt normally int o occlusion, but t hen subsequent ly f ail t o keep
pace w it h occlusal development . As grow t h of t he rest of t he dent it ion and
alveolar processes cont inues, lack of movement of t he aff ect ed t oot h or
t eet h result s in relat ive submergence (Fig. 12. 15). The aet iology is not
underst ood and again t he usual t reat ment is ext ract ion of t he aff ect ed t oot h
or t eet h.

Fig. 12. 14. DPT radiographs show ing f ailure of erupt ion of t he upper lef t f irst
permanent molar.
Fig. 12. 15. DPT radiograph show ing arrest of erupt ion of t he low er lef t f irst
permanent molar.

More rarely, post erior open bit e is seen in associat ion w it h unilat eral condylar
hyperplasia, w hich also result s in f acial asymmet ry. I f t his problem is suspect ed,
a bone scan w ill be required. I f t he scan indicat es excessive cell division in t he
condylar head region, a condylect omy alone, or in combinat ion w it h surgery t o
correct t he result ant def ormit y, may be required.

PRINCIPAL SOURCES AND FURTHER READING


Chat e, R. A. C. (1994). The burden of proof : a crit ical review of ort hodont ic
claims made by some general pract it ioners. Ameri can Journal of
O rthodonti cs and Dentof aci al O rthopedi cs, 106, 96 1 05.

An excellent discussion of t he evidence on t he post ulat ed and act ual eff ect s of
mout h breat hing upon t he dent it ion, plus much ot her inf ormat ion. Highly
recommended.

Di Biase, D. (1992). The management of open bit e. Dental Practi ce,


November, 11 1 4.
An excellent and very readable account of t he aet iology and management of
ant erior open bit e.

Linder-Aronson, S. (1970). Adenoids: t heir eff ect on mode of breat hing and
nasal airf low and t heir relat ionship t o charact erist ics of t he f acial skelet on
and dent it ion. Acta O tol aryngol ogi ca (Suppl ement), 265, 1.

Lopez-G avit o, G . , Wallen, T. R. , Lit t le, R. M. , and Joondeph, D. R. (1985).


Ant erior open-bit e malocclusion: a longit udinal 10-year post ret ent ion
evaluat ion of ort hodont ically t reat ed pat ient s. Ameri can Journal of
O rthodonti cs, 87, 175 8 6.

Mizrahi, E. (1978). A review of ant erior open bit e. Bri ti sh Journal of


O rthodonti cs, 5, 21 7 .
A w ort hy review.

O liver, R. G . (1980). Submerged permanent molars: f our case report s. Bri ti sh


Dental Journal, 160, 128 3 0.

The cases report ed are classif ied int o primary f ailure of erupt ion and arrest of
erupt ion. The management of t hese t w o condit ions is discussed.

O rt on, H. S. (1990). Functi onal appl i ances i n orthodonti c treatment.


Q uint essence Books, London.

A beaut if ully illust rat ed and inf ormat ive book. The maxillary and buccal
int rusion splint s are described.

Vaden, J. L. (1998). Non-surgical t reat ment of t he pat ient w it h vert ical


discrepancy. Ameri can Journal of O rthodonti cs and Dentof aci al O rthopedi cs,
113, 567 8 2.
Authors: Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> Table of C ontents > 13 - C r os s bites

13
Crossbites

13.1. DEFINITIONS
Crossbite: a discrepancy in t he buccolingual relat ionship of t he upper and
low er t eet h.

By convent ion t he t ransverse relat ionship of t he arches is described in t erms of


t he posit ion of t he low er t eet h relat ive t o t he upper t eet h.

Buccal crossbite: t he buccal cusps of t he low er t eet h occlude buccal t o t he


buccal cusps of t he upper t eet h (Fig. 13. 1).
Lingual crossbite: t he buccal cusps of t he low er t eet h occlude lingual t o t he
lingual cusps of t he upper t eet h. This is also know n as a scissors bite ( Fig.
13. 2).
Displacement: on closing f rom t he rest posit ion t he mandible encount ers a
def lect ing cont act (s) and is displaced t o t he lef t or t he right , and/ or
ant eriorly, int o maximum int erdigit at ion (Fig. 13. 3).

Fig. 13. 1. A buccal crossbit e.


Fig. 13. 2. A lingual (scissors) crossbit e.

13.2. AETIOLOGY
A variet y of f act ors act ing eit her singly or in combinat ion can lead t o t he
development of a crossbit e.

13.2.1. Local causes


The most common local cause is crow ding w here one or t w o t eet h are displaced
f rom t he arch. For example, a crossbit e of an upper lat eral incisor of t en arises
ow ing t o lack of space bet w een t he upper cent ral incisor and t he deciduous
canine, w hich f orces t he lat eral incisor t o erupt palat ally and in linguo-occlusion
w it h t he opposing t eet h. Post eriorly, early loss of a second deciduous molar in a
crow ded mout h may result in f orw ard movement of t he f irst permanent molar,
f orcing t he second premolar t o erupt palat ally. Also, ret ent ion of a primary t oot h
can def lect t he erupt ion of t he permanent successor leading t o a crossbit e.

Fig. 13. 3. Displacement on closure int o crossbit e.


13.2.2. Skeletal
G enerally, t he great er t he number of t eet h in crossbit e, t he great er is t he
skelet al component of t he aet iology. A crossbit e of t he buccal segment s may be
due purely t o a mismat ch in t he relat ive w idt h of t he arches, or t o an
ant eropost erior discrepancy, w hich result s in a w ider part of one arch occluding
w it h a narrow er part of t he opposing jaw. For t his reason buccal crossbit es of an
ent ire buccal segment are most commonly associat ed w it h Class I I I
malocclusions (Fig. 13. 4), and lingual crossbit es are associat ed w it h Class I I
malocclusions. Ant erior crossbit es are associat ed w it h Class I I I skelet al
pat t erns.

Fig. 13. 4. A Class I I I malocclusion w it h buccal crossbit e.

13.2.3. Soft tissues


A post erior crossbit e is of t en associat ed w it h a digit -sucking habit , as t he
posit ion of t he t ongue is low ered and a negat ive pressure is generat ed int ra-
orally.

13.2.4. Rarer causes


These include clef t lip and palat e, w here grow t h in t he w idt h of t he upper arch is
rest rained by t he scar t issue of t he clef t repair. Trauma t o, or pat hology of , t he
t emporomandibular joint s can lead t o rest rict ion of grow t h of t he mandible on
one side, leading t o asymmet ry.

13.3. TYPES OF CROSSBITE


13.3.1. Anterior crossbite
An ant erior crossbit e is present w hen one or more of t he upper incisors is in
linguo-occlusion (i. e. in reverse overjet ) relat ive t o t he low er arch (Fig. 13. 5).
Ant erior crossbit es involving only one or t w o incisors are considered in t his
chapt er, w hereas management of more t han t w o incisors in crossbit e is
considered in Chapt er 11 on Class I I I malocclusions. Ant erior crossbit es are
f requent ly associat ed w it h displacement on closure (see Fig. 13. 3).

Fig. 13.5. Correction of an anterior crossbite. Using a


removable appliance: (a) pretreatment. (note the
gingival recession of the lower incisor in crossbite); (b)
post-treatment.

(a)

(b)

13.3.2. Posterior crossbites


Crossbit es of t he premolar and molar region involving one or t w o t eet h or an
ent ire buccal segment can be subdivided as f ollow s.

Unilateral buccal crossbite w ith displacement


This t ype of crossbit e can aff ect only one or t w o t eet h per quadrant , or t he
w hole of t he buccal segment . When a single t oot h is aff ect ed, t he problem
usually arises because of t he displacement of one or bot h t eet h f rom t he arch,
leading t o a def lect ing cont act on closure int o t he crossbit e.
When t he w hole of t he buccal segment is involved, t he underlying aet iology is
usually t hat t he maxillary arch is of a similar w idt h t o t he mandibular arch (i. e. it
is t oo narrow ) w it h t he result t hat on closure f rom t he rest posit ion t he buccal
segment t eet h meet cusp t o cusp. I n order t o achieve a more comf ort able and
eff icient int ercuspat ion, t he pat ient displaces t heir mandible t o t he lef t or right
(see Chapt er 5, Fig. 5. 12). I t is of t en diff icult t o det ect t his displacement on

closure as t he pat ient soon learns t o close st raight int o t he posit ion of maximal
int erdigit at ion. This t ype of crossbit e may be associat ed w it h a cent reline shif t in
t he low er arch in t he direct ion of t he mandibular displacement (Fig. 13. 6).

Fig. 13. 6. A unilat eral crossbit e w it h associat ed cent reline shif t .

Fig. 13. 7. A bilat eral buccal crossbit e.

Unilateral buccal crossbite w ith no displacement


This cat egory of crossbit e is less common. I t can arise as a result of def lect ion
of t w o (or more) opposing t eet h during erupt ion, but t he great er t he number of
t eet h in a segment t hat are involved, t he great er is t he likelihood t hat t here is an
underlying skelet al asymmet ry.
Bilateral buccal crossbite
Bilat eral crossbit es (Fig. 13. 7) are more likely t o be associat ed w it h a skelet al
discrepancy, eit her in t he ant eropost erior or t ransverse dimension, or in bot h.

Unilateral lingual crossbite


This t ype of crossbit e is most commonly due t o displacement of an individual
t oot h as a result of crow ding or ret ent ion of t he deciduous predecessor.

Bilateral lingual crossbite (scissors bite)


Again, t his crossbit e is t ypically associat ed w it h an underlying skelet al
discrepancy, of t en a Class I I malocclusion w it h t he upper arch f urt her f orw ard
relat ive t o t he low er so t hat t he low er buccal t eet h occlude w it h a w ider segment
of t he upper arch.

13.4. M ANAGEM ENT


13.4.1. Rationale for treatment
Research has show n t hat displacing cont act s may predispose t ow ards
t emporomandibular joint dysf unct ion syndrome in a suscepti bl e individual (see
Chapt er 1, Sect ion 1. 7).

Theref ore a crossbit e associat ed w it h a displacement is a f unct ional indicat ion


f or ort hodont ic t reat ment . Similarly, t reat ment f or a bilat eral crossbit e w it hout
displacement should be approached w it h caut ion, as part ial relapse may result in
a unilat eral crossbit e w it h displacement . I n addit ion, a bilat eral crossbit e is
probably as eff icient f or chew ing as t he normal buccolingual relat ionship of t he
t eet h. How ever, t he same cannot be said of a lingual crossbit e w here t he cusps
of aff ect ed t eet h do not meet t oget her at all.
Ant erior crossbit es, as w ell as being f requent ly associat ed w it h displacement ,
can lead t o movement of a low er incisor labially t hrough t he labial support ing
t issues, result ing in gingival recession. I n t his case early t reat ment is advisable
(see Fig. 13. 5).

13.4.2. Treatment of anterior crossbite


The f ollow ing f act ors should be considered:

What t ype of movement is required? I f t ipping movement s w ill suff ice, a


removable appliance can be considered, how ever, if bodily or apical
movement is required t hen f ixed appliances are indicat ed.
How much overbit e is expect ed at t he end of t reat ment ? For t reat ment t o be
successf ul t here must be some overbit e present t o ret ain t he correct ed
incisor posit ion. How ever, w hen planning t reat ment it should be remembered
t hat proclinat ion of an upper incisor w ill result in a reduct ion of overbit e
compared w it h t he pret reat ment posit ion.
I s t here space available w it hin t he arch t o accommodat e t he t oot h/ t eet h t o
be moved? I f not , are ext ract ions required and if so w hich t eet h?
I s movement of t he opposing t oot h/ t eet h required? I f reciprocal movement is
required, a f ixed appliance is indicat ed.

Provided t hat t here is suff icient overbit e and t ilt ing movement s w ill suff ice,
t reat ment can of t en be accomplished w it h a removable appliance. The appliance
should incorporat e t he f ollow ing f eat ures:

good ant erior ret ent ion t o count eract t he displacing eff ect of t he act ive
element (w here t w o or more t eet h are t o be proclined, a screw appliance
may circumvent t his problem);
buccal capping just t hick enough t o f ree t he occlusion w it h t he opposing arch
(if t he overbit e is signif icant ly increased a f lat ant erior bit e-plane may be
ut ilized inst ead);
an act ive element , f or example a Z-spring (see Chapt er 16).
Fixed appliances are indicat ed in t he f ollow ing cases:
The apex of t he incisor in crossbit e is palat ally posit ioned.
I f t here w ill be insuff icient overbit e t o ret ain t he correct ed incisor(s),
considerat ion should be given t o using f ixed appliances t o move t he low er
incisor(s) lingually at t he same t ime as t he upper incisor(s) is moved labially
in order t o t ry and increase overbit e.
O t her f eat ures of a malocclusion necessit at e t he use of f ixed appliances
(Fig. 13. 8).

Fig. 13.8. A patient with a crossbite of the permanent


canines on the right side who was treated by extraction
of all four second premolars and fixed appliances: (a)
pretreatment; (b) fixed appliances; (c) post-treatment.
(a)

(b)

(c)

I f t he upper arch is crow ded, t he upper lat eral incisor of t en erupt s in a palat al
posit ion relat ive t o t he arch. I f t he lat eral incisor is markedly bodily displaced,

relief of crow ding by ext ract ion of t he displaced t oot h it self may somet imes be
an opt ion, but it is w ise t o seek a specialist opinion bef ore t aking t his st ep.

13.4.3. Treatment of posterior crossbite


I t is import ant t o consider t he aet iology of t his f eat ure bef ore embarking on
t reat ment . For example, is t he crossbit e due t o displacement of one t oot h f rom
t he arch, in w hich case correct ion w ill involve aligning t his t oot h, or is reciprocal
movement of t w o or more opposing t eet h required? Also, if t here is a skelet al
component , w ill it be possible t o compensat e f or t his by t oot h movement ? The
inclinat ion of t he aff ect ed t eet h should also be evaluat ed. Upper arch expansion
is more likely t o be st able if t he t eet h t o be moved w ere t ilt ed palat ally init ially.
As expansion w ill creat e addit ional space, it may be advisable t o def er a
decision regarding ext ract ions unt il af t er t he expansion phase has been
complet ed.
Even w hen f ixed appliances are used, expansion of t he upper buccal segment
t eet h w ill result in some t ipping dow n of t he palat al cusps (Fig. 13. 9). This has
t he eff ect of hinging t he mandible dow nw ards leading t o an increase in low er
f ace height , w hich may be undesirable in pat ient s w ho already have an increased
low er f acial height and/ or reduced overbit e. I f expansion is indicat ed in t hese
pat ient s, f ixed appliances are required t o apply buccal root t orque t o t he buccal
segment t eet h in order t o t ry and resist t his t endency, perhaps w it h high-pull
headgear as w ell.

Fig. 13. 9. Expansion of t he upper arch result s in t he palat al cusps of t he


buccal segment t eet h sw inging dow n occlusally.

Unilateral buccal crossbite


Where t his problem has arisen ow ing t o t he displacement of one t oot h f rom t he
arch, f or example an upper premolar t oot h w hich has been crow ded palat ally,
t reat ment w ill involve movement of t he displaced t oot h int o t he line of t he arch,
relieving crow ding w here and if necessary. I f t he displacement is marked,
considerat ion can be given t o ext ract ing t he displaced t oot h it self or using f ixed
appliances t o t ry and achieve bodily movement . Mild displacement of an upper
premolar palat ally can of t en be correct ed using a T-spring on a removable
appliance, but a screw t ype of appliance is pref erable if buccal movement of a
molar is required.
I f correct ion of a crossbit e requires movement of t he opposing t eet h in opposit e
direct ions, t his can be achieved by t he use of cross elast ics (Fig. 13. 10)
at t ached t o bands or bonded bracket s on t he t eet h involved. I f t his is t he only
f eat ure of a malocclusion requiring t reat ment , it is w ise t o leave t he at t achment s
i n si tu f ollow ing correct ion, st opping t he elast ics f or a mont h t o review w het her
t he correct ed posit ion is st able. I f t he crossbit e relapses, t he cross elast ics can
be re-inst it ut ed and an alt ernat ive means of ret ent ion considered.
Fig. 13. 10. Cross elast ics.

A unilat eral crossbit e involving all t he t eet h in t he buccal segment is usually


associat ed w it h a displacement , and t reat ment is direct ed t ow ards expanding t he
upper arch so t hat it f it s around t he low er arch at t he end of t reat ment . I f t he

upper buccal t eet h are not already t ilt ed buccally, t his can be accomplished w it h
an upper removable appliance incorporat ing a midline screw and buccal capping.
Alt ernat ively, a quadhelix appliance can be used (see below ). As a degree of
relapse can be ant icipat ed, some overexpansion of t he upper arch is advisable,
but not t o t he degree w here a lingual crossbit e or f enest rat ion of t he buccal
periodont al support result s. Ret ent ion should be cont inued f or approximat ely 3
mont hs f ull t ime f ollow ed by 3 mont hs night s only w it h t he removable appliance,
and t he quadhelix should be made passive and recement ed as a ret ainer f or 3 t o
6 mont hs.

Fig. 13. 11. Expansion of a repaired clef t maxilla w it h a quadhelix appliance.


Bilateral buccal crossbite
Unless t he upper buccal segment t eet h are t ilt ed palat ally t o a signif icant
degree, bilat eral buccal crossbit es are usually accept ed. Rapid maxillary
expansion can be used t o t ry and expand t he maxillary basal bone, but even w it h
t his t echnique a degree of relapse in t he buccopalat al t oot h posit ion occurs
f ollow ing t reat ment , w it h t he risk of development of a unilat eral crossbit e w it h
displacement .
Bilat eral buccal crossbit es are common in pat ient s w it h a repaired clef t of t he
palat e. Expansion of t he upper arch by st ret ching of t he scar t issue is of t en
indicat ed in t hese cases (see Chapt er 21) and is readily achieved using a
quadhelix appliance (Fig. 13. 11).

Lingual crossbite
I f a single t oot h is aff ect ed, t his is of t en t he result of displacement due t o
crow ding. I f ext ract ion of t he displaced t oot h it self is not indicat ed t o relieve
crow ding, t hen provided t hat space can be made available it is of t en possible t o
use an upper removable appliance t o f ree t he occlusion w it h t he low er arch and
move t he aff ect ed upper t oot h palat ally w it h a buccal spring. More severe cases
w it h a great er skelet al element usually need a combinat ion of buccal movement
of t he aff ect ed low er t eet h and palat al movement of t he upper t eet h w it h f ixed
appliances. Treat ment is not st raight f orw ard and should only be t ackled by t he
experienced ort hodont ist , part icularly as a scissors bit e w ill of t en dislodge f ixed
at t achment s on t he buccal aspect of t he low er t eet h unt il t he crossbit e is
eliminat ed.

Fig. 13. 12. A quadhelix appliance.

13.4.4. The quadhelix appliance


The quadhelix is a very eff icient f ixed slow expansion appliance (Fig. 13. 12). The
quadhelix appliance can also be adjust ed t o give more expansion ant eriorly or
post eriorly as required, and w hen act ive t reat ment is complet e it can be made
passive and recement ed t o act as a ret ainer.
A quadhelix is f abricat ed in 1 mm st ainless st eel w ire and at t ached t o t he t eet h
by bands cement ed t o a molar t oot h on each side. Pref ormed t ypes are available
w hich slot int o palat al at t achment s w elded ont o bands on t he molars and can be
readily removed by t he operat or f or adjust ment . How ever, t he appliance can also
be cust om-made in a laborat ory. The usual act ivat ion is about half a t oot h w idt h
each side. O verexpansion can occur readily if t he appliance is overact ivat ed, and
t heref ore it s use should be limit ed t o t hose w ho are experienced w it h f ixed
appliances.

Fig. 13. 13. A rapid maxillary expansion appliance being used t o expand a
repaired clef t maxilla.

13.4.5. Rapid maxillary expansion


This upper appliance incorporat es a screw similar t o t he t ype used f or expansion
in removable appliances except t hat it is soldered t o bands, usually t o bot h a
pre-molar and molar t oot h on bot h sides. The screw is t urned t w ice daily, usually

over an act ive t reat ment period of 2 w eeks (Fig. 13. 13). The large f orce
generat ed is designed t o open t he midline sut ure and expand t he upper arch by
skelet al expansion rat her t han by movement of t he t eet h. For t his reason it s use
is really limit ed t o pat ient s in t heir early t eens bef ore t he sut ure f uses, or clef t
palat e pat ient s w here it can be ut ilized t o expand t he clef t segment s by
st ret ching t he scar t issue.
O nce expansion is complet e t he appliance is lef t i n si tu as a ret ainer, usually f or
several mont hs. Bony inf ill of t he expanded sut ure has been demonst rat ed but on
removing t he appliance approximat ely 50 per cent relapse due t o sof t t issue
pressures can be ant icipat ed, and f or t his reason some overexpansion is
indicat ed.
This appliance should only be used by t he experienced.

13.5. CLINICAL EFFECTIVENESS


The management of post erior crossbit es is one of t he f ew areas in ort hodont ics,
w hich has been t he subject of a syst emat ic review. This process involves
st udying all t he available lit erat ure on a subject and select ing only t hose
randomized, cont rolled clinical t rails, w hich have been carried out t o t he highest
scient if ic st andards (w it h no bias, adequat e sample size, et c. ). Disappoint ingly,
only a f ew st udies w ere suit able f or inclusion. The aut hors concluded t hat
removal of premat ure cont act s of t he deciduous t eet h is eff ect ive in prevent ing a
post erior cross-bit e being perpet uat ed int o t he mixed dent it ion. I n t hose cases
w here it is not eff ect ive, an upper removable appliance can be used t o expand
t he upper arch t o reduce t he risk of t he crossbit e cont inuing int o t he permanent
dent it ion. The paucit y of good qualit y research in t his area meant t hat clear
recommendat ions could not be made regarding t reat ment in t he lat e mixed and
permanent dent it ion. This does not mean t hat t he management approaches
discussed above are w rong. I n f act t hey ref lect current ly accept ed good
pract ice, but f urt her st udies w it h appropriat e sample sizes and met hodology are
required.

PRINCIPAL SOURCES AND FURTHER READING


Birnie, D. J. and McNamara, T. G . (1980). The quadhelix appliance. Bri ti sh
Journal of O rthodonti cs, 7, 115 2 0.

The f abricat ion, management , and modif icat ions of t he quadhelix appliance are
described in t his paper.

Harrison, J. E. and Ashby, D. (1998). O rthodonti c treatment f or posteri or


crossbi tes (Cocrane Revi ew), The Cochrane Library, I ssue 4. Updat e
Sof t w are, O xf ord.
This is a syst emat ic review of t he eff ect iveness of diff erent t reat ment
modalit ies used in t he correct ion of a post erior crossbit e. Well w ort h t he t rouble
t aken t o f ind it (t ry t he Cochrane Collaborat ion on t he I nt ernet
ht t p: / / w w w. cochrane-oral. man. ac. uk)

Hermanson, H. , Kurol, J. , and Ronnerman, A. (1985). Treat ment of unilat eral


post erior crossbit es w it h quadhelix and removable plat es. A ret rospect ive
st udy. European Journal of O rthodonti cs, 7, 97 1 02.
I n t his st udy it w as f ound t hat t he clinical result s achieved w ere similar w it h
t he t w o t ypes of appliance. How ever, t he number of visit s and chairside t ime
w ere great er f or t he removable appliance. The aut hors calculat ed t hat t he mean
cost of t reat ment w as 40 per cent great er f or t he removable appliance compared
w it h t he quadhelix.

Linder-Aronson, S. and Lindgren, J. (1979). The skelet al and dent al eff ect s of
rapid maxillary expansion. Bri ti sh Journal of O rthodonti cs, 6, 25 9 .
Authors: Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> Table of C ontents > 14 - C anines

14
Canines

14.1. FACTS AND FIGURES


Development of t he upper and low er canines commences bet w een 4 and 5
mont hs of age. The upper canines erupt , on average, at 11 1 2 years of age. The
low er canines erupt , on average, at 10 11 years of age.
I n a Caucasian populat ion (G orlin et al . 1990 ): congenit al absence of upper
canines, 0. 3 per cent ; congenit al absence of low er canines, 0. 1 per cent ;
impact ion of upper canines, 1 2 per cent , of w hich 8 per cent are bilat eral;
impact ion of low er canines, 0. 35 per cent ; resorpt ion of upper incisors due t o
impact ed canine, 0. 7 per cent of 10 1 3 year olds; t ransposit ion, exact prevalence
not know n (rare).

14.2. NORM AL DEVELOPM ENT


The development of t he maxillary canine commences around 4 t o 5 mont hs of
age, high in t he maxilla. Crow n calcif iat ion is complet e around 6 t o 7 years of
age. The permanent canine t hen migrat es f orw ards and dow nw ards t o lie buccal
and mesial t o t he apex of t he deciduous canine bef ore erupt ing dow n t he dist al
aspect of t he root of t he upper lat eral incisor. Pressure f rom t he unerupt ed
canine on t he root of t he lat eral incisor leads t o f laring of t he incisor crow ns,
w hich resolves as t he canine erupt s.

14.3. AETIOLOGY OF M AXILLARY CANINE


DISPLACEM ENT
Canine displacement is generally classif ied int o buccal or palat al displacement .
More rarely, canines can be f ound lying horizont ally above t he apices of t he
t eet h of t he upper arch (Fig. 14. 1) or displaced high adjacent t o t he nose (Fig.
14. 2).
Fig. 14. 1. Horizont ally displaced maxillary canines.

Fig. 14. 2. Severely displaced maxillary canine.

The f ollow ing have been suggest ed as possible causat ive f act ors. How ever, t he
aet iology of canine displacement is st ill not f ully underst ood.

Displacement of the crypt. This is t he probable aet iology behind t he more


marked displacement s such as t hose show n in Figs 14. 1 and 14. 2.
Long path of eruption.
Short-rooted or absent upper lateral incisor. A 2. 4-f old increase in t he
incidence of palat ally displaced canines in pat ient s w it h absent or short -
root ed lat eral incisors has been report ed (Becker et al. 1981) (Fig. 14. 3). I t
has been suggest ed t hat a lack of guidance during erupt ion is t he reason
behind t his associat ion. Because of t he associat ion of palat al displacement
of an upper canine w it h missing or peg-shaped lat eral incisors it is import ant
t o be part icularly observant in pat ient s w it h t his anomaly.
Crowding. Jacoby (1983) f ound t hat 85 per cent of buccally displaced
canines w ere associat ed w it h crow ding, w hereas 83 per cent of palat al
displacement s had suff icient space f or erupt ion. I f t he upper arch is
crow ded, t his of t en manif est s as insuff icient space f or t he canine, w hich is
t he last t oot h ant erior t o t he molar t o erupt . I n normal development t he
canine comes t o lie buccal t o t he arch and in t he presence of crow ding w ill
be def lect ed buccally.
Retention of the primary deciduous canine. This usually result s in mild
displacement of t he permanent t oot h buccally. How ever, if t he permanent
canine it self is displaced, normal resorpt ion of t he deciduous canine w ill not
occur. I n t his sit uat ion t he ret ained deciduous t oot h is an indicat or, rat her
t han t he cause, of displacement .
G enetic factors. I t has been suggest ed t hat palat al displacement of t he
maxillary canine is an inherit ed t rait w it h a pat t ern t hat suggest s polygenic
inherit ance. The evidence cit ed f or t his includes:
a. t he prevalence varies in diff erent populat ions w it h a great er prevalence
in Europeans t han ot her racial groups;
b. aff ect s f emales more commonly t han males;
c. f amilial occurrence;
d. occurs bilat erally w it h a great er t han expect ed f requency;
e. occurs in associat ion w it h ot her dent al anomalies (e. g. hypodont ia,
microdont ia).
Fig. 14. 3. DPT radiograph of pat ient w it h an absent upper right lat eral
incisor, a peg-shaped upper lef t lat eral incisor, and displaced maxillary
canines.

14.4. INTERCEPTION OF DISPLACED CANINES


Because of t heir high propensit y f or ect opic erupt ion, it is essent ial t o palpat e
f or unerupt ed canines w hen examining any child aged 9 years and older, as early
det ect ion of an abnormal erupt ion pat h gives t he opport unit y, if appropriat e, f or
int ercept ive measures. I t is also import ant t o locat e t he posit ion of t he canines
bef ore undert aking t he ext ract ion of ot her permanent t eet h. Canines, w hich are
palpable in t he normal development al post ion, buccal and slight ly dist al t o t he
upper lat eral incisor root , have a good prognosis f or erupt ion.
Clinically, if a def init e hollow and/ or asymmet ry is f ound on palpat ion, f urt her
invest igat ion is w arrant ed. O n occasion, rout ine panoramic radiographic
examinat ion may demonst rat e asymmet ry in t he posit ion and development of t he
canines.

Fig. 14. 4. DPT radiographs of a pat ient w hose displaced maxillary


permanent canines improved f ollow ing t he ext ract ion of t he upper deciduous
canines.

I t has been show n t hat ext ract ion of a deciduous canine may result in
improvement of t he posit ion of a displaced permanent canine, suff icient t o allow
normal erupt ion t o occur (Fig. 14. 4). As t he success of t his approach reduces
w it h t he degree of displacement it is advisable t o seek t he advice of a specialist
bef ore t his st ep is undert aken in t hose cases w here t he canine is markedly
displaced. The likelihood of t he displaced canine posit ion improving is also
reduced in cases w it h crow ding. I t is prudent t o w arn t he pat ient and t heir
guardian t hat it may be necessary t o expose t he unerupt ed t oot h and apply
t ract ion via an ort hodont ic appliance. This int ercept ive approach has also been
used successf ully f or displaced mandibular canines.

14.5. ASSESSING M AXILLARY CANINE POSITION


The posit ion of an unerupt ed canine should init ially be assessed clinically,
f ollow ed by radiographic examinat ion if displacement is suspect ed.

Clinically
I t is usually possible t o obt ain a good est imat e of t he likely locat ion of an
unerupt ed maxillary canine by palpat ion (in t he buccal sulcus and palat ally) and
by t he inclinat ion of t he lat eral incisor (Fig. 14. 5).

Fig. 14.5. (a) Patient aged 9 years showing distal


inclination of the upper lateral incisor caused by the
position of the unerupted canine; (b) the same patient
aged 13 years showing the improvement that has
occurred in the inclination of the lateral incisor
following eruption of the permanent canine.

(a)
(b)

Radiographically
The radiographic assessment of a displaced canine should include t he f ollow ing:

locat ion of t he posit ion of bot h t he canine crow n and t he root apex relat ive t o
adjacent t eet h and t he arch;
t he prognosis of adjacent t eet h and t he deciduous canine, if present ;

t he presence of resorpt ion, part icularly of t he adjacent cent ral and/ or lat eral
incisors.
The view s commonly used f or assessing ect opic canines include t he
f ollow ing.
Dental panoramic tomogram (DPT), also know n as an O PG or O PT. This
f ilm gives a good overall assessment of t he development of t he dent it ion and
canine posit ion. How ever, t his view suggest s t hat t he canine is f urt her aw ay
f rom t he midline and at a slight ly less acut e angle t o t he occlusal plane, i. e.
more f avourably posit ioned f or alignment , t han is act ually t he case (Fig.
14. 6(a)). This view should be supplement ed w it h a periapical view.
Periapical. This view is usef ul f or assessing t he prognosis of a ret ained
deciduous canine and f or det ect ing resorpt ion (Fig. 14. 6(b)).
Lateral cephalometric. For accurat e localizat ion t his view should be
combined w it h an ant eropost erior view (e. g. a DPT) (Fig. 14. 6(c)).
Vertex occlusal. This view is popular w it h oral surgeons, but involves a
relat ively high X-ray dose and irradiat ion of t he orbit .

The principle of parallax can be used t o det ermine t he posit ion of an unerupt ed
t oot h relat ive t o it s neighbours. To use parallax t w o radiographs are required
w it h a change in t he posit ion of t he X-ray t ube bet w een t hem. The object f urt hest
aw ay f rom t he X-ray beam w ill appear t o move in t he same direct ion as t he t ube
shif t . Theref ore, if t he canine is more palat ally posit ioned t han t he incisor root s
it w ill move w it h t he t ube shif t (Fig. 14. 6 (b)). Conversely, if it is buccal it w ill
move in t he opposit e direct ion t o t he t ube shif t . Examples of combinat ions of
radiographs w hich can be used f or parallax include t w o periapical radiographs
(horizont al parallax) and a DPT and an upper ant erior occlusal (vert ical parallax).

14.6. M ANAGEM ENT OF BUCCAL DISPLACEM ENT


The w idt h of t he maxillary canine is great er t han t he f irst premolar w hich in t urn
is great er t han t he deciduous canine.
Buccal displacement is usually associat ed w it h crow ding, and t heref ore relief of
crow ding prior t o erupt ion of t he canine w ill usually eff ect some spont aneous
improvement (Fig. 14. 7). Buccal displacement s are more likely t o erupt t han
palat al displacement s because of t he t hinner buccal mucosa and bone. Buccally
displaced erupt ed canines are managed by relief of crow ding, if indicat ed, and
alignment . An upper removable appliance w it h a buccal canine ret ract or can be
used w here t he canine t oot h is mildly displaced, mesially inclined and t ilt ing
movement s w ill suff ice. Fixed appliances are indicat ed if t he canine is upright or
dist ally inclined and/ or rot at ed. I n such a case a sect ional f ixed appliance on t he
buccal segment t eet h in t hat quadrant and t he aff ect ed canine only may be
usef ul t o prevent r ound-t ripping t he upper lat eral incisor.
I n severely crow ded cases w here t he upper lat eral incisor and f irst premolar are
in cont act and no addit ional space exist s t o accommodat e t he w ider canine
t oot h, ext ract ion of t he canine it self may be indicat ed. I n some pat ient s t he
canine is so severely displaced t hat a good result is unlikely, necessit at ing
removal of t he canine t oot h and t he use of f ixed appliances t o close any residual
spacing.
More rarely a buccally displaced canine t oot h does not erupt or it s erupt ion is so
delayed t hat t reat ment f or ot her aspect s of t he malocclusion is compromised. I n
t hese sit uat ions exposure of t he impact ed t oot h may be indicat ed. To ensure an
adequat e w idt h of at t ached gingiva eit her an apically reposit ioned or, pref erably,
a replaced f lap should be used. I n order t o be able t o apply t ract ion t o align t he
canine, eit her an at t achment can be bonded or a band cement ed t o t he t oot h at
t he t ime of surgery. A gold chain or a st ainless st eel ligat ure can be at t ached t o
t he bond or band and used t o apply t ract ion.

Fig. 14.6. The radiographs of a patient with displaced


maxillary canines (note that the upper right lateral
incisor is absent and the upper left lateral incisor is
peg-shaped): (a) DPT radiograph; (b) periapical
radiographs (note that both maxillary canines are
palatally positioned as their position changes in the
same direction as the tube shift); (c) lateral
cephalometric radiograph.

(a)

(b)
(c)

Fig. 14. 7. Mildly buccally displaced maxillary canine w hich erupt ed


spont aneously int o a sat isf act ory posit ion f ollow ing relief of crow ding.

14.7 M ANAGEM ENT OF PALATAL DISPLACEM ENT


14.7.1. Factors affecting treatment decision
Pat ient 's opinion of appearance and mot ivat ion t ow ards ort hodont ic
t reat ment .
Presence of spacing/ crow ding.
Posit ion of displaced canine: is it w it hin range of ort hodont ic alignment ?
Malocclusion.
Condit ion of ret ained deciduous canine, if present .
Condit ion of adjacent t eet h.

14.7.2. Treatment options


Surgical removal of canine
This opt ion can be considered under t he f ollow ing condit ions:

The ret ained deciduous canine has an accept able appearance and t he pat ient
is happy w it h t he aest het ics and/ or reluct ant t o embark on more complicat ed
t reat ment (Fig. 14. 8). The clinician must ensure t hat t he pat ient underst ands
t hat t he primary canine w ill be lost event ually and a prost het ic replacement
required. How ever, if t he occlusion is unf avourable, f or example a deep and
increased overbit e is present , t his may aff ect t he f easibilit y of bridgew ork
lat er, necessit at ing t he explorat ion of alt ernat ive opt ions.
The upper arch is very crow ded and t he upper f irst premolar is adjacent t o
t he upper lat eral incisor. Provided t hat t he f irst premolar is not
mesiopalat ally rot at ed, t he aest het ic result can be accept able (Fig. 14. 9).
The canine is severely displaced. Depending upon t he presence of crow ding
and t he pat ient 's w ishes, eit her any residual spacing can be closed by
f orw ard movement of t he upper buccal segment s w it h f ixed appliances, or a
prost het ic replacement can be considered.

Fig. 14. 8. This pat ient decided t hat t he appearance of her ret ained
deciduous canine w as sat isf act ory and elect ed t o have her unerupt ed
displaced maxillary canine removed.
Fig. 14. 9. Aest het ic result f ollow ing removal of t he displaced upper lef t
permanent canine.

I f space closure is not planned, it may be pref erable t o keep t he unerupt ed


canine under biannual radiographic observat ion unt il t he f at e of t he t hird molars
is decided. How ever, if any pat hology, f or example resorpt ion of adjacent t eet h
or cyst f ormat ion, int ervenes, removal should be arranged as soon as possible.

Surgical exposure and orthodontic alignment


I ndicat ions are as f ollow s:

w ell-mot ivat ed pat ient


w ell-cared-f or dent it ion
f avourable canine posit ion
space available (or can be creat ed).

Whet her ort hodont ic alignment is f easible or not depends upon t he t hree-
dimensional posit ion of t he unerupt ed canine:

Height. The higher a canine is posit ioned relat ive t o t he occlusal plane t he
poorer is t he prognosis. I n addit ion, t he access f or surgical exposure w ill be
more rest rict ed. I f t he crow n t ip is at or above t he apical t hird of t he incisor
root s, ort hodont ic alignment w ill be very diff icult .

Anteroposterior position. The nearer t he canine crow n is t o t he midline, t he


more diff icult alignment w ill be. Most operat ors regard canines, w hich are
more t han half w ay across t he upper cent ral incisor t o be out side t he limit s of
ort hodont ics.
Position of the apex. The f urt her aw ay t he canine apex is f rom normal, t he
poorer is t he prognosis f or successf ul alignment . I f it is dist al t o t he second
premolar, ot her opt ions should be considered.
Inclination. The smaller t he angle w it h t he occlusal plane t he great er is t he
need f or t ract ion.

I f t hese f act ors are f avourable, t he usual sequence of t reat ment is as f ollow s:

1. Make space available (alt hough some operat ors are reluct ant t o embark on
permanent ext ract ions unt il af t er t he t oot h has been exposed and t ract ion
successf ully st art ed).
2. Arrange exposure.
3. Allow t he t oot h t o erupt f or 2 t o 3 mont hs.
4. Commence t ract ion.

Wit h deeply buried canines t here is a danger t hat t he gingivae may cover t he
t oot h again. I f t his is likely t o be a problem, eit her an at t achment plus t he means
of t ract ion (f or example a w ire ligat ure or gold chain) can be bonded t o t he t oot h
at t he t ime of exposure or about 2 days af t er pack removal.
Tract ion can be applied using eit her a removable appliance (Fig. 14. 10) or a
f ixed appliance (Fig. 14. 11). To complet e alignment a f ixed appliance is
necessary, as movement of t he root apex buccally is required t o complet e
posit ioning of t he canine int o a f unct ional relat ionship w it h t he low er arch.

Fig. 14. 10. Tract ion applied t o an exposed canine using a removable
appliance.
Fig. 14. 11. A f ixed appliance being used t o move an exposed canine t ow ards
t he line of t he arch.

Transplantation
Most ort hodont ist s w ould agree t hat t his opt ion is best conf ined t o t hose cases
w here t here is no ot her alt ernat ive. I f t ransplant at ion is at t empt ed, it must be
possible t o remove t he canine int act and t here must be space available t o
accommodat e t he canine w it hin t he arch and occlusion. I n some cases t his w ill
mean t hat some ort hodont ic t reat ment w ill be required prior t o t ransplant at ion.
The main causes of f ailure of t ransplant ed canines are replacement resorpt ion
and inf lammat ory resorpt ion. Replacement resorpt ion, or ankylosis, occurs w hen
t he root surf ace is damaged during t he surgical procedure, and is promot ed by
rigid splint ing of t he t ransplant ed t oot h, w hich encourages healing by bony rat her
t han f ibrous union. Caref ul handling of t he root surf ace and prevent ion of
desiccat ion during surgery, f ollow ed by a met hod of splint ing w hich allow s
f unct ional movement of t he canine during t he immediat e post -surgical phase, is
now recommended. This can be achieved by use of an acid-et ch composit e splint
f or 1 t o 2 w eeks. Alt ernat ively, a f ixed appliance w it h a bracket on t he canine
can be employed, and is most suit able if space has t o be creat ed prior t o
t ransplant at ion.
I nf lammat ory resorpt ion f ollow s deat h of t he pulpal t issues, and f or t his reason
early pulp ext irpat ion has been advocat ed by some aut hors.
Despit e a bet t er underst anding of t he f act ors leading t o f ailure w it h
t ransplant at ion, t he long-t erm survival rat es are not good in pract ice. The
prognosis is improved if t ransplant at ion can be accomplished bef ore root is 75
per cent f ormed. How ever, as t his st age is reached around 12 years of age,
early det ect ion and planning is required t o accomplish t his.

14.8. RESORPTION
Unerupt ed and impact ed canines can cause resorpt ion of adjacent lat eral incisor
root s and may somet imes progress t o cause resorpt ion of t he cent ral incisor.
St udies have indicat ed t hat incisor resorpt ion is more common in f emales t han
males. Also, if t he angulat ion of an ect opic canine t o t he midline on a DPT is
great er t han 25° t hen t he risk increases by 50 per cent .
Sw if t int ervent ion is essent ial, as resorpt ion of t en proceeds at a rapid rat e. I f it
is discovered on radiographic examinat ion, specialist advice should be sought
quickly. Ext ract ion of t he canine may be necessary t o halt t he resorpt ion.
How ever, if t he resorpt ion is severe it may be w iser t o ext ract t he aff ect ed
incisor(s), t hus allow ing t he canine t o erupt (Fig. 14. 12).

Fig. 14.12. (a) Resorption of the upper right lateral


incisor by an unerupted maxillary canine; (b) following
extraction of the lateral incisor the canine erupted
adjacent to the central incisor.

(a)

(b)
14.9. TRANSPOSITION
Transposit ion is t he t erm used t o describe int erchange in t he posit ion of t w o
t eet h. This anomaly is comparat ively rare, but almost alw ays aff ect s t he canine
t oot h. I t aff ect s t he sexes equally and is more common in t he maxilla. I n t he
upper arch t he canine and t he f irst premolar are most commonly involved;
how ever, t ransposit ion of t he canine and lat eral incisor is also seen (Fig. 14. 13).
I n t he mandible t he canine and lat eral incisor appear t o be almost exclusively
aff ect ed. The aet iology of t his condit ion is not underst ood.

Management depends upon w het her t he t ransposit ion is complet e (i. e. apical
t ransposit ion is evident ) or part ial, t he malocclusion, and t he presence or
absence of crow ding. Possible t reat ment opt ions include accept ance (part icularly
if t ransposit ion is complet e), ext ract ion of t he most displaced t oot h if t he arch is
crow ded, or ort hodont ic alignment . I n t he last case, t he relat ive posit ions of t he
root apices w ill be a major f act or in deciding w het her t he aff ect ed t eet h are
correct ed or aligned in t heir t ransposed arrangement .

Fig. 14. 13. Transposit ion of t he upper lef t maxillary canine and lat eral
incisor.

PRINCIPAL SOURCES AND FURTHER READING


Becker, A. , Smit h, P. , and Behar, R. (1981). The incidence of anomalous
maxillary lat eral incisors in relat ion t o palat ally-displaced cuspids. Angl e
O rthodonti st, 51, 24 9 .
The aet iology and management of displaced maxillary canines are considered
in t his very t horough paper.

Edmunds, D. H. and Beck, C. (1989). Root resorpt ion in aut ot ransplant ed


maxillary canine t eet h. Internati onal Endodonti c Journal, 22, 29 3 8.
The f act ors t hat lead t o root resorpt ion, and met hods of reducing t his sequela,
are discussed.

Ericson, S. and Kurol, J. (1986). Longit udinal st udy and analysis of clinical
supervision of maxillary canine erupt ion. Communi ty Denti stry and O ral
Epi demi ol ogy, 14, 172 6 .

Ericson, S. and Kurol, J. (1988). Early t reat ment of palat ally erupt ing
maxillary canines by ext ract ion of t he primary canines. European Journal of
O rthodonti cs, 10, 283 9 5.

The f irst scient if ic evaluat ion of t he w idely held belief t hat ext ract ion of a
deciduous canine could improve t he posit ion of a displaced successor w as given
in t his import ant paper.

G orlin, R. J. , Cohen, M. M. , and Levin, L. S. (1990). Syndromes of the head


and neck (3rd edn). O xf ord Universit y Press. , O xf ord.

This excellent ref erence book includes, amongst a w ealt h of ot her inf ormat ion,
dat a on t he development and incidence of canine anomalies.

Jacoby, H. (1983). The et iology of maxillary canine impact ions. Ameri can
Journal of O rthodonti cs, 84, 125 3 2.

Evidence t hat leads t he aut hors t o conclude t hat palat al and buccal
displacement s have diff ering aet iologies is present ed in t his paper.

McSherry, P. F. (1998). The ect opic maxillary canine: A review. Bri ti sh Journal
of O rthodonti cs, 25, 209 1 6.
G ood review art icle in w hich t he opt ions f or management of displaced canines
are discussed.

Peck, S. M. , Peck, L. and Kat aja, M. (1994). The palat ally displaced canine
as a dent al anomaly of genet ic origin. Angl e O rthodonti st, 64, 249 5 6.
Authors: Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> Table of C ontents > 15 - Anc hor age, tooth m ovem ent, and r etention ( B . D oubleday)

15
Anchorage, tooth movement, and retention (B.
Doubleday)

15.1. WHAT IS ANCHORAGE AND WHY IS IT


IM PORTANT?
Anchorage has been def ined as t he source of resist ance t o t he f orces generat ed
in react ion t o t he act ive component s of an appliance. Anchorage is required t o
prevent unw ant ed t oot h movement s.
Anchorage is a diff icult concept t o grasp, but it may be helpf ul t o consider it
init ially as t he balance bet w een t he applied f orce and t he available space.
Whenever t oot h movement is at t empt ed t here w ill be an equal and opposit e
react ion t o t he f orce(s) applied by t he act ive component s (New t on's t hird law of
mot ion). This react ion f orce is spread over t he t eet h w hich are cont act ed by t he
appliance. For example, if bot h upper canines are being ret ract ed w it h an upper
f ixed appliance, w hich has at t achment s on all t he erupt ed t eet h, an equal and
opposit e f orce t o t hat being generat ed by t he act ive canine ret ract ion w ill also
be act ing on t he remaining upper arch t eet h w hich comprise t he anchorage or
resist ance t o t hat movement (Fig. 15. 1). The amount of f orw ard movement of t he
anchor t eet h w ill depend upon t heir root surf ace area and t he f orce applied (see
Sect ion 15. 4). How ever, anchorage is not merely an ant eropost erior phenomenon
unw ant ed t oot h movement s can also occur in t he vert ical and t ransverse
dimensions.
Fig. 15. 1. Diagram show ing t he eff ect upon t he anchor t eet h of ret ract ing
upper canines w it h a f ixed appliance.

The import ance of anchorage is perhaps most keenly appreciat ed w hen it has
been neglect ed. Anchorage loss may jeopardize a successf ul result because
inappropriat e movement of t he anchor t eet h result s in insuff icient space
remaining t o achieve t he int ended t oot h movement s. I n some cases anchorage
loss can result in a w orsening of t he occlusion, f or example, during t he canine
ret ract ion phase of appliance t reat ment f or a Class I I malocclusion, f orw ard
movement of t he anchor t eet h can result in an increase in overjet . How ever, in
some sit uat ions loss of anchorage can be used t o advant age, f or example, in a
class Class I I I malcclusion an increase in overjet can be advant ageous.
Theref ore anchorage requirement s need t o be assessed at t he t ime of t reat ment
planning.

15.2. THE HISTOLOGICAL BASIS OF TOOTH


M OVEM ENT
When a point f orce is applied t o t he crow n of a t oot h, it w ill t ilt around an axis
approximat ely at t he junct ion of t he apical one-t hird and t he coronal t w o-t hirds of
t he root (how ever, t his is variable depending upon t he size of t he f orce and local
anat omy). As a result t he f orce is concent rat ed at t he coronal one-t hird of t he
socket w all in t he direct ion of t he f orce and at t he root apex in t he opposit e
direct ion, as show n in Fig. 15. 2.

Fig. 15. 2. Diagram show ing t he eff ect of a t ipping f orce applied t o t he crow n
of a t oot h (P = pressure T = t ension).

When an opt imal f orce is applied, cell prolif erat ion occurs w it hin t he periodont al
ligament in areas of compression and ost eoclast s (bone-resorbing cells)

migrat e in f rom t he surrounding blood vessels. Direct resorpt ion of t he bone of


t he socket w all adjacent t o t he areas of pressure t akes place w it hin a f ew days.
O n t he t ension side t he periodont al f ibres are st ret ched, and prolif erat ion of
f ibroblast s and ost eoblast s (bone-f orming cells) is f ollow ed by an increase in t he
lengt h of t he periodont al f ibres w hich are subsequent ly remodelled. O st eoid is
deposit ed on t he bony socket w all on t he t ension side and is t hen calcif ied t o
f orm w oven bone, w hich in t urn is remodelled int o mat ure bone. Thus t he t oot h
moves t hrough t he alveolar bone under t he inf luence of an applied f orce (see
Table 15. 1).
As t hese changes are mediat ed by cells derived f rom t he blood supply, t he lat t er
is an import ant prerequisit e f or t oot h movement t o occur. Theref ore a f orce
w hich exceeds capillary pressure and reduces blood f low w ill not produce
opt imal movement .
I f an excessive f orce is applied cont inuously, direct resorpt ion of bone does not
t ake place because compression of t he blood vessels w it hin t he periodont al
ligament result s in a st erile necrosis (know n as hyalinizat ion because of it s
homogeneous, glass-like microscopic appearance) and init ially a cessat ion of
movement . Af t er a delay of t w o t o t hree w eeks, indirect resorpt ion t akes place
out w ards f rom t he marrow spaces of t he adjacent alveolar bone (Fig. 15. 3) and
t hen t he t oot h moves. This is know n as undermining resorpt ion (see Table 15. 1).

Fig. 15.3. Diagram showing the effect of applying an


excessive force: (a) areas of hyalinization (1); (b)
undermining resorption (2) and direct resorption in
areas where force is less (3).

(a)
(b)

Table 15. 1 Cellular reactions to the application of an orthodontic force

Optimal force
Pressure areas

1. Cellular proliferation within a few days


2. Osteoclasts migrate into the PDL from blood vessels
3. Resorption of bone and remodelling of PDL fibres

Tension areas

1. Stretching of PDL fibres


2. Cellular proliferation of fibroblasts and osteoblasts
3. Increase in length of PDL fibres
4. Deposition of osteoid
5. Remodelling and reattachment of PDL fibres, and
calcification of osteoid into mature bone

Excessive force
Pressure areas

1. Capillary blood vessels are crushed resulting in


death of cells in PDL (hyalinization)
2. In areas adjacent to the hyalinized sections of PDL
cellular proliferation occurs
3. Resorption occurs deep to hyalinized area from
cancellous bone outwards toward lamina dura of
PDL (undermining resorption)
4. Tooth movement occurs

Tension areas
As for optimal force

PDL, periodontal ligament.

The opt imum f orce f or t oot h movement is around 20 2 5 g/ cm2 of root surf ace
area. The size of t he f orce applied t o an individual t oot h w ill depend upon it s
root surf ace area and t he t ype of t oot h movement planned. I n bodily t oot h
movement t he applied f orce is spread over t he w hole of t he root surf ace in t he
direct ion of t ranslat ion (Fig. 15. 4). Thus a larger f orce is required t o achieve t he
t hreshold f or movement . I n cont rast , int rusion requires light f orces as t he applied
st ress is concent rat ed at t he apex of t he t oot h and t he applicat ion of an
excessive f orce runs t he risk of occluding t he blood supply t o t he pulpal t issues.
Average f orces f or t he

common t oot h movement s are given in Table 15. 2, but it should be remembered
t hat t he opt imal f orce f or a given t oot h w ill depend upon it s root surf ace area.

Fig. 15. 4. Diagram show ing dist ribut ion of t he applied f orce w it h bodily
movement (P = pressure T = t ension).

Table 15. 2 A guide to force levels for tooth movement


Tipping movements 30 6 0 g

Bodily movements 100 1 50 g

Rotational movements 50 7 5 g

Extrusion 50 7 5 g

Intrusion 15 2 5 g

The use of excessive f orce in ort hodont ic t oot h movement is not advocat ed f or a
number of reasons, including t he f ollow ing:

delay in t oot h movement ;


t he dispersal of an excessive f orce over t he anchor t eet h is more likely t o
reach t he t hreshold f or t heir movement , result ing in an increased risk of
anchorage loss;
a great er f orce leads t o increased discomf ort of t he t oot h being moved;
increased t oot h mobilit y (due t o t he removal of a great er amount of
support ing bone);
a great er risk of root resorpt ion.

The success of ort hodont ic t oot h movement also depends upon t he durat ion of
t he applied f orce. I t has been show n t hat t he chemical mediat ors of t oot h
movement appear in t he bloodst ream w it hin a f ew hours of a cont inuous f orce
being applied and t hat clinical t oot h movement w ill occur w it h a f orce durat ion of
as lit t le as 6 hours per day. How ever, f or opt imal t oot h movement applicat ion of
a cont inuous f orce, f or 24 hours per day is pref erable (but see Table 15. 3 f or t he
reasons f or more rapid t oot h movement in children). I rregularit ies in t he bony
socket w all mean t hat , even t hough overall an opt imal f orce is applied, excessive
f orces can develop in small areas. To allow t hese areas t o repair and t o limit
root resorpt ion, react ivat ion of t he f orce exert ed by an appliance should be
undert aken at int ervals more t han 3 w eeks apart .
This discussion has out lined t he response of cancellous bone t o an ort hodont ic
f orce. The great er densit y and reduced vascularit y of cort ical bone means t hat ,
if a f orce is applied w hich result s in t he t oot h root cont act ing bone, resorpt ion of
t he root rat her t han bone may result . I n addit ion, alt hough some remodelling of
t he alveolar process occurs during t oot h movement , t his is not limit less and it is
quit e possible t o move a t oot h root t hrough t he labial or palat al cort ical plat e.
This may result in dehiscence of t he root , w it h severe gingival recession and
possibly loss of pulp vit alit y as w ell as root resorpt ion.
By necessit y t his sect ion has been a summary of t he complex biochemical
changes w hich occur as a result of pressure or t ension applied t o a t oot h and it s
support ing st ruct ures. This int erest ing area is current ly t he subject of much
research, and t he reader is ref erred t o t he sect ion on f urt her reading.

Table 15. 3 Reasons for more rapid tooth movement in children

Physiological tooth movement is greatest when the


teeth are erupting
The periodontal ligament is more cellular, and
therefore there are more cells available for
resorption and remodelling
The alveolar bone has a greater proportion of
osteoblasts
The cellular response in reaction to an applied force
is quicker
The width of the periodontal ligament is increased in
newly erupted teeth, and so a greater force can be
applied before constriction of the blood vessels
occurs
Growth can be utilized

15.3. TYPES OF ANCHORAGE


15.3.1. Intra-oral anchorage
I nt ra-oral anchorage has classically been subdivided as f ollow s:

Simple anchorage: act ive movement of one t oot h versus several anchor
t eet h.
Compound anchorage: t eet h of great er resist ance t o movement are ut ilized
as anchorage f or t he t ranslat ion of t eet h w hich have less resist ance t o
movement .
Stationary anchorage: t his is a misnomer as it is ext remely diff icult t o
prevent movement of anchor t eet h alt oget her.
Reciprocal anchorage: t w o groups of t eet h are pit t ed against each ot her,
result ing in equal reciprocal movement of bot h. This concept is ut ilized in
appliances t o expand t he upper arch. Act ivat ion of t he expansion appliance
result s in a f orce act ing equally but opposit ely on t he post erior t eet h of bot h
upper quadrant s (Fig. 15. 5).

Fig. 15. 5. An expansion appliance, show ing t he use of reciprocal anchorage.

I n pract ice, it may be more helpf ul t o consider int ra-oral anchorage in t erms of
w het her it is derived f rom t eet h in t he same arch, i. e. intramaxillary anchorage,
or w het her it is gained f rom t he opposing arch, i. e. intermaxillary anchorage
(see Sect ion 15. 6).

15.3.2. Extra-oral anchorage


Ext ra-oral anchorage is achieved by t he pat ient w earing headgear w hich applies
a dist al f orce upon t he t eet h. Essent ially t he pat ient 's head is used f or
anchorage (see Sect ion 15. 7).

15.4. FACTORS AFFECTING ANCHORAGE


15.4.1. Type of tooth movement planned
A t ipping f orce result s in a concent rat ion of t he applied f orce at t he apex and
crest al bone margins of a t oot h (see Fig. 15. 2). I n cont rast , during bodily
movement t he f orce is spread over t he root surf ace in t he direct ion of movement
(see Fig. 15. 4), and so a great er f orce is required t o achieve t oot h movement
and consequent ly a great er st rain is placed on anchorage. How ever, t his can be
used t o advant age as it is possible t o increase t he value of anchorage t eet h by
t rying t o ensure t hat t hey can only move bodily.

15.4.2. Root surface area of the teeth used for


anchorage
I ncreasing t he root surf ace area of t he anchorage unit means t hat t he react ion t o
an act ive ort hodont ic f orce is dissipat ed over a larger area. For t his reason
molar t eet h are pref erable t o single-root ed t eet h. I ncreasing t he number of
anchor t eet h (e. g. by including second molars w hen bonding f ixed appliances)
also increases t he root surf ace area resist ing anchorage loss, but by t he same
t oken, movement of molar t eet h places a great er st rain on anchorage.

15.4.3. Skeletal pattern


I t has been not ed t hat , in pat ient s w it h increased vert ical skelet al dimensions
and a backw ard pat t ern of grow t h rot at ion, mesial t oot h movement and
anchorage loss seem t o occur more readily t han in pat ient s w it h reduced vert ical
skelet al proport ions and a f orw ard pat t ern of grow t h rot at ion (see Chapt er 4,
Figs 4. 15 and 4. 16). O ne possible explanat ion f or t his is t he relat ive s t rengt h of
t he f acial musculat ure of t he t w o f acial t ypes.

15.4.4. Occlusal interlock


A good buccal occlusion may act t o resist t oot h movement . This may or may not
be an advant age, depending upon w het her t he t oot h or t eet h t o be moved
act ively or t he anchor t eet h are aff ect ed.

15.4.5. Tendency for tooth movement in the arch


Anchorage loss is more rapid in t he maxillary arch as upper t eet h have a great er
t endency f or mesial drif t .

15.5. ASSESSING ANCHORAGE REQUIREM ENTS


When planning t reat ment , t he t ype of t oot h movement required (f or example
t ipping or bodily movement ) and t he demands t hat t his w ill place upon anchorage
should be considered, t oget her w it h t he ant icipat ed f inal posit ion of bot h t he
molars and incisors. As a result of t his process t he part icular malocclusion under
considerat ion w ill f all int o one of t he f ollow ing cat egories.

1. Excess space w ill remain f ollow ing t reat ment . I n t his sit uat ion eit her t he
t reat ment plan should be re-examined or measures t aken t o t ry and b urn up
anchorage.
2. The anchorage available should suff ice. How ever, it is prudent t o monit or
anchorage t hroughout t reat ment .
3. No loss of anchorage can be t olerat ed. Theref ore measures t o reinf orce
anchorage should be inst it ut ed f rom t he beginning of t reat ment .
4. I nsuff icient anchorage is available even w it h reinf orcement during t reat ment .
I n t his sit uat ion it is necessary t o ret urn t o t he aims of t he t reat ment and t o
det ermine if t hese need t o be modif ied. I f not , addit ional ext ract ions and/ or
ext ra-oral t ract ion w ill be indicat ed.

15.6. REINFORCING ANCHORAGE


15.6.1. Intra-oral reinforcement of anchorage
Anchorage can be preserved int ra-orally during t reat ment in t he f ollow ing w ays.

Increasing the number of teeth in the anchor unit


This means including more t eet h in t he appliance t o t ry t o resist t he unw ant ed
eff ect s of act ive t oot h movement . For example, w hen f ixed appliances are used,
banding t he second molars helps t o increase anchorage.

M aking movement of the anchor teeth more difficult


Wit h f ixed appliances it is possible t o ensure t hat t he anchor t eet h can only move
bodily. As bodily movement requires great er f orces, t he resist ance of t he
anchorage unit is increased.

Intermaxillary anchorage
The anchorage available in one arch can be reinf orced if t he pat ient w ears
elast ic t ract ion t o t he opposing arch. For example, in a Class I I malocclusion
elast ics f rom t he upper canine region backw ards t o t he low er f irst molars on
bot h sides assist overjet reduct ion. This direct ion of elast ic pull is described as
Class I I int er-maxillary t ract ion (Fig. 15. 6). Class I I I t ract ion is show n in Fig.
15. 7.
Fig. 15. 6. Class I I int ermaxillary t ract ion.

Fig. 15. 7. Class I I I int ermaxillary t ract ion.

Elast ic int ermaxillary t ract ion is diff icult w it h removable appliances and is almost
exclusively employed in f ixed appliance t reat ment s. I nt ra-oral elast ics (see
Chapt er 17, Fig. 17. 20) are available in a w ide variet y of sizes and w eight s.
How ever, int ermaxillary t ract ion is not w it hout it s disadvant ages. Class I I or
Class I I I t ract ion can lead t o ext rusion of t he molar t eet h, w hich has t he eff ect of
increasing t he low er f ace height and reducing overbit e. I n pat ient s w it h
increased vert ical proport ions t his w ill be count erproduct ive. Class I I t ract ion
encourages f orw ard movement of t he low er molars, w hich may be advant ageous
if t here is excess low er ext ract ion space t o close. How ever, t he use of t his t ype
of t ract ion w here no low er arch space exist s w ill have t he eff ect of proclining t he
low er labial segment .
I nt ermaxillary t ract ion can also be achieved w it h f unct ional appliances (see
Chapt er 18).

Palatal and lingual arches


An arch w hich connect s cont ralat eral molars eit her across t he vault of t he palat e
or around t he lingual aspect of t he low er arch w ill help t o prevent movement of
t he molars and t hus reinf orce anchorage. The arches are usually at t ached t o
bands cement ed t o t he molar t eet h (Figs 15. 8 and 15. 9).

Fig. 15. 8. Palat al arch.

Fig. 15. 9. Lingual arch.

Choice of appliance
Upper removable appliances act ually aff ord more anchorage t han f ixed
appliances because of t heir palat al coverage.

Implants
I mplant s act as a f ixed st ruct ure and are usef ul f or providing anchorage in
pat ient s w it h hypodont ia or marked t oot h loss.

15.6.2. Extra-oral reinforcement of anchorage


Ext ra-oral reinf orcement of anchorage is discussed in Sect ion 15. 7.

15.7. EXTRA-ORAL ANCHORAGE AND TRACTION


15.7.1. General principles
I n pract ice, t he dist inct ion bet w een ext ra-oral anchorage (EO A) and ext ra-oral
t ract ion (EO T) is a mat t er of degree (Table 15. 4), alt hough conf usingly t he t erms
are of t en used int erchangeably. Ext ra-oral anchorage is a met hod of increasing
anchorage and t heref ore is designed t o prevent f orw ard movement of t he anchor
t eet h. Ext ra-oral t ract ion is a met hod of achieving t oot h movement , most
commonly in a dist al direct ion. I t is also somet imes used t o t ry t o move t he
maxilla dist ally and/ or vert ically, alt hough in realit y t he net result is rat her a
rest raint of maxillary grow t h. I n order t o achieve t rue (ort hopaedic) maxillary
movement , prolonged w ear w it h f orces in excess of 500 g over t he years of
act ive grow t h is required, f ollow ed by prolonged ret ent ion t o reduce any rebound
grow t h. Perhaps not surprisingly, most pat ient s are unable t o sust ain t his level of
cooperat ion.

Table 15. 4 Extra-oral traction and anchorage

EOA EOT

Reinforcement of Tooth
Purpose
anchorage movement

Force 200 2 50 g 400 5 00 g

W ear
10 1 2 hours 14 1 6+ hours
required

I n addit ion t o magnit ude and durat ion, t he direct ion of t he headgear f orce also
needs t o be considered, alt hough t his is of more consequence w it h ext ra-oral
t ract ion. A direct ion of f orce below t he level of t he occlusal plane (cervical-pull
headgear) w ill t end t o ext rude t he upper molar t eet h and t hus cause an increase
in t he vert ical dimension of t he low er f ace. While t his may be an advant age in a
pat ient w it h a reduced low er f acial height , it is cont raindicat ed in a pat ient w it h
increased vert ical proport ions. I n t he lat t er case, a direct ion of pull above t he
occlusal plane (high-pull headgear) is usually pref erable, as t his w ill have t he
eff ect of int ruding t he upper buccal segment t eet h and w ill also t end t o rest rain
vert ical maxillary development .
To achieve dist al movement of t he upper f irst permanent molars, a f orce direct ed
slight ly above t he occlusal plane, t hrough t he cent re of resist ance of t hose t eet h,
is desirable. I t is import ant t o monit or t he direct ion in w hich t he t eet h are being
t ranslat ed. For example, if it can be seen t hat t he crow ns of t he t eet h are being
t ilt ed dist ally, t he direct ion of pull needs t o be raised t o count eract t his.
The cent re of resist ance of t he maxilla is est imat ed t o lie at a point
approximat ely above and bet w een t he premolar root s. I f rest raint of maxillary
grow t h is t o be at t empt ed, t he direct ion of headgear pull should be adjust ed so
t hat t he f orce passes t hrough t his area.
I nt rusion of t he upper incisors can be at t empt ed by applying headgear t o t he
upper labial sect ion of t he archw ire during f ixed appliance t reat ment s, but t o
avoid root resorpt ion a f orce of less t han 200 g is advisable.
A direct ion of f orce above t he occlusal plane is also advisable w hen headgear is
employed in conjunct ion w it h a removable appliance, t o aid ret ent ion of t he
appliance.

15.7.2. Components of headgear


Headgear consist s essent ially of t hree part s.

M eans of attachment to the teeth


This is achieved by using one of t he f ollow ing:

1. A f ace-bow (Fig. 15. 10) w hich slot s int o t ubes soldered ont o t he bridge of a
removable appliance crib (see Chapt er 16, Fig. 16. 17), t ubes w hich f orm an
int egral part of a molar band at t achment (see Chapt er 17, Fig. 17. 29), or
t ubes w hich are incorporat ed in t he design of a f unct ional appliance.
2. J-hooks (Fig. 15. 11) w hich can be direct ly at t ached ont o t he archw ire in a
f ixed appliance or at t ached t o hooks soldered ont o t he labial bow of a
removable appliance.
Fig. 15. 10. A f ace-bow.

Fig. 15. 11. J-hooks.

Strap or headcap
A number of diff erent t ypes are available w hich are mainly described by t he
direct ion of pull t hat t he headgear aff ords:

cervical pull w hich consist s of a neck st rap (Fig. 15. 12);


variable pull w hich consist s of a headcap w it h a variet y of posit ions f or t he
applicat ion of f orce (Fig. 15. 13);
high pull w hich is a headcap f it t ing over t he back of t he head (Fig. 15. 14).
Fig. 15. 12. Cervical-pull headgear w it h t he f orce produced by an elast ic
st rap. The headgear is at t ached t o a f ace-bow and t he pat ient is also
w earing a rigid saf et y st rap.

Fig. 15. 13. Variable-pull headgear w it h f orce provided by elast ic bands


bet w een t he headgear and t he f ace-bow. A rigid saf et y st rap is also being
used.
Fig. 15. 14. High-pull headgear at t ached t o a f ace-bow.

Elastic component or spring mechanism


This connect s t he t w o ot her element s and cont rols t he magnit ude of t he f orce
applied. Elast ic f orce is produced eit her by an elast ic st rap (see Fig. 15. 12) or
by diff erent sizes of ext ra-oral elast ic bands (see Fig. 15. 13). Spring
mechanisms are show n in Figs 15. 14 and 15. 15.

Fig. 15. 15. Saf et y release headgear w it h a spring mechanism w hich breaks
apart w hen excessive f orce is applied.

15.7.3. Headgear safety


Tragically, several cases have been report ed w here severe ocular injuries,
including blindness, have occurred ow ing t o accident s w it h headgear. These
incident s have mainly occurred w it h f ace-bow s used in conjunct ion w it h some
f orm of elast ic f orce, w here t he f ace-bow has been pulled out of t he mout h and
recoiled back int o t he f ace or eyes. Various met hods of increasing t he saf et y of
headgear have been int roduced. O ne of t he simplest designs is t he rigid saf et y
st rap (Fig. 15. 16; see also Figs 15. 12 and 15. 13) w hich, if correct ly f it t ed, helps
t o prevent t he f ace-bow f rom being dislodged. The spring mechanisms have also
gained popularit y as a saf et y release f eat ure can be more easily be built int o t he
headgear; if an excessive f orce is applied, t he component s come apart t hus
prevent ing recoil of t he f ace-bow (see Figs 15. 14 and 15. 15). , Face-bow s w it h
t he ends re-curved t o f orm a guard over t he sharp end of t he int ra-oral bow are
available (Fig. 15. 17). I n addit ion a f ace-bow has been developed w it h a small
cat ch t o lock it int o t he molar t ubes (Figs 15. 18a and b), t hese are st rongly
recommended as t hey prevent t he f ace-bow being pulled out .

Fig. 15. 16. Rigid saf et y st rap.

Fig. 15. 17. Saf et y f ace-bow.

Care is also required w it h J-hooks as t he hook can be dislodged and cause


serious injury. I t is pref erable t o bend t he hook round so t hat it f orms a circle
and is at t ached ont o a hook soldered t o t he removable appliance or archw ire. A
relat ively large headcap should be used w it h small heavy elast ics so t hat t he
dist ance t hat t he J-hook can t ravel is minimized.
I t w ould now be considered neglilent t o use headgear w it hout saf et y f eat ures.
Pat ient s should be w arned of t he dangers and inst ruct ed t hat headgear should
not be w orn during any horseplay . I f t he headgear dislodges during t he night ,
pat ient s should be advised t o discont inue it s use and t o ret urn f or adjust ment by
t he clinician.

15.7.4. Reverse headgear


This t ype of headgear is also know n as a f ace-mask and is used t o t ry and move
t eet h mesially t o close up excess spacing or in Class I I I malocclusions in an
at t empt t o move t he maxilla f orw ard (see Chapt er 11, Fig. 11. 15).

15.8. M ONITORING ANCHORAGE DURING TREATM ENT


15.8.1. Single-arch treatments
Monit oring anchorage during single-arch f ixed or removable t reat ment s is
relat ively st raight f orw ard, as it is possible t o use t he ot her arch as a ref erence.
This can be done by recording t he overjet and molar posit ions during t reat ment ,
pref erably at each visit . The progress of t he t oot h or t eet h being moved can be
recorded most easily using dividers w hich can t hen be imprint ed int o t he record
card.

15.8.2. Upper and lower fixed appliance treatments


Where t oot h movement is occurring in bot h arches simult aneously it is a lit t le
more diff icult t o det ermine w here t he t eet h are spat ially compared w it h t heir

st art ing posit ion. For example, in a Class I I , division 1, malocclusion f orw ard
movement of t he upper arch may occur ow ing t o loss of anchorage, but if t he
low er labial incisor t eet h have also been inadvert ent ly proclined, due t o
ent husiast ic use of Class I I t ract ion f or example, loss of anchorage is more
diff icult t o det ect as t he overjet measurement may be unchanged or even
reduced. For t his reason a lat eral cephalomet ric radiograph should be t aken
prior t o t he placement of appliances, and t hen progress w it h t oot h movement and
grow t h can be evaluat ed by repeat ing t he radiograph. I f necessary, t he
t reat ment mechanics can t hen be modif ied. I t is also advisable cont inually t o
bear in mind t he f inal ant icipat ed t oot h posit ions, f or example t he desired buccal
segment occlusion, and t o record progress t ow ards t his goal at every visit .

Fig. 15.18. Locking face-bow: (a) open; (b) closed.


(a)

(b)

15.9. COM M ON PROBLEM S WITH ANCHORAGE


The most common reasons f or t he occurrence of anchorage problems during
t reat ment are as f ollow s.

Failure t o appreciat e f ully t he anchorage requirement s of a part icular


malocclusion at t he t reat ment planning st age. I f t his becomes apparent
during t reat ment , it is probably w ise t o t ake up-t o-dat e records and
reassess t he case. I t may be necessary t o inst it ut e ext ra-oral anchorage or,
if problems are marked, ext ra-oral t ract ion or even addit ional ext ract ions. I t
is advisable t o explain caref ully t o t he pat ient and t heir parent s t he reasons
f or t he change of t reat ment plan.
Poor pat ient compliance. I t is import ant during any ort hodont ic t reat ment t o
monit or caref ully pat ient compliance w it h t he appliance, ideally at every visit .
The major problem w it h removable appliance t reat ment is t o ensure t hat t he
pat ient w ears t he appliance f ull-t ime. I f compliance is part icularly poor,
f orw ard movement of t he anchor molars ow ing t o mesial drif t can occur,
leading t o loss of anchorage. Wit h f ixed appliances, breakages and f ailure t o
w ear headgear or elast ic t ract ion are t he most common problems leading t o
anchorage loss. Somet imes encouragement and an explanat ion of t he eff ect
of t he pat ient 's act ions upon t he success of t reat ment may be suff icient .
How ever, f or a proport ion of pat ient s t his does not have t he desired eff ect ,
w hich emphasizes t he need f or caref ul pat ient select ion. Unf ort unat ely,
escalat ing t reat ment t o overcome anchorage loss is of t en poorly received by
t his group of pat ient s, and a compromise result may have t o be accept ed.

15.10. RETENTION
Relapse has been def ined by t he Brit ish St andards I nst it ut e as t he ret urn,
f ollow ing correct ion, of t he f eat ures of t he original malocclusion.
Af t er a course of ort hodont ic t reat ment a period of ret ent ion is usually
necessary. This allow s t he recent ly f ormed ost eoid and bone t o mat ure and gives
t ime f or reorganizat ion of new periodont al f ibres. Ret ent ion should not be
relegat ed t o being an af t ert hought at t he end of t reat ment ; it should be
considered at t he planning st age and explained t o t he pat ient as an int egral part
of t he overall management package. I n addit ion, it is advisable t o ident if y t hose
cases w here t he prognosis f or a st able result has t o be guarded and a decision
made w het her t o embark on t reat ment at all.

15.10.1. Factors to be considered when planning


retention
Soft tissues
Where possible, appliance t herapy should aim t o place t he t eet h in a posit ion of
sof t t issue balance f ollow ing t reat ment . Sadly, no amount of ret ent ion w ill
st abilize an inherent ly unst able result .
I f t he lips are incompet ent prior t o t reat ment , t he met hod by w hich a pat ient
achieves an ant erior oral seal should be assessed and t he probable eff ect of
t reat ment upon lip compet ence det ermined. For example, in a Class I I division 1,
malocclusion, t he low er lip should ideally rest in f ront of t he ret ract ed upper
incisors at t he end of t reat ment . This is more likely t o be achieved in t he pat ient
show n in Fig. 15. 19 t han in t he pat ient show n in Fig. 15. 20, w ho has grossly
incompet ent lips w hich w ill not act in f ront of t he incisors even if t he overjet is
reduced.
Fig. 15. 19. Pot ent ially compet ent lips.

Fig. 15. 20. G rossly incompet ent lips.

I n pat ient s w it h advanced periodont al disease, normal sof t t issue pressures may
lead t o drif t ing of t he t eet h. I n t hese cases, permanent ret ent ion is usually
required f ollow ing t reat ment t o prevent relapse (see Chapt er 19).

Facial grow th
The probable direct ion of any f ut ure grow t h and it s eff ect should be est imat ed
and t aken int o considerat ion at t he t ime of t reat ment planning. Class I I I
malocclusions and t he ext remes of t he vert ical range, i. e. ant erior open bit es
and deep overbit es, are most commonly adversely aff ect ed by f urt her grow t h. I n
t hese cases it is w ise t o overcorrect t he incisor relat ionship and, if possible, t o
cont inue ret ent ion unt il t he end of t he t eens w hen t he grow t h rat e slow s or t o
def er t reat ment unt il t his t ime. I n severe class Class I I I cases part icularly it may
be appropriat e t o w ait unt il t he slow rat e of adult grow t h has been reached
bef ore deciding w het her ext ract ion of t eet h and ort hodont ic c amouf lage or
surgical correct ion w ould be t he best t reat ment .
Alt hough low er incisor crow ding is mult if act orial, lat e f acial grow t h has been
implicat ed. Crow ding of t he low er labial segment is common, even f ollow ing
ort hodont ic t reat ment . O ne st udy in t he USA f ound t hat low er incisor crow ding
increased in around 66 per cent of a sample of 450 post -ort hodont ic pat ient s.
G iven t hese st at ist ics, it is not surprising t hat , part icularly in t he USA, t here is a
grow ing t rend t ow ards permanent ret ent ion of t he low er labial segment , f or
example w it h a bonded ret ainer.

Supporting tissues
During act ive t oot h movement t he periodont al ligament f ibres are placed under
t ension. I f t he f orce is removed, t he t ension in t hese f ibres could result in t he
t oot h's springing back against t he new ly f ormed immat ure bone w hich is more
readily resorbed, result ing in relapse. The rat e of t urnover of t he diff erent
groups of periodont al ligament f ibres varies. The f ibres w hich run bet w een t he
socket w all and t he cement um are remodelled w it h t he bony changes; how ever,
t he supracrest al f ibres t ake over six 6 mont hs t o be reorganized. Theref ore
some ret ent ion is advisable t o allow t he support ing t issues t o adapt . How ever,
de-rot at ion is part icularly prone t o relapse. This is relat ed t o t he slow t urnover
of t he f ree gingival f ibres, w hich remain under t ension f or mont hs or even years
af t er rot at ional movement s. O ne met hod of overcoming t his is pericision or
circumf erent ial supracrest al f ibrot omy, in w hich a scapel blade is run around t he
gingival crevice t o cut t hrough t he supracrest al f ibres. Alt ernat ively, rot at ed t eet h
can be overcorrect ed, but relapse is unpredict able and some t eet h remain
st ubbornly overcorrect ed. I n any case prolonged ret ent ion, f or example w it h a
bonded ret ainer, is advisable.
An upper midline diast ema present af t er erupt ion of t he permanent canines also
has a st rong t endency t o reopen af t er closure. I t has been suggest ed t hat t his

is due t o discont inuit y of t he t ransept al f ibres bet w een t he cent ral incisors. I f t he
diast ema is associat ed w it h radiographic and clinical evidence of insert ion of t he
f raenal f ibres t hrough t he midline sut ure t o t he incisive papilla, a f raenect omy
during space closure is advisable. Again, prolonged ret ent ion is usually required.

Occlusal factors
Achievement of a sat isf act ory int er-incisal relat ionship w ill aid ret ent ion: f or
example est ablishment of an adequat e overbit e is essent ial t o ret ain an ant erior
t oot h (or t eet h) w hich has been proclined f rom being in crossbit e (Fig. 15. 21)
and correct ion of t he int er-incisal angle is necessary t o prevent relapse of a
deep overbit e (Chapt er 10, Fig. 10. 11). I n cont rast , a poor buccal segment
int erdigit at ion, part icularly associat ed w it h a displacement on closure, can
cont ribut e t o relapse.

Fig. 15. 21. I f t he ant erior t eet h are proclined t o correct t he crossbit e, lack
of overbit e w ill lead t o relapse.

15.10.2. Retention regimes


To minimize relapse it is advisable t o commence ret ent ion immediat ely af t er t he
end of act ive appliance t herapy. I t is diff icult t o lay dow n rigid rules f or
ret ent ion, as each case should be assessed individually. Theref ore t he f ollow ing
regimes are f or guidance only.

Tilting movements into the line of the arch


Follow ing a course of removable appliance t herapy t o align one or t w o t eet h, 3
mont hs f ull-t ime w ear of t he passive appliance w ill usually suff ice. I f t he t eet h
have been proclined f rom a crossbit e posit ion and t here is suff icient overbit e, 3
mont hs of night -only w ear is usually adequat e.

Bodily movements
Af t er correct ion of more severe malocclusions w it h a f ixed appliance it is
common pract ice t o f it removable Haw ley ret ainers (Fig. 15. 22) or vacuum-
f ormed t hermo-plast ic ret ainers (Fig. 15. 23) f or 3 t o six 6 mont hs of f ull-t ime
w ear f ollow ed by 6 mont hs of night -only w ear. Alt ernat ively, many operat ors f it
bonded ret ainers on t he lingual aspect of t he low er incisors and canines (Fig.
15. 24). These are of t en lef t i n si tu unt il t he f at e of t he t hird molars is
det ermined. Bonded ret ainers lie passively against t he t eet h and are ret ained
using light -cured acid-et ch ret ained composit e. They may be f abricat ed f rom
f lexible mult ist rand w ire and bonded t o each t oot h or f ormed f rom more rigid
solid st ainless st eel w ire and bonded at eit her end t o t he canine t eet h only. Pre-
f ormed bonded ret ainers w it h pads f or bonding t o t he palat al surf aces of t he
upper cent ral incisors can be eff ect ive in holding a median diast ema closed.
Micro-magnet s have also been used in t his sit uat ion.

Fig. 15. 22. Upper and low er removable ret ainers.

Fig. 15. 23. Vacuum-f ormed t hermoplast ic upper removable ret ainer.

Fig. 15. 24. Bonded ret ainer.


Opening space for prosthetic replacement of missing
teeth
This has been considered separat ely f or t he f ollow ing reasons:

1. I f a removable part ial dent ure cum ret ainer is t o be used f ollow ing act ive
t oot h movement , C-clasps or st ops should be placed mesial and dist al t o t he
pont ic t oot h t o help prevent relapse.
2. I t has been show n t hat if acid-et ch ret ained bridgew ork is placed
immediat ely af t er t he end of act ive t oot h movement t here is a higher rat e of
bond f ailure. Theref ore it is advisable t o ret ain w it h a removable ret ainer f or
at least 9 mont hs.

De-rotation
Prolonged ret ent ion is w ise af t er correct ion of rot at ions. This is perhaps most
easily accomplished w it h a bonded lingual/ palat al ret ainer (see Fig. 15. 24).

Orthopaedic movement
Af t er grow t h modif icat ion w it h a f unct ional appliance or w it h t he use of
headgear, it is advisable t o cont inue ret ent ion w it h t he appliance, at least f or
night s only, unt il t he grow t h rat e has slow ed t o t he low levels of adult hood, in t he
lat e t eens.

15.11. SUM M ARY


Anchorage is t he balance bet w een t he t oot h movement s desired t o achieve
correct ion of a malocclusion and t he undesirable movement of any ot her t eet h.
The st rain placed upon anchorage depends upon t he t ype of t oot h movement t o
be carried out and t he applied f orce(s). Anchorage can be increased by
maximizing t he number of t eet h (and root surf ace area) resist ing t he act ive t oot h
movement , eit her w it hin t he same arch (int ramaxillary anchorage) or in t he
opposing arch (int ermaxillary anchorage). Ext ra-oral f orces can also be ut ilized
w it h headgear. I t is import ant t o map out anchorage requirement s at t he planning
st age and monit or t hroughout t reat ment .
Ret ent ion is usually necesssary t o overcome t he elast ic recoil of t he periodont al
support ing f ibres and t o allow remodelling of t he alveolar bone. Ret ent ion
requirement s should be planned prior t o t he st art of t reat ment .

PRINCIPAL SOURCES AND FURTHER READING


Bow den, D. E. J. (1978). Theoret ical considerat ions of headgear t herapy: a
lit erat ure review. Bri ti sh Journal of O rthodonti cs, 5, 145 5 2.

Bow den, D. E. J. (1978). Theoret ical considerat ions of headgear t herapy: a


lit erat ure review. Clinical response and usage. Bri ti sh Journal of
O rthodonti cs, 5, 173 8 1.

These t w o papers provide an aut horit at ive review of t he principles of


headgear.

Firouz, M. , Zernik, J. , and Nanda, R. (1992). Dent al and ort hopedic eff ect s of
high-pull headgear in t reat ment of Class I I , division 1, malocclusion. Ameri can
Journal of O rthodonti cs and Dentof aci al O rthopedi cs, 102, 197 2 05.

Hill, P. A. (1998). Bone remodelling. Bri ti sh Journal of O rthodonti cs, 25, 101 7

Kaplan, H. (1988). The logic of modern ret ent ion procedures. Ameri can
Journal of O rthodonti cs and Dentof aci al O rthopedi cs, 93, 325 4 0.

Lit t le, R. M. , Reidel, R. A. , and Ĺrt un, J. (1988). An evaluat ion of changes in
mandibular ant erior alignment f rom 10 t o 20 years post ret ent ion. Ameri can
Journal of O rthodonti cs and Dentof aci al O rthopedi cs, 93, 423 8 .

Meghji, S. (1992). Bone remodelling. Bri ti sh Dental Journal, 172, 235 4 2.

Melrose, C. and Millet t , D. T. (1998). Tow ard a perspect ive on ort hodont ic
ret ent ion? Ameri can Journal of O rthodonti cs and Dentof aci al O rthopedi cs,
113, 507 1 4.

Nanda, R. S. and Nanda, S. K. (1992). Considerat ions of dent of acial grow t h


in long-t erm ret ent ion and st abilit y. I s act ive ret ent ion needed? Ameri can
Journal of O rthodonti cs and Dentof aci al O rthopedi cs, 101, 297 3 02.

Post let hw ait e, K. (1989). The range and eff ect iveness of saf et y headgear
product s. European Journal of O rthodonti cs, 11, 228 3 4.

Proff it , W. R. (2000). Contemporary O rthodonti cs (3rd edn). Mosby, St Louis,


MO .

Samuels, R. H. (1996) A review of ort hodont ic f ace-bow injuries and saf et y


equipment . Ameri can Journal of O rthodonti cs and Dentof aci al O rthopedi cs,
110, 269 7 2.
Samuels, R. H. (1997) A new locking f ace-bow Journal of Cl i ni cal
O rthodonti cs, 31, 24 7 .

Sandy, J. R. (1992). Toot h erupt ion and ort hodont ic movement . Bri ti sh Dental
Journal , 172, 141 9 .
An erudit e paper det ailing t he cellular and biochemical t heories of t he
mechanisms involved in t oot h movement .

Seel, B. D. S. (1980). Ext ra-oral hazards of ext ra-oral t ract ion. Bri ti sh
Journal of O rthodonti cs, 7, 53 5 .
Authors: Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> Table of C ontents > 16 - R em ovable applianc es

16
Removable appliances

This chapt er concerns t hose appliances t hat are f abricat ed mainly in acrylic and
w ire, and (as t he name suggest s) can be removed f rom t he mout h. Most
removable appliances are made f or t he upper arch. Funct ional appliances are
made of t he same mat erials, but w ork primarily by exert ing int ermaxillary
t ract ion and so are considered separat ely in Chapt er 18.

16.1. INDICATIONS FOR THE USE OF REM OVABLE


APPLIANCES
Alt hough w idely ut ilized in t he past as t he sole appliance t o t reat a malocclusion,
w it h t he increasing availabilit y and accept ance of f ixed appliances t he limit at ions
of t he removable appliance have become more apparent . The removable
appliance is only capable of producing t ilt ing movement s of individual t eet h,
w hich can be used t o advant age w here simple movement s are required t o
correct a mild malocclusion but can lead t o a compromise result if employed
w here more complex t oot h movement s are indicat ed. As a result t he role of t he
removable appliance is changing, and it is becoming more w idely used t o
t ransmit f orces t o blocks of t eet h and as an adjunct t o f ixed appliance t reat ment .
Removable appliances provide a usef ul means of applying ext ra-oral t ract ion t o
segment s of t eet h, or an ent ire arch, t o help achieve int rusive and/ or dist al
movement . Examples of t hese t ypes of appliance include t he en masse
appliance, w hich is described in Sect ion 16. 4. 6 or t he maxillary and buccal
segment int rusion splint s discussed in Chapt er 12. Removable appliances are
also employed f or arch expansion, w hich is anot her example of t heir usef ulness
in moving blocks of t eet h.
Removable appliances are part icularly helpf ul w here a f lat ant erior bit e-plane or
buccal capping is required t o inf luence development of t he buccal segment t eet h
and/ or t o f ree t he occlusion w it h t he low er arch. They are used passively as
space maint ainers f ollow ing permanent t oot h ext ract ions and also as ret aining
appliances f ollow ing f ixed appliance t reat ment , as w ear can gradually be
reduced, allow ing t he occlusion t o s et t le in . The advant ages and disadvant ages
of removable appliances are summarized in Table 16. 1.
Table 16. 1 Advantages and disadvantages of removable appliances

Advantages Disadvantages

Appliance can be
Can be removed for tooth-
left out
brushing
Only tilting
Palatal coverage increases
movements possible
anchorage
Good technician
Easy to adjust
required
Can be used for overbite
Affects speech
reduction in a growing child
Intermaxillary
avoiding a lower appliance
traction not
Acrylic can be thickened to form
practicable
flat anterior bite plane or buccal
Lower removable
capping
appliances are
Useful as passive retainer or
difficult to tolerate
space maintainer
Inefficient for
Can be used to transmit forces
multiple individual
to blocks of teeth
tooth movements

O n occasion it may be helpf ul t o t est out t he cooperat ion of pat ient s w hose
mot ivat ion f or more complex t reat ment is uncert ain by f it t ing a removable
appliance and review ing progress bef ore deciding w het her t o proceed.
Low er removable appliances are generally poorly t olerat ed by pat ient s. This is
due in part t o t heir encroachment upon t ongue space, but also t he lingual t ilt of
t he low er molars makes ret ent ive clasping diff icult .

16.2. DESIGNING REM OVABLE APPLIANCES


16.2.1. General principles
The design of an appliance should never be delegat ed t o a laborat ory (t o do t his
is equivalent t o driving a car blindf olded w it h t he passenger giving direct ions) as
t hey are only able t o ut ilize t he inf ormat ion provided by t he plast er cast s.
Success depends upon designing an appliance t hat is easy f or t he pat ient t o
insert and w ear, and is relevant t o t he occlusal aims of t reat ment .

16.2.2. Steps in designing a removable appliance


Four component s need t o be considered f or every removable appliance:
Act ive component (s)
Ret aining t he appliance
Anchorage
Baseplat e.
This gives t he acronym ARAB, w hich may help t o jog t he memory. A det ailed
considerat ion of each of t hese component s is given in t he sect ions below.
G enerally, ext ract ions should be def erred unt il af t er an appliance is f it t ed. The
rat ionale f or t his is t w of old:

1. I f t he ext ract ions are carried out f irst , t here is a real risk t hat t he t eet h
post erior t o t he ext ract ion sit e w ill drif t f orw ard, result ing in an appliance
t hat does not f it w ell or even does not f it at all. This is most not iceable w hen
upper f irst permanent molars have been ext ract ed or t here is a conspicuous
delay bef ore t he appliance is f it t ed.
2. O ccasionally a pat ient decides af t er an appliance is f it t ed t hat t hey do not
w ish t o cont inue w it h t reat ment . I t is obviously pref erable if t his change of
mind occurs bef ore any ext ract ions have been undert aken.

Rarely, it is necessary t o carry out ext ract ions f irst , f or example w hen a
displaced t oot h w ill int erf ere w it h t he design of t he appliance. How ever, even in
t hese cases it is pref erable t o t ake impressions f or t he f abricat ion of t he
appliance bef ore t he ext ract ions and t o inst ruct t he t echnician t o remove t he
t oot h concerned f rom t he model. The appliance should t hen be f it t ed as soon as
pract icable af t er t he t eet h are ext ract ed.

16.3. ACTIVE COM PONENTS


16.3.1. Springs
Springs are t he most commonly used act ive component . Their design can readily
be adapt ed t o t he needs of a part icular clinical sit uat ion and t hey are
inexpensive. How ever, a skilled t echnician w ill make t he diff erence bet w een a
spring t hat w orks eff icient ly w it h t he minimum of adjust ment on f it t ing and one
t hat requires t he clinician t o t ry t o compensat e f or it s inadequacies at every
visit .

The expression f or t he f orce F exert ed by an ort hodont ic spring is t he only


f ormula remembered by t he aut hor and on t his basis is recommended t o t he
reader as being w ort hw hile:

w here d is t he def lect ion of t he spring on act ivat ion, r is t he radius of t he w ire,
and l is t he lengt h of t he spring. Thus even small changes in t he diamet er or
lengt h of w ire used in t he const ruct ion of a spring w ill have a prof ound impact
upon t he f orce delivered. I t is obviously desirable t o deliver a light
(physiological) f orce (Chapt er 15) over a long act ivat ion range, but t here are
pract ical rest rict ions upon t he lengt h and diamet er of w ire used t o const ruct a
spring. The span of a spring is usually const rained by t he size of t he arch or t he
dept h of t he sulcus. How ever, incorporat ing a coil int o t he design of a spring
increases t he lengt h of w ire and t heref ore result s in t he applicat ion of a smaller
f orce f or a given def lect ion. A spring w it h a coil w ill w ork more eff icient ly if it is
act ivat ed in t he direct ion t hat t he w ire has been w ound so t hat t he coil unw inds
as t he t oot h moves.
I n pract ice t he smallest diamet er of w ire t hat can be used f or spring const ruct ion
is 0. 5 mm. How ever, w ire of t his diamet er is liable t o dist ort ion or breakage and
t heref ore t he spring has t o be st rengt hened by being sleeved in t ubing (e. g. t he
Robert s ret ract or) or prot ect ed w it h acrylic (e. g. t he palat al f inger spring).
The eff ect of w ire diamet er upon t he f orce delivered by a spring can be
appreciat ed by considering t he amount of act ivat ion required t o deliver a f orce in
t he region of 30 5 0 g f or t he same design of buccal canine ret ract ion spring (Fig.
16. 1) f abricat ed using w ires of t w o diff erent diamet ers. For a spring composed
of 0. 5 mm w ire an act ivat ion of about 3 mm w ill be required. For t he same spring
composed of 0. 7 mm w ire an act ivat ion of 1 mm is required. I t can readily be
appreciat ed t hat t he 0. 7 mm spring gives lit t le margin f or error an act ivat ion of
1. 5 mm w ould give an excessive f orce, but an act ivat ion of 0. 5 mm w ould deliver
insuff icient f orce.

Fig. 16. 1. Buccal canine ret ract or.


The st abilit y rat io of a spring is readily appreciat ed w hen t rying t o adjust a
buccal canine ret ract ion spring. I n mechanical t erms it is:

I n pract ice, springs w hich have a high st abilit y rat io, f or example, t he palat al
f inger spring are st raight f orw ard t o adjust , w hereas t hose w it h a low st abilit y
rat io are diff icult t o posit ion precisely on t he t oot h t o be moved.

16.3.2. Screws
Screw s are less versat ile t han springs, as t he direct ion of t oot h movement is
det ermined by t he posit ion of t he screw in t he appliance. They are also bulky
and expensive. How ever, a screw appliance may be usef ul w hen it is desirable t o
ut ilize t he t eet h t o be moved f or addit ional clasping t o ret ain t he appliance. This
is helpf ul w hen a number of t eet h are t o be moved t oget her (f or example in an
appliance t o expand t he upper arch (Fig. 16. 2)) or in t he mixed dent it ion w here
ret aining an appliance is alw ays diff icult .

Fig. 16. 2. Screw appliance t o expand t he upper arch.

There are basically t w o t ypes of screw. The most commonly used t ype consist s
of t w o halves on a t hreaded cent ral cylinder (Fig. 16. 3) t urned by means of a
key w hich separat es t he t w o halves by a predet ermined dist ance, usually about
0. 2 mm f or each quart er t urn. The ot her variet y is t he spring-loaded pist on screw
(Fig. 16. 4) w hich is act ivat ed by moving t he w hole screw assembly f orw ards by
means of a screw driver.
Fig. 16. 3. Component s of a screw.

Fig. 16. 4. Spring-loaded pist on screw (Landin screw ).

Act ivat ion of a screw is limit ed by t he w idt h of t he periodont al ligament , as t o


exceed t his w ould result in crushing of t he ligament cells and cessat ion of t oot h
movement (see Chapt er 15).

16.3.3. Elastics
Special int ra-oral elast ics are manuf act ured f or ort hodont ic use (see Chapt er 17,
Fig. 17. 20). These elast ics are usually classif ied by t heir size, ranging f rom 1/ 8
inch t o 3/ 4 inch, and t he f orce t hat t hey are designed t o deliver, usually 2 oz, 3. 5
oz or 4. 5 oz. Select ion of t he appropriat e size and f orce is based upon t he root
surf ace area of t he t eet h t o be moved and t he dist ance over w hich t he elast ic is
t o be st ret ched. The elast ics should be changed every day.

16.4 COM M ONLY USED COM PONENTS


16.4.1. Labial movement of the incisors
Z-spring (Fig. 16.5)
This is act ually a small double-cant ilever spring f abricat ed in 0. 5 mm w ire. I t has
t he advant age t hat t he direct ion of movement can be alt ered. G ood ant erior
ret ent ion is required t o resist t he displacing eff ect of t his spring.

Fig. 16. 5. Z-spring.

Act ivat ion is by pulling t he spring about 1 2 mm aw ay f rom t he baseplat e at an


angle of approximat ely 45° in t he direct ion of desired movement (so t hat t he
spring is not caught on t he incisal edge as t he appliance is insert ed).

Double-cantilever spring (Fig. 16.6)


This spring is designed f or moving more t han one t oot h labially and is made in
0. 7 or 0. 8 mm w ire depending upon it s lengt h.
Fig. 16. 6. Double-cant ilever spring.

Act ivat ion is in t he same w ay as f or t he Z-spring.

Crossed-cantilever springs
This design is used f or proclining more t han one t oot h and also allow s variat ion
in t he direct ion of individual t oot h movement .
Act ivat ion is t he same as f or t he Z-spring.

Screw appliance (Fig. 16.7)


This design is helpf ul w here ret ent ion is limit ed, as t he incisors t o be moved can
also be clasped f or addit ional ret ent ion. How ever, a screw appliance t ends t o be
bulky, w hich limit s it s applicat ion t o t he movement of at least t hree incisors.
Fig. 16. 7. Screw appliance f or proclinat ion of t he incisors.

Act ivat ion is by giving t he screw one-quart er t urn every t hree t o f our days.

Landin screw (Fig. 16.4)


The pist on or Landin screw is used f or proclining one incisor, but t he direct ion of
t oot h movement is det ermined by t he t echnician's placement of t he screw in t he
acrylic. Now rarely used.
Act ivat ion is by t urning t he screw w it h a w at chmaker's screw driver (or f lat
plast ic inst rument ) in t he direct ion of movement (about 1 mm).

16.4.2. Palatal movement (retraction) of the incisors


Removable appliances are only indicat ed f or overjet reduct ion if t he upper
incisors are proclined and t he overjet not signif icant ly increased.

Labial bow (0.7 mm w ire)


A convent ional labial bow is really t oo st iff f or act ive overjet reduct ion. Alt hough
split t ing t he bow increases it s f lexibilit y, it also increases it s liabilit y t o dist ort ion
and t o causing t issue t rauma. O t her designs are pref erable.

Roberts retractor (Fig. 16.8)


This spring is made of 0. 5 mm w ire w hich is sheat hed w it h t ubing dist al t o t he
coils. While usef ul f or ret ract ing proclined incisors, it is diff icult t o repair and
requires an adequat e dept h of sulcus. A separat e ret aining appliance is
advisable af t er overjet reduct ion.
Fig. 16. 8. Robert s ret ract or.

Act ivat ion is by bending t he arms of t he spring t ow ards t he incisors.

Strap spring (Fig. 16.9)


The spring is also know n as a self -st raight ening arch. I t is f abricat ed by w inding
0. 5 mm w ire ont o a heavier labial bow w it h one end at t ached t o t he U-loop of t he
bow and t he ot her f ree-sliding. I t has t he advant age t hat t he same appliance can
be used f or canine ret ract ion, overjet reduct ion, and ret ent ion, as t he st rap
spring can easily be added and removed. Some ort hodont ist s recommend using
t w o st rap springs t o prevent f lat t ening of t he arch, w hilst ot hers f eel t hat t his is
unnecessary. Cert ainly, it is easier t o adjust and insert one st rap spring t han
t w o.

Fig. 16. 9. St rap spring appliance (t he palat al f inger spring on t he canine w as


removed at t his visit ). Not e t hat t he labial bow has been soldered t o t he
bridge of t he Adams clasp.
Act ivat ion is by t ight ening t he base labial bow, and not t he st rap spring it self . I t
is import ant t o ensure t hat t he f ree-sliding end is indeed f ree-sliding. I f it is not ,
t hen it is usually necessary t o replace t he st rap spring.

Elastics
Using elast ics t o reduce an overjet is popular w it h pat ient s as t hey are less
visible t han a met al spring. An appliance used f or canine ret ract ion can be
convert ed f or overjet reduct ion w it h elast ics by dividing t he labial bow and
f ashioning hooks adjacent t o t he upper canines. Alt ernat ively, a purpose-
designed appliance can be made. For most pat ient s a 3. 5 oz, 5/ 8 inch elast ic is
required. This met hod of overjet reduct ion should be avoided in cases w it h very
proclined incisors as t he elast ics t end t o slide up t he t eet h and ret ract t he
gingivae inst ead.
What ever t he means of overjet reduct ion, if a bit e-plane has been used f or
overbit e reduct ion t his must be t rimmed aw ay behind t he incisors as t hey are
ret ract ed. Adjust ment should be made f rom t he f it t ing surf ace, as w ell as
ant eropost eriorally (Fig. 16. 10). Cont act needs t o be maint ained w it h t he low er
incisors t o prevent t heir re-erupt ion, and t he bit e-plane should only be t rimmed
aw ay complet ely during t he f inal phases of overjet reduct ion.

Fig. 16. 10. Diagram show ing how a f lat ant erior bit e-plane should be
t rimmed during overjet reduct ion t o give space f or ret ract ion of t he upper
incisors and t heir associat ed gingivae. The bit e-plane should be maint ained
t o prevent re-erupt ion of t he low er incisors and only removed t ow ards t he
end of overjet reduct ion.

16.4.3. Mesial/distal movement of incisors


Palatal finger spring
See t he sect ion below on t he canine palat al f inger spring.
Act ivat ion (half a t oot h w idt h) as f or t he canine palat al f inger spring.

16.4.4. Retraction of canines


I t is somet imes t empt ing t o st art ret ract ion of a canine bef ore it has erupt ed
suff icient ly. Placement of an act ive spring on t he inclined mesial cusp of a canine
t oot h w ill at best delay f urt her erupt ion and may int rude t he t oot h.

Palatal finger spring (Fig. 16.11)


This design of spring has bet t er vert ical st abilit y t han a buccal ret ract or t his is
readily appreciat ed w hen t rying t o adjust a buccal spring. I t is w ise t o ask t he
t echnician t o box out t he acrylic overlying t he spring and t o place a guard w ire t o
prevent dist ort ion. To make adjust ment of a spring as st raight f orw ard as
possible t he coil should be posit ioned midw ay bet w een t he st art ing posit ion of
t he t oot h and t he int ended f inishing locat ion. Where possible, a palat al f inger
spring should be used in conjunct ion w it h a labial bow, as t his w ill help t o guide
t he t oot h around t he arch and prevent f laring of t he t oot h buccally.

Fig. 16. 11. Palat al f inger spring. Not e t hat t he spring is boxed in w it h acrylic
and a guard w ire is present t o help prevent dist ort ion.
Bef ore act ivat ion is at t empt ed t he spring should be adjust ed so t hat it is lying at
t he level of t he gingival margin w it h a point of applicat ion at 90° t o t he int ended
direct ion of movement . The spring can be act ivat ed at any point bet w een t he coil
and w here it emerges f rom underneat h t he guard w ire, but placing t he bend
nearer t o t he t ip of t he spring moves t he point of applicat ion more buccally. As a
rule of t humb an opt imal f orce f or canine ret ract ion is delivered by an act ivat ion
of just under half a t oot h w idt h.

Buccal canine retractor 0.5 mm tubed


Where a canine needs t o be moved palat ally a buccally approaching spring is
required. The aut hor's pref erred design is show n in Fig. 16. 1.
Act ivat ion is by w inding up t he coil or by adjust ing t he ant erior leg. How ever, t his
has t he eff ect of low ering t he point of applicat ion of t he spring, and a
compensat ory adjust ment of t he more post erior leg is needed t o correct t his.

Buccal canine retractor 0.7 mm


There are several permut at ions of t he 0. 7 mm buccal canine ret ract or. A similar
design t o t he 0. 5 mm ret ract or in Fig. 16. 1 or t he t ype show n in Fig. 16. 12 can
be used. This t ype of spring is know n colloquially as a c ut and bend spring, as
t his is t he manner by w hich it is act ivat ed.

Fig. 16. 12. C ut and bend buccal canine ret ract or.

Act ivat ion w ill depend upon t he design of spring used, but t o be eff ect ive it must
curve around and engage t he mesial aspect of t he t oot h. The disadvant age of a
ret ract or f ormed in 0. 7 mm w ire is t hat an act ivat ion of about 1 mm is required
t o deliver an opt imal f orce f or canine ret ract ion, and t his is diff icult t o achieve
precisely in pract ice.
16.4.5. Buccal movement of premolars and molars
T-spring
This spring is used f or t he buccal movement of a single premolar or molar t oot h
(Fig. 16. 13). G ood ret ent ion is required t o resist t he displacing eff ect of t he
spring.

Fig. 16. 13. T s pring.

Act ivat ion is by pulling t he spring aw ay f rom t he acrylic at an angle of 45°.

Screw appliance
This design is applicable if it is required t o move more t han one t oot h buccally,
f or example correct ion of a crossbit e by upper arch expansion (see Fig. 16. 2).
Act ivat ion: t he pat ient should give t he screw a one-quart er t urn t w ice a w eek
(f or example on a Wednesday and a Sat urday). I f opened t oo f ar, t he screw w ill
come apart ; t heref ore pat ient s should be w arned t hat if t he screw port ion
becomes loose t hey should t urn it back one t urn and not advance t he screw
again.

16.4.6. Mesial/distal movement of premolars and


molars
Palatal finger spring
See t he sect ion on t he canine palat al f inger spring.
Nudger appliance (Fig. 16.14)
This appliance is used in conjunct ion w it h headgear t o bands on t he f irst molar
t eet h. I t is usually used t o achieve dist al movement of t he molar t eet h w hen it is
int ended t o go ont o f ixed appliances t o complet e alignment . The appliance
incorporat es palat al f inger springs t o ret ract t he f irst permanent molars. The
appliance is w orn f ull-t ime and t he pat ient asked t o w ear t he headgear f or 12 t o
16 hours per day. The palat al f inger springs are only light ly act ivat ed w it h t he
aim of minimiszing f orw ard movement of t he molars w hen t he headgear is not
w orn. This appliance is also very usef ul if unilat eral dist al movement is required.
I n t his case t he cont ralat eral molar can be clasped t o aid ret ent ion. I f overbit e
reduct ion is required t hen a bit e-plane can be included in t he appliance. I t is
advisable t o f it t he bands on t he molar t eet h and t hen t ake an impression t o
f abricat e t he appliance.

Fig. 16. 14. Nudger appliance f or unilat eral movement of t he upper right f irst
permanent molar.

Act ivat ion: t he palat al f inger springs are act ivat ed 1 2 mm.

Screw appliance
This is similar t o t he design used f or buccal movement of one or t w o molars or
premolars, except t hat t he screw is posit ioned t o open ant eropost eriorly.

En masse appliance
The en masse appliance is used f or dist al movement of t he upper buccal
segment s w it h headgear. There are several variant s, but essent ially t he
appliance comprises ext ra-oral t ract ion, eit her as an int egral part of t he
appliance or by t ubes soldered t o t he bridge of t he cribs, w hich allow t he
insert ion of a f ace-bow and a means of expansion t o maint ain arch coordinat ion.
Act ivat ion: t he act ive f orce is provided by t he headgear and at least 14 1 6 hours
w ear per day is required. I f t he appliance incorporat es a midline screw t his
should be given a one-quart er t urn per w eek. A coff in spring is act ivat ed by
pulling apart t he t w o halves of t he appliance. (Somet imes appliances w it h a
coff in spring arrive f rom t he laborat ory w it hout t he acrylic being divided it is
advisable t o cut t he acrylic dow n t he middle bef ore at t empt ing t o act ivat e t he
coff in spring! )

16.4.7. Palatal movement of an individual tooth


Self-supporting buccal spring
As f or t he buccal canine ret ract or.
Act ivat ion is t he same as f or t he buccal canine ret ract or, bearing in mind t he
root surf ace area of t he t oot h t o be moved (i. e. less act ivat ion f or a lat eral
incisor).

16.5. RETAINING THE APPLIANCE


16.5.1. Adams clasp
This crib w as designed t o engage t he undercut s present on a f ully erupt ed f irst
permanent molar at t he junct ions of t he mesial and dist al surf aces w it h t he
buccal aspect of t he t oot h (Fig. 16. 15). The crib is usually f abricat ed in hard 0. 7
mm st ainless st eel w ire and should engage about 1 mm of undercut . I n pract ice
t his means t hat in children t he arrow heads w ill lie at or just below t he gingival
margin. How ever, in adult s w it h some gingival recession t he arrow heads should
lie part w ay dow n t he crow n of t he t oot h (Fig. 16. 16).

Fig. 16. 15. Adams clasp.


Fig. 16. 16. I deally t he Adams clasp should engage about 1 mm of undercut .
Theref ore in adult s w it h some gingival recession t he arrow heads w ill
probably lie part w ay dow n t he crow n of t he t oot h.

This crib can also be used f or ret ent ion on premolars, canines, cent ral incisors,
and deciduous molars. How ever, it is advisable t o use 0. 6 mm w ire f or t hese
t eet h. When second permanent molars have t o be ut ilized f or ret ent ion soon
af t er t heir erupt ion it is w ise t o omit t he dist obuccal arrow head, as lit t le
undercut exist s and if included it may irrit at e t he cheek.
The reason f or t he popularit y of t he Adams crib is it s versat ilit y as it can be
easily adapt ed:

Ext ra-oral t ract ion t ubes, labial bow s, or buccal springs can be soldered
ont o t he bridge of t he clasp (Fig. 16. 17; see also Fig. 16. 9).
Hooks or coils can be f abricat ed in t he bridge of t he clasp during
const ruct ion (Fig. 16. 18).
Double cribs can be const ruct ed (see Fig. 16. 12).
Fig. 16. 17. A t ube f or an ext ra-oral f ace-bow has been soldered t o t he
bridge of t his clasp.

Adjust ment : t he crib can be adjust ed in t w o places. Bends in t he middle of t he


f lyover w ill move t he arrow head dow n and in t ow ards t he t oot h. Adjust ment s
near t he arrow head w ill result in more movement t ow ards t he t oot h and w ill have
less eff ect in t he vert ical plane (Fig. 16. 19).

Fig. 16. 18. A loop w hich provides a hook f or placement of elast ic t ract ion
has been incorporat ed int o t his Adams crib.
Fig. 16. 19. Adjust ment of an Adams clasp.

16.5.2. Other methods of retention


Southend clasp (Fig. 16.20)
This clasp is designed t o ut ilize t he undercut beneat h t he cont act point bet w een
t w o incisors. I t is usually f abricat ed in 0. 7 mm hard st ainless st eel w ire.

Fig. 16. 20. Sout hend clasp


Adjust ment : ret ent ion is increased by bending t he arrow head in t ow ards t he
t eet h.

Ball-ended clasps (see Fig. 18.12)


These clasps are designed t o engage t he undercut int erproximally. This design
aff ords minimal ret ent ion and can have t he eff ect of prising t he t eet h apart .
Adjust ment : t he ball is bent in t ow ards t he cont act point bet w een t he t eet h.

Plint clasp (Fig. 16.21)


This clasp is used t o engage under t he t ube assembly on a molar band.

Fig. 16. 21. Plint clasp.

Adjust ment : by moving t he clasp under t he molar t ube.

Labial bow s (Fig. 16.22)


A labial bow is usef ul f or ant erior ret ent ion, part icularly if mesial or dist al t oot h
movement is planned, as it w ill help t o guide t oot h movement along t he arch and
prevent buccal f laring. Fit t ed labial bow s provide part icularly good ret ent ion and
are of t en employed in ret aining appliances f ollow ing f ixed appliance t reat ment .
Fig. 16. 22. Tw o t ypes of labial bow.

Adjust ment : t his w ill depend upon t he exact design of an individual bow.
How ever, t he most commonly used t ype w it h U-loops is adjust ed by squeezing
t oget her t he legs of t he U-loop and t hen adjust ing t he height of t he labial bow by
a bend at t he ant erior leg t o compensat e (Fig. 16. 23).

Fig. 16. 23. Diagram illust rat ing how t o t ight en a labial bow. The f irst
adjust ment is t o squeeze t oget her t he t w o legs of t he U-loop. This causes
t he ant erior sect ion of t he bow t o move occlusally and t heref ore a second
adjust ment is required t o lif t it back t o t he desired horizont al posit ion.

16.6. BASEPLATE
The ot her individual component s of a removable appliance are connect ed by
means of an acrylic baseplat e, w hich can be a passive or act ive component of
t he appliance.
16.6.1. Self-cure or heat-cure acrylic
Heat -curing of polymet hylmet hacrylat e increases t he degree of polymerizat ion of
t he mat erial and opt imizes it s propert ies, but is t echnically more demanding t o
produce. I t is common pract ice t o make t he majorit y of appliances in self -cure
acrylic, ret aining heat -cure acrylic f or t hose sit uat ions w here addit ional st rengt h
is desirable, f or example some f unct ional appliances.

16.6.2. Anterior bite-plane


I ncreasing t he t hickness of acrylic behind t he upper incisors f orms a bit e-plane
ont o w hich t he low er incisors occlude. A bit e-plane is prescribed w hen eit her t he
overbit e needs t o be reduced by erupt ion of t he low er buccal segment t eet h or
eliminat ion of possible occlusal int erf erences is necessary t o allow t oot h
movement t o occur.
Ant erior bit e-planes are usually f lat . I nclined bit e-planes may lead t o proclinat ion
or ret roclinat ion of t he low er incisors, depending upon t heir angulat ion, and
t heref ore should be avoided.
When prescribing a f lat ant erior bit e-plane t he f ollow ing inf ormat ion needs t o be
given t o t he t echnician:

How f ar post eriorly t he bit e-plane should ext end. This is most easily
conveyed by not ing t he overjet .
The dept h of t he bit e-plane. To increase t he likelihood t hat t he pat ient w ill
w ear t he appliance, t he bit e-plane should result in a separat ion of only 1 2
mm bet w een t he upper and low er molars. The dept h is prescribed in t erms of
t he height of t he bit e-plane against t he upper incisors, f or example half
height of t he upper incisor .

I n a proport ion of cases more t han 1 2 mm of overbit e reduct ion is required, and
t heref ore it w ill be necessary t o add t o t he height of t he bit e-plane during
t reat ment .

16.6.3. Buccal capping


Buccal capping is prescribed w hen occlusal int erf erences need t o be eliminat ed
t o allow t oot h movement t o be complet ed and reduct ion of t he overbit e is
undesirable. Buccal capping is produced by carrying t he acrylic over t he occlusal
surf ace of t he buccal segment t eet h (Fig. 16. 24) and has t he eff ect of propping
t he incisors apart . The acrylic should be as t hin as pract icably possible t o aid
pat ient t olerance. To assist adjust ment of post erior clasping, t he buccal capping
can be ext ended only half w ay across t he buccal segment t eet h. During t reat ment
it is not uncommon f or t he bit e-plane t o f ract ure aw ay and it is w ise t o w arn
pat ient s of t his, advising t hem t o ret urn if a sharp edge result s. How ever, if as a
result a t oot h is lef t f ree of t he acrylic and is liable t o over-erupt , a new
appliance w ill be necessary (as addit ions t o buccal capping are rarely
successf ul).

Fig. 16. 24. Buccal capping.

16.7. FITTING A REM OVABLE APPLIANCE


I t is alw ays usef ul t o explain again t o t he pat ient (and t heir parent / guardian) t he
overall t reat ment plan and t he role of t he appliance t hat is t o be f it t ed. I t is also
prudent t o delay any permanent ext ract ions unt il af t er an appliance has been
f it t ed and t he pat ient 's abilit y t o achieve f ull-t ime w ear has been demonst rat ed.

Table 16. 2 Instruments which are useful for fitting and adjusting
removable appliances

Adams pliers (no. 64)


Spring-forming pliers (no. 65)
Maun's wire cutters
Pair of autoclavable dividers
Steel rule (these are generally cheaper from
ironmongers than from dental supply companies)
A straight handpiece and an acrylic bur (preferably
tungsten carbide)
A pair of robust hollow-chop pliers is a useful
addition, but not essential

Fit t ing an appliance can be approached in t he f ollow ing w ay (see also Table
16. 2):

1. Check t hat you have t he correct appliance f or t he pat ient in t he chair


(everyone w ill make t his mist ake at some st age) and t hat your prescript ion
has been f ollow ed.
2. Show t he appliance t o t he pat ient and explain how it w orks. I t is advisable t o
st ress t o t he pat ient t hat t hey should not remove t he appliance by t he
springs.
3. Check t he f it t ing surf ace f or any roughness.
4. Try in t he appliance. I f it does not f it check t he f ollow ing:
Have any t eet h erupt ed since t he impression w as t aken? I f necessary,
adjust t he acrylic.
Have any t eet h moved since t he impression w as recorded? This usually
occurs if any ext ract ions have been recent ly carried out . O ccasionally, t o
salvage t he sit uat ion, it is necessary t o bend t he cribs f orw ard t o
compensat e f or ant erior movement of t he molars.
Has t here been a signif icant delay bet w een t aking t he impression and
f it t ing t he appliance?
5. Adjust t he ret ent ion unt il t he appliance just clicks int o place.
6. I f t he appliance has a bit e-plane or buccal capping, t his w ill need t o be
t rimmed so t hat it is act ive but not t oo bulky.
7. The act ive element (s) t o be used in t he f irst st age of t reat ment should be
gent ly act ivat ed, provided t hat ext ract ions are not required t o make space
available int o w hich t he t eet h are t o be moved.
8. G ive t he pat ient a mirror and demonst rat e how t o insert and remove t he
appliance. Then let t hem pract ice.
9. G o t hrough t he inst ruct ions w it h t he pat ient (and parent or guardian),
st ressing t he import ance of f ull-t ime w ear. A sheet out lining t he import ant
point s and cont aining det ails of w hat do in t he event of problems is
advisable, but unf ort unat ely is not alw ays read (Table 16. 3). Medicolegally it
is prudent t o not e in t he pat ient 's records if inst ruct ions have been given.
10. Arrange t he next appoint ment .
I f a w orking model is available, it is w ise t o st ore t his w it h t he pat ient 's st udy
models as it may prove helpf ul if t he appliance has t o be repaired

Table 16. 3 Sample instructions to patients for removable appliances

Your appliance should be worn all the time, including


meals and in bed at night
Your appliance should only be removed for tooth
cleaning and during vigorous sports (when it should
be stored in a strong container)
It is usual to experience some discomfort and a little
difficulty with speech initially, but this should pass in
a few days as you become accustomed to wearing
the appliance
It is important to avoid hard or sticky foods and
chewing gum
If you cannot wear your appliance as instructed or if
it becomes damaged or causes pain, please contact
( ) immediately.

16.8. M ONITORING PROGRESS


I deally, pat ient s w earing act ive removable appliances should be seen every 3 t o
4 w eeks. Act ivat ion of an appliance more f requent ly t han t his w ill increase t he
risk of anchorage loss and root resorpt ion (see Chapt er 15). The except ion t o
t his guideline is t he screw appliance w here only a small amount of act ivat ion is
possible at a t ime and t heref ore more f requent small act ivat ions are required.
Passive appliances can be seen less f requent ly, but it is advisable t o check, and
if necessary adjust , t he ret ent ion of t he clasps every 3 mont hs.
During act ive t reat ment it is import ant t o est ablish t hat t he pat ient is w earing t he
appliance as inst ruct ed. A more accurat e answ er may given in response t o t he
quest ion How much are you managing t o w ear your brace? rat her t han A re you
w earing your brace f ull-t ime? I ndicat ions of a lack of compliance include t he
f ollow ing:
t he appliance show s lit t le evidence of w ear and t ear;
t he pat ient lisps (ask t he pat ient t o count f rom 65 t o 70 w it h, and w it hout ,
t heir appliance);
no marks in t he pat ient 's mout h around t he gingival margins palat ally or
across t he palat e;
f requent breakages.

16.8.1. At each visit


I f w ear is sat isf act ory t he f ollow ing should be checked at each visit :

The t reat ment plan: t his may seem f acet ious, but it is all t oo easy t o lose
sight of t he precise aims of t reat ment . Ref erring back t o t he original plan w ill
ensure t hat each st ep is carried out met hodically and w ill act as a reminder
of how long t reat ment has been under w ay, so t hat progress can be
monit ored.
The pat ient 's oral hygiene.
Loss of anchorage by recording overjet and buccal segment relat ionship.
Toot h movement since t he last visit : a good t ip is t o use dividers w hich can
be imprint ed int o t he records.
Ret ent ion of t he appliance by asking t he pat ient and adjust ing t he clasps or
labial bow (see Sect ion 16. 5) as indicat ed.
Whet her t he act ive element s of t he appliance need adjust ment (see Sect ion
16. 4).

Whet her t he bit e-plane or buccal capping need t o be increased and/ or


adjust ed.
Record w hat act ion needs t o be undert aken at t he next visit .

16.8.2. Common problems during treatment


Slow rate of tooth movement
Normally t oot h movement should proceed at approximat ely 1 mm per mont h in
children, and less in adult s. I f progress is slow, check t he f ollow ing.

I s t he pat ient w earing t he appliance f ull-t ime? I f t he appliance is not being


w orn as much as required, t he implicat ions of t his need t o be discussed w it h
t he pat ient and t he parent . I f poor cooperat ion cont inues, result ing in a lack
of progress, considerat ion w ill have t o be given t o abandoning t reat ment .
Are t he springs correct ly posit ioned? I f not , explain again t o t he pat ient t he
purpose of t he spring and show t hem how t o insert t he appliance correct ly.
Are t he springs underact ive, overact ive, or dist ort ed? I f t he springs w ere
correct ly adjust ed at t he pat ient 's last visit (see Sect ion 16. 4), check t hat
t he pat ient is not using t hem t o remove t he appliance or put t ing it in t heir
pocket during meals.
I s t oot h movement obst ruct ed by t he acrylic or w ires of t he appliance? I f t his
is t he case, t hese should be removed or adjust ed.
I s t oot h movement prevent ed by occlusion w it h t he opposing arch? I t may be
necessary t o increase t he bit e-plane or buccal capping t o f ree t he occlusion.

Frequent breakage of the appliance


The main reasons f or t his are as f ollow s:

The appliance is not being w orn f ull-t ime.


The pat ient has a habit of clicking t he appliance in and out (see below ).
The pat ient is eat ing inappropriat e f oods w hilst w earing t he appliance.
Success lies in dissuading t he pat ient f rom eat ing hard and/ or st icky f oods
alt oget her. Part ial success is a pat ient w ho removes t heir appliance t o eat
hard or st icky f oods!

Appliance quickly becomes loose fitting


The most common cause of t his is a pat ient w ho is clicking t he appliance in and
out . This habit can also lead t o int rusion of t he t eet h, w hich are clasped by t he
appliance and t o f requent breakages. The pat ient 's close f amily are of t en very
grat ef ul if t he habit is st opped, as t he clicking noise t hat it generat es can be
very irrit at ing.

Excessive tilting of tooth being moved


Removable appliances are only capable of t ilt ing movement s. How ever, t his is
exaggerat ed by t he f ollow ing:

The f urt her t hat t he spring is f rom t he cent re of resist ance of t he t oot h t he
great er is t he degree of t ilt ing. Theref ore a spring should be adjust ed so t hat
it is as near t he gingival margin as possible w it hout causing gingival t rauma.

Excessive f orce is being applied t o t he t oot h, as t his has t he eff ect of


moving t he cent re of resist ance more apically.

Anchorage loss
This can be increased by t he f ollow ing:

Part -t ime appliance w ear, t hus allow ing t he anchor t eet h t o drif t f orw ards.
The f orces being applied by t he act ive element s exceed t he anchorage
resist ance of t he appliance. Care is required t o ensure t hat t he springs, et c.
are not being overact ivat ed or t hat t oo much act ive t oot h movement is being
at t empt ed at a t ime.

I f anchorage loss is a problem see Chapt er 15.

Palatal inflammation
This can occur f or t w o reasons:

1. Poor oral hygiene. I n t he majorit y of cases t he ext ent of t he inf lammat ion
exact ly mat ches t he coverage of t he appliance and is caused by a mixed
f ungal and bact erial inf ect ion (Fig. 16. 25). This may occur in conjunct ion w it h
angular cheilit is. Management of t his condit ion must address t he underlying
problem, w hich is usually poor oral hygiene. How ever, in marked cases it
may be w ise t o supplement t his w it h an ant if ungal agent (e. g. nyst at in,
amphot ericin, or miconazole gel) w hich is applied t o t he f it t ing surf ace of t he
appliance f our t imes daily. I f associat ed w it h angular cheilit is, miconazole
cream may be helpf ul.
2. Ent rapment of t he gingivae behind t he upper incisors during overjet reduct ion
bet w een t he incisors t hemselves and t he acrylic of t he bit e-plane (Fig.
16. 26). A mist ake commonly made during overjet reduct ion is t o t rim aw ay
t he f it t ing surf ace of t he appliance t o allow f or palat al movement of t he
incisors only, f orget t ing t hat space should also be creat ed f or ret ract ion of
t he palat al gingivae. To prevent t his f rom occurring, it is necessary t o
achieve good over-bit e reduct ion in t he init ial st ages of appliance t herapy
and t rim t he acrylic as show n in Fig. 16. 10 during overjet reduct ion.
Fig. 16. 25. I nf lammat ion of t he palat e corresponding t o t he coverage of a
removable appliance.

Fig. 16. 26. I nadequat e t rimming of t he f it t ing surf ace under t he ant erior bit e-
plane during overjet has result ed in ent rapment of t he gingivae bet w een t he
acrylic and t he t eet h.

Lack of overbite reduction


Lack of progress w it h overbit e reduct ion can be a problem in pat ient s w ho are
not act ively grow ing vert ically, such as adult s or t hose w it h a horizont al direct ion
of mandibular grow t h. I n t hese cases it may be necessary t o proceed ont o f ixed
appliances. I n children, t he most common reason f or lack of progress w it h
overbit e reduct ion is t hat t he appliance is not being w orn during meals. Pat ient s
should be advised t hat t heir t reat ment w ill be quicker and more successf ul if t hey
w ear t heir appliance f or eat ing, and t hat adapt at ion w ill be enhanced if t hey st art
w it h sof t er f oods.
16.9. LOWER REM OVABLE APPLIANCES
Low er removable appliances are rarely used because t hey are poorly t olerat ed
by pat ient s. Not only do t hey encroach upon t ongue space, but ret ent ion is a
problem ow ing t o t he lingual t ilt of t he low er molars and t he displacing act ion of
t he t ongue. I n addit ion, it is diff icult t o incorporat e lingual springs and t here is

limit ed dept h of sulcus f or buccal springs. Various designs have been suggest ed
t o overcome t hese short comings, but w here t oot h movement in t he low er arch is
required a f ixed appliance is usually more eff icient . Theref ore t he most
commonly used design of low er removable appliance is t he ret ainer.

16.10. APPLIANCE REPAIRS


Bef ore arranging f or a removable appliance t o be repaired t he f ollow ing should
be considered:

How w as t he appliance broken? I f a breakage has been caused by t he


pat ient f ailing t o f ollow inst ruct ions, it is import ant t o be sure any
cooperat ion problems have been overcome bef ore proceeding w it h t he
repair.
Would it be more cost -eff ect ive t o make a new appliance, perhaps
incorporat ing t he next st age of t he t reat ment planned?
O ccasionally it is possible t o adapt w hat remains of t he spring or anot her
component of t he appliance t o cont inue t he desired movement . For example,
a long labial bow can be cut and adapt ed t o f orm a buccal ret ract or.
I s t he w orking model available, or is an up-t o-dat e impression required t o
f acilit at e t he repair?
How w ill t he t oot h movement s w hich have been achieved be ret ained w hile
t he repair is being carried out ? O f t en t here is no alt ernat ive but t o t ry and
carry out t he repair in t he short est possible t ime.

PRINCIPAL SOURCES AND FURTHER READING


Houst on, W. J. B. and I saacson, K. G . (1980). O rthodonti c treatment wi th
removabl e appl i ances (2nd edn). Wright , Brist ol.

Houst on, W. J. B. and Wat ers, N. E. (1977). The design of buccal canine
ret ract ion springs f or removable ort hodont ic appliances. Bri ti sh Journal of
O rthodonti cs, 4, 191 5 .

Kerr, W. J. S. , Buchanan, I . B. , and McColl, J. H. (1993). Use of t he PAR


I ndex in assessing t he eff ect iveness of removable ort hodont ic appliances.
Bri ti sh Journal of O rthodonti cs, 20, 351 7 .

This st udy f ound t hat w hen removable appliances w ere used in select ed cases,
89 per cent show ed an improved or a great ly improved result (as indicat ed by
t he PAR I ndex).

Lloyd, T. G . and St ephens, C. D. (1979). Spont aneous changes in molar


occlusion af t er ext ract ion of all f irst premolars: a st udy of Class I I division 1
cases t reat ed w it h removable appliances. Bri ti sh Journal of O rthodonti cs, 6,
91 4 .
Authors: Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> Table of C ontents > 17 - Fixed applianc es

17
Fixed appliances

17.1. PRINCIPLES OF FIXED APPLIANCES


Fixed appliances are at t ached t o t he t eet h and are t hus are capable of a great er
range of t oot h movement s t han is possible w it h a removable appliance. Not only
does t he at t achment on t he t oot h surf ace (called a bracket ) allow t he t oot h t o be
moved vert ically or t ilt ed, but also a f orce couple can be generat ed by t he
int eract ion bet w een t he bracket and an archw ire running t hrough t he bracket
(Fig. 17. 1). Thus rot at ional and apical movement s are also possible. The
int erplay bet w een t he archw ire and t he bracket slot det ermines t he t ype and
direct ion of movement achieved. A bew ildering variet y of diff erent t ypes of
bracket are now manuf act ured, and t he choice of archw ire mat erials and
conf igurat ions is ext ensive. Theref ore, f or clarit y, w e shall consider t he
edgew ise t ype of bracket (Fig. 17. 2) in t his sect ion; ot her bracket syst ems are
described brief ly in Sect ion 17. 6.

Fig. 17. 1. G enerat ion of a f orce couple by t he int eract ion bet w een t he
bracket slot and t he archw ire.
Fig. 17. 2. Diagrammat ic represent at ion of an edgew ise bracket .

The edgew ise bracket is rect angular in shape and is t ypically described by t he
w idt h of t he bracket slot , usually 0. 018 or 0. 022 inch. The dept h of t he slot is
commonly bet w een 0. 025 and 0. 032 inch. Modif ying t he shape of t he bracket can
aff ect t oot h movement . For example, a narrow bracket (Fig. 17. 3) result s in a
great er span of archw ire bet w een t he bracket s w hich increases t he f lexibilit y of
t he archw ire. I n cont rast , a w ider bracket reduces t he int erbracket archw ire
span, but is more eff icient f or de-rot at ion and mesiodist al cont rol. Now adays a
w ide variet y of bracket designs are available. I n most modern appliance syst ems
each bracket is a diff erent w idt h corresponding t o t he t ype of t oot h f or w hich it
is int ended; f or example, low er incisors have t he narrow est bracket s (see
phot ographs of f ixed appliances show n lat er in t he chapt er).

Fig. 17. 3. Narrow er bracket s increase t he span of w ire bet w een bracket s,
t hus increasing t he f lexibilit y of t he archw ire. How ever, w ider bracket s allow
great er rot at ional and mesiodist al cont rol, as t he f orce couple generat ed has
a great er moment .
A round w ire in a rect angular edgew ise t ype of slot w ill give a degree of cont rol
of mesiodist al t ilt , vert ical height , and rot at ional posit ion. The closer t he f it of
t he archw ire in t he bracket , t he great er is t he cont rol gained. How ever, w it h a
round w ire only t ipping movement s in a buccolingual direct ion are possible (Fig.
17. 4). When a rect angular w ire is used in a rect angular slot , a f orce couple can
be generat ed by t he int eract ion bet w een t he w alls of t he slot and t he sides of
t he archw ire and buccolingual apical movement produced (Fig. 17. 5). How ever,
some t ipping movement s w ill t ake place bef ore t he rect angular w ires engage t he
sides of t he bracket slot , w it h t he degree of s lop depending on t he diff erences
bet w een t he dimensions of t he archw ire and t he bracket slot (Fig. 17. 6).
Thus f ixed appliances can be used in conjunct ion w it h rect angular archw ires t o
achieve t oot h movement in all t hree spat ial planes. I n ort hodont ics t hese are
described by t he t ypes of bend t hat are required in an archw ire t o produce each
t ype of movement (Fig. 17. 7):

First-order bends are made in t he plane of t he archw ire t o compensat e f or


diff ering t oot h w idt hs.
Second-order bends are made in t he vert ical plane t o achieve correct
mesiodist al angulat ion or t ilt of t he t oot h.
T hird-order bends are applicable t o rect angular archw ires only. They are
made by t w ist ing t he plane of t he w ire so t hat w hen it is insert ed int o t he
rect angular bracket slot a buccolingual f orce is exert ed on t he t oot h apex.
This t ype of movement is also know n as t orque.
Fig. 17. 4. When a round w ire is used in a rect angular slot , buccolingual
f orces t ip t he t oot h around a f ulcrum in t he root .

Fig. 17. 5. When a rect angular w ire is used w it h a rect angular slot more
cont rol of buccolingual root movement is achieved, allow ing bodily and
t orquing movement s t o be accomplished.
Fig. 17. 6. When an archw ire closely f it s t he dimensions of t he bracket slot
t here is less lat it ude bef ore it binds and t heref ore int eract s w it h t he bracket .
Wit h a smaller rect angular archw ire, more t ilt ing and rot at ion can occur
bef ore it binds w it h t he w alls of t he bracket slot . This lat it ude is know n as
s lop .

I n t he original edgew ise appliance (see below ) t hese bends w ere placed in t he
archw ire during t reat ment so t hat t he t eet h w ere moved int o t heir correct
posit ions. Modern bracket syst ems have average values f or t ip (Fig. 17. 8) and
t orque built int o t he bracket slot it self , and t he bracket bases are of diff ering
t hicknesses t o produce an average buccolingual crow n posit ion (know n
ingeniously as in o ut ). These p re-adjust ed syst ems have t he advant age t hat t he
amount of w ire bending required is reduced. How ever, t hey do not eliminat e t he
need f or archw ire adjust ment s because average values do not alw ays suff ice.
The disadvant age t o t hese pre-adjust ed syst ems is t hat a larger invent ory of
bracket s is required as each individual t oot h has diff erent requirement s in t erms
of t ip, in o ut , and t orque. Pre-adjust ed syst ems are discussed in more det ail in
Sect ion 17. 6.
Fig. 17. 7. (a) A f irst -order bend; (b) a second-order bend; (c) a t hird-order
bend.

Fig. 17. 8. Diagram (a) an edgew ise bracket w it h a second-order bend


placed in t he archw ire t o achieve t he desired amount of t ip. Diagram (b) a
pre-adjust ed bracket w it h t ip built int o t he bracket slot .

Whilst it is possible t o achieve a more sophist icat ed range of t oot h movement


w it h f ixed appliances t han w it h removable appliances, t he opport unit y f or
problems t o arise is increased. Fixed appliances are also more demanding of
anchorage, and t heref ore adequat e t raining should be sought bef ore embarking
on t reat ment w it h f ixed appliances.

17.2. INDICATIONS FOR THE USE OF FIXED


APPLIANCES
Correction of mild to moderate skeletal discrepancies As f ixed appliances
can be used t o achieve bodily movement it is possible, w it hin limit s, t o
compensat e f or skelet al discrepancies and t reat a great er range of
malocclusions.
Intrusion/ extrusion of teeth Vert ical movement of individual t eet h, or t oot h
segment s, requires some f orm of at t achment on t he t oot h surf ace ont o w hich
t he f orce can act .
Correction of rotations

O verbite reduction by intrusion of incisors


Multiple tooth movements required in one arch
Active closure of extraction spaces, or spaces due to hypodontia Fixed
appliances can be used t o achieve bodily space closure and ensure a good
cont act point bet w een t he t eet h.

Fixed appliances are not indicat ed as an alt ernat ive t o poor cooperat ion w it h
removable appliances. I ndeed, if a successf ul result is t o be achieved w it h t he
minimum of delet erious side-eff ect s, t reat ment w it h f ixed appliances should only
be embarked upon in pat ient s w ho are w illing t o:

maint ain a high level of oral hygiene;


avoid hard or st icky f oods and t he consumpt ion of sugar-cont aining
f oodst uff s bet w een meals;
cooperat e f ully w it h w earing headgear or elast ic t ract ion, if required;
at t end regularly t o have t he appliance adjust ed.

17.3. COM PONENTS OF FIXED APPLIANCES


Toot h movement w it h f ixed appliances is achieved by t he int eract ion bet w een t he
at t achment or bracket on t he t oot h surf ace and t he archw ire w hich is t ied int o
t he bracket . Bracket s can be carried on a band w hich is cement ed t o t he t oot h
or at t ached direct ly t o t he t oot h surf ace by means of an adhesive (know n
colloquially as bonds).

17.3.1. Bands
These are rings encircling t he t oot h t o w hich buccal, and as required, lingual,
at t achment s are soldered or w elded (Fig. 17. 9). Prior t o t he int roduct ion of t he
acid-et ch t echnique, bands w ere t he only means of at t aching a bracket t o a
t oot h. Wit h t he development of modern bonding t echniques, direct ly bonded
at t achment s became popular. How ever, many operat ors st ill use bands f or molar
t eet h because a band w ill remain i n si tu if cement f ailure occurs, w hereas a
debonded molar at t achment (t hrough w hich t he end of t he archw ire passes) may
t raumat ize a pat ient 's cheek. I n addit ion, a molar band is more secure w here
headgear is t o be used.

Fig. 17. 9. A low er f irst permanent molar band. Not e t he gingivally posit ioned
hook, w hich is usef ul f or applying elast ic t ract ion.

Bands can be used on t eet h ot her t han molars, most commonly f ollow ing t he
f ailure of a bonded at t achment or w here de-rot at ion or correct ion of a crossbit e
dict at e t he need f or bot h lingual and buccal at t achment s. How ever, t his must be
balanced against t he poorer aest het ics of a band (Fig. 17. 10).

Fig. 17. 10. Fixed appliance case w here bands have been used f or t he
canines, premolars and molar t eet h. The impact of bands upon t he aest het ics
of t he appliance can be readily appreciat ed.

Prior t o placement of a band it may be necessary t o separat e t he adjacent t oot h


cont act s. The most w idely used met hod involves placing a small elast ic doughnut
around t he cont act point (Fig. 17. 11), w hich is lef t i n si tu f or 2 t o 7 days and
removed prior t o band placement . These separat ing elast ics are insert ed by
being st ret ched, w it h eit her special pliers or f loss (Fig. 17. 12), and w orking one
side t hrough t he cont act point .

Fig. 17. 11. Separat ing elast ics have been placed bet w een t he cont act point s
of t he second premolars and f irst permanent molars prior t o placement of
bands on t he lat t er.

Fig. 17. 12. A separat ing elast ic being st ret ched bet w een t w o pieces of f loss.
O ne side of t he elast ic is t hen w orked t hrough t he cont act point so t hat it
encircles t he cont act point .

Band select ion is aided by t rying t o guess t he approximat e size of t he t oot h f rom
t he pat ient 's st udy models. A snug f it is essent ial t o help prevent t he band f rom
becoming loose during t reat ment . The edges of t he band should be f lush w it h t he
marginal ridges w it h t he bracket in t he midpoint of t he clinical crow n at 90° t o
t he long axis of t he t oot h (or crow n, depending upon t he t ype of bracket ). Most
ort hodont ist s use glass ionomer cement f or band cement at ion.
17.3.2. Bonds
Bonded at t achment s w ere int roduced w it h t he advent of t he acid-et ch t echnique
and t he modern composit e (see Sect ion 17. 3. 3). Adhesion t o t he base of met al
bracket s is gained by mechanical int erlock (Fig. 17. 13). More recent ly, ceramic
bracket s have been int roduced (Fig. 17. 14), but despit e t he obvious aest het ic
advant ages t heir use has been limit ed by a number of disadvant ages w hich are
current ly t he subject of considerable research. Ceramic bracket s w ere originally
market ed w it h a silane coupler designed t o provide chemical adhesion bet w een
t he bracket and t he bonding composit e. This w as unf ort unat ely so successf ul
t hat enamel f ract ure occasionally occurred during debonding, because t he bond
bet w een t he bracket and t he adhesive w as so st rong. Manuf act urers have t ried
t o overcome t his problem in a variet y of w ays, f or example using mechanical
rat her t han chemical ret ent ion, w it h varying success. Ceramic bracket s are
brit t le and are prone t o f ract ure in clinical usage. Fract uring aw ay of t he w ings
of t he bracket makes t ying in t he archw ire diff icult , and in addit ion t he bracket s
t end t o break up during removal of t he appliance. The hardness of ceramic
bracket s can lead t o w ear of opposing t eet h; t heref ore using ceramic bracket s
f or low er incisors is inadvisable. The hard ceramic can also not ch t he archw ire,
w hich makes sliding t he t eet h along t he w ire diff icult .

Fig. 17. 13. Bracket s f or bonding show ing a mesh base w hich increases t he
surf ace area f or mechanical at t achment of t he composit e.
Fig. 17. 14. A pat ient w it h ceramic bracket s on t he upper ant erior t eet h.

Edgew ise bracket s are subdivided according t o t he w idt h of t he bracket slot in


inches. Tw o syst ems are w idely used, 0. 018 and 0. 022. The dept h of t he slot
varies bet w een 0. 025 and 0. 032.

17.3.3. Orthodontic adhesives


The most popular cement f or cement ing bands is glass ionomer (Fig. 17. 15),
mainly because of it s f luoride-releasing pot ent ial and aff init y t o st ainless st eel
and enamel. G lass ionomers can also be used f or ret aining bonded at t achment s,
but unf ort unat ely t he bracket f ailure rat e w it h t his mat erial is great er t han t hat
w it h composit e. Much current research w ork is direct ed t ow ards hybrid
compomer mat erials w hich it is hoped w ill combine t he advant ages of composit es
and glass ionomer adhesives.

Fig. 17. 15. G lass ionomer cement .

Use of t he acid-et ch t echnique w it h a composit e produces clinically accept able


bonded at t achment f ailure rat es of t he order of 5 1 0 per cent f or bot h self - and
light -cured mat erials. Alt hough convent ional self -cured composit es can be used
f or bonding, a modif icat ion has been manuf act ured specif ically f or ort hodont ics
t o circumvent t he problem of air bubbles, w hich w ould obviously compromise
bond ret ent ion. No-mix ort hodont ic composit es (Fig. 17. 16) comprise an
act ivat or, w hich is paint ed ont o bot h t he bracket base and t he t oot h surf ace
(af t er et ching). Follow ing t his, a small amount of t he composit e it self is applied
t o t he bracket , w hich is t hen placed on t he t oot h surf ace under pressure.
Squeezing t he sandw ich of composit e and cat alyst int o a t hin layer mixes t he t w o
component s, and t he mat erial usually set s w it hin a f ew minut es.

Fig. 17. 16. No-mix composit e f or ort hodont ic bonding.

What ever mat erial is used, any excess should be cleared f rom t he perimet er of
t he bracket bef ore t he f inal set t o reduce plaque ret ent ion around t he bonded
at t achment .

17.3.4. Auxiliaries
Very small elast ic bands, of t en described as elast omeric modules (Fig. 17. 17),
or w ire ligat ures (Fig. 17. 18) are used t o secure t he archw ire int o t he archw ire
slot (Fig. 17. 19). Elast ic modules are quicker t o place and are usually more
comf ort able f or t he pat ient , but w ire ligat ures are of t en pref erred, part icularly in
t he

lat er st ages of t reat ment , as t hey can be t ight ened t o maximize cont act bet w een
t he w ire and t he bracket .
Fig. 17. 17. Coloured elast omeric modules used t o secure t he archw ire int o
t he bracket slot .

Fig. 17. 18. Met al ligat ures f or securing t he archw ire int o t he bracket slot .

Fig. 17. 19. This pat ient 's upper archw ire has been t ied int o place w it h w ire
ligat ures in t he upper arch and w it h elast omeric modules in t he low er arch.
Fig. 17. 20. I nt ra-oral elast ics.

Fig. 17. 21. A palat al arch, w hich is used t o help provide addit ional
anchorage in t he upper arch by helping t o resist f orw ard movement of t he
maxillary molars.
Fig. 17. 22. A propriet ary removable quadhelix. The dist al aspect of t he arms
of t he helix slot int o t he lingual sheat hs (also show n) w hich are w elded ont o
t he palat al surf ace of bands on t he upper molars.

I nt ra-oral elast ics f or t ract ion are commonly available in 2 oz, 3. 5 oz and 4. 5 oz
st rengt hs and a variet y of sizes, ranging f rom 1/ 8 inch t o 3/ 4 inch (Fig. 17. 20).
For most purposes t hey should be changed every day. Class I I and Class I I I
elast ic t ract ion is discussed in Sect ion 15. 6. Lat ex-f ree variet ies are now
available.
Palat al or lingual arches can be used t o reinf orce anchorage, t o achieve
expansion (t he quadhelix appliance), or molar de-rot at ion. They can be made in
t he laborat ory f rom an impression of t he t eet h (Fig. 17. 21). Propriet ary f orms of
most of t he commonly used designs are also available, and t hese have t he
addit ional advant age t hat t hey are removable, t hus f acilit at ing adjust ment (Fig.
17. 22).
Springs are an int egral part of t he Begg t echnique (see Sect ion 17. 6. 2).

17.3.5 Archwires
O nce an operat or has chosen t o use a part icular t ype of bracket , t he amount and
t ype of f orce applied t o an individual t oot h can be cont rolled by varying t he
cross-sect ional diamet er and f orm of t he archw ire, and/ or t he mat erial of it s
const ruct ion. I n t he init ial st ages of t reat ment a w ire w hich is f lexible w it h good
resist ance t o permanent def ormat ion is desirable, so t hat displaced t eet h can be
aligned w it hout t he applicat ion of excessive f orces. I n cont rast , in t he lat er
st ages of t reat ment rigid archw ires are required t o engage t he archw ire slot f ully
and t o provide f ine cont rol over t oot h posit ion w hile resist ing t he unw ant ed
eff ect s of ot her f orces, such as elast ic t ract ion.
The physical propert ies of an archw ire mat erial w hich are of int erest t o t he
ort hodont ist are as f ollow s.
Springback This is t he abilit y of a w ire t o ret urn t o it s original shape af t er a
f orce is applied. High values of springback mean t hat it is possible t o t ie in a
displaced t oot h w it hout permanent dist ort ion.
Stiffness The amount of f orce required t o def lect or bend a w ire. The
great er t he diamet er of an archw ire t he great er t he st iff ness.
Formability This is t he ease w it h w hich a w ire can be bent t o t he desired
shape, f or example t he placement of a coil in a spring, w it hout f ract ure.
Resilience This is t he st ored energy available af t er def lect ion of an archw ire
w it hout permanent def ormat ion.
Biocompatibility
Joinability This is w het her t he mat erial can be soldered or w elded.
Frictional characteristics I f t oot h movement is t o proceed quickly a w ire
w it h low surf ace f rict ion is pref erable.

Fig. 17. 23. The most popular archw ire mat erial is st ainless st eel w hich is
available in st raight lengt hs, as a coil on a spool, or pre-f ormed int o
archw ires.

Table 17. 1 Properties of some of the more commonly used archwire


materials

SS NiTi T MA CoCr*

Springback Low High Medium Low

Stiffness High Low Medium High


Formability Good Poor Good Good

Resilience Low High Medium Low

Biocompatibility Good ? Good Good

Friction Low Medium High Medium

SS, stainless steel; NiTi, nickel titanium; TMA, β-


titanium; CoCr, cobalt chromium.
*CoCr wires can be manipulated in the softened state
and then heat-treated to increase resistance to
deformation.

The most popular w ire is st ainless st eel (Fig. 17. 23), because it is relat ively
inexpensive, easily f ormed and exhibit s good st iff ness. Because of t hese
charact erist ics, st ainless st eel is part icularly usef ul in t he lat er st ages of
t reat ment . More f lexible st ainless st eel w ires have been developed w hich consist
of t hree or more st rands of f ine st ainless st eel w ire t w ist ed or braided t oget her.
These are know n as mult ist rand or t w ist f lex w ire (Fig. 17. 24) and t hey are more
f lexible t han a solid st ainless st eel w ire of comparable diamet er. How ever, w hilst
relat ively inexpensive, mult ist rand w ires can exert t oo high a f orce, and be
dist ort ed if t ied int o a markedly displaced t oot h.

Fig. 17.24. Multistrand wire (a) wound onto a coil and


(b) as an initial archwire to align the upper arch.
(a)

(b)

Alt ernat ively, ot her alloys w hich have a great er resist ance t o def ormat ion and
great er f lexibilit y can be used. O f t hese, nickel t it anium (Fig. 17. 25) is t he most
popular. Archw ires made of nickel t it anium are capable of applying a light f orce
w it hout def ormat ion, even w hen def lect ed several millimet res, but t his alloy is
more expensive t han st ainless st eel. By virt ue of t heir f lexibilit y, nickel t it anium
w ires provide less cont rol against t he unw ant ed side-eff ect s of auxiliary f orces.
Cobalt chromium has t he advant age t hat it can be readily f ormed, and t hen t he
st iff ness and rigidit y of t he archw ire can be improved by heat -t reat ment . β -
t it anium, popularly know n as TMA (t ungst en molybdenum alloy), has propert ies
midw ay bet w een st ainless st eel and nickel t it anium; it has been est imat ed t hat a
β -t it anium w ire exert s approximat ely half t he f orce of a st ainless st eel w ire of
comparable diamet er. I t is of t en employed in t he lat er st ages of t reat ment , being
part icularly usef ul w hen t he operat or w ishes t o t orque individual t eet h.
Fig. 17. 25. Nickel t it anium w ire.

Archw ires are described according t o t heir dimensions. An archw ire described as
0. 016 inches (0. 4 mm) is a round archw ire, and an 0. 016 × 0. 022 inches (0. 4 ×
0. 55 mm), is a rect angular archw ire.
Archw ires are available in st raight lengt hs, as coils, or as pref ormed archw ires
(see Fig. 17. 23). The lat t er variant is more cost ly t o buy but saves chairside
t ime. There are a w ide variet y of archf orm shapes; how ever, regardless of w hat
design is chosen, some adjust ment of t he archw ire t o mat ch t he pret reat ment
archf orm of t he pat ient w ill be required (see Sect ion 17. 4).
The f orce exert ed by a part icular archw ire mat erial is given by t he f ormula

w here d is t he dist ance t hat t he spring/ w ire is def lect ed, r is t he radius of t he
w ire, and l is t he lengt h of t he w ire.
Thus it can be appreciat ed t hat increasing t he diamet er of t he archw ire w ill
signif icant ly aff ect t he f orce applied t o t he t eet h, and increasing t he lengt h or
span of w ire bet w een t he bracket s w ill inversely aff ect t he applied f orce. As
ment ioned earlier, t he dist ance bet w een t he bracket s can be increased by
reducing t he w idt h of t he bracket s, but t he int erbracket span can also be
increased by t he placement of loops in t he archw ire. Prior t o t he int roduct ion of
t he new er more f lexible alloys, mult ilooped st ainless st eel archw ires w ere
commonly used in t he init ial st ages of t reat ment . Loops are st ill ut ilized in
ret ract ion archw ires (see Sect ion 17. 5) and w here a combinat ion of a rigid
archw ire (t o resist unw ant ed f orces) w it h localized f lexibilit y is required.
17.4. TREATM ENT PLANNING FOR FIXED APPLIANCES
By virt ue of t heir coverage of t he palat e, removable appliances inherent ly
provide more anchorage t han f ixed appliances. I t is import ant t o remember t hat ,
w it h a f ixed appliance, movement of one t oot h or a segment of t eet h in one
direct ion w ill result in an equal but opposit e f orce act ing on t he remaining t eet h
included in t he appliance. I n addit ion, apical movement w ill place a great er st rain
on anchorage. For t hese reasons it is necessary t o pay part icular at t ent ion t o
anchorage w hen planning t reat ment involving f ixed appliances and, if necessary,
t his can be reinf orced w it h headgear and/ or a palat al or lingual arch (see
Chapt er 15).

Fig. 17. 26. The amount of adjust ment required t o a pre-f ormed low er
archw ire, as t aken f rom t he packet , t o ensure t hat it conf orms t o t he
pat ient 's pret reat ment archf orm and w idt h.

The import ance of keeping t he t eet h w it hin t he zone of sof t t issue balance has
been discussed in Chapt er 7. Theref ore care is required t o ensure t hat t he arch-
f orm, part icularly of t he low er arch, present at t he beginning of t reat ment is
largely preserved. I t is w ise t o check t he dimensions of any archw ire against a
model of t he low er arch, t aken bef ore t he st art of t reat ment (Fig. 17. 26),
bearing in mind t hat t he upper arch w ill of necessit y be slight ly broader. O f
course, t here

are except ions, as discussed in Chapt er 7. How ever, t hese should be f oreseen
at t he t ime of t reat ment planning and, if necessary, t he implicat ions f or ret ent ion
of t he f inal result discussed f ully w it h t he pat ient at t hat t ime.

17.5. PRACTICAL PROCEDURES


Accurat e bracket placement is crucial t o achieving success w it h f ixed
appliances. The c orrect posit ion of t he bracket on t he f acial surf ace w ill depend
upon t he bracket syst em used. Some f ixed appliance syst ems require t he
operat or t o posit ion t he bracket at diff erent height s on each t oot h t o compensat e
f or diff ering crow n lengt hs. O t hers, not ably t he pre-adjust ed syst ems, require
t he bracket t o be placed in t he middle of t he t oot h along t he long axis of t he
clinical crow n. Bracket placement is part icularly import ant w it h t hese pre-
adjust ed syst ems, as t he values f or t ip and t orque are calculat ed f or t he
midpoint of t he f acial surf ace of t he t oot h. I ncorrect bracket posit ioning w ill lead
t o incorrect t oot h posit ion and ult imat ely aff ect t he f unct ional and aest het ic
result ; t heref ore errors in bracket placement should be correct ed as early as
possible in t he t reat ment . Alt ernat ively, adjust ment s can be made t o each
archw ire t o compensat e, but over t he course of a t reat ment t his can be t ime-
consuming.
As ment ioned in Sect ion 17. 3. 5, w hen a f ixed appliance is f irst placed a f lexible
archw ire is advisable t o avoid applying excessive f orces t o displaced t eet h,
w hich can be painf ul f or t he pat ient and result in bond f ailure. Commonly, eit her
a pre-f ormed nickel t it anium archw ire or a mult ist randed st ainless st eel archw ire
is used t o achieve init ial alignment . Alt ernat ively, loops can be placed in a
st ainless st eel archw ire, as ment ioned in Sect ion 17. 3. 5, t o increase t he span of
w ire bet w een bracket s and t hus increase f lexibilit y. This approach is usef ul if a
rigid archw ire is desirable in ot her areas of t he arch.
I t is import ant t o move on f rom t hese init ial aligning archw ires as soon as
alignment is achieved, as by virt ue of t heir f lexibilit y t hey do not aff ord much
cont rol of t oot h posit ion. How ever, it is equally import ant t o ensure t hat f ull
bracket engagement has been achieved bef ore proceeding t o a more rigid
archw ire. I n t he edgew ise or pre-adjust ed appliance syst ems it is usual t o
progress t hrough round archw ires of increasing diamet er t o achieve
progressively bet t er int ra-arch alignment . I f t oot h alignment alone is required, f or
example in a Class I malocclusion w it h rot at ions, a st iff round archw ire w hich
nearly f ills t he bracket slot w ill suff ice. How ever, correct ion of int er-arch
relat ionships and space closure is usually best carried out using rect angular
w ires f or apical cont rol. The exact archw ire sequence w ill depend upon t he
dimensions of t he archw ire slot and operat or pref erence.
Mesiodist al t oot h movement can be achieved by one of t he f ollow ing:

1. Moving t eet h w it h t he archw ire: t his is achieved by incorporat ing loops int o
t he archw ire w hich, w hen act ivat ed, move a sect ion of t he archw ire and t he
at t ached t eet h as show n in Fig. 17. 27.
2. Sliding t eet h along t he archw ire (Fig. 17. 28), usually under t he inf luence of
elast ic f orce: t his approach requires great er f orce t o overcome f rict ion
bet w een t he bracket and t he w ire, and t heref ore places a great er st rain on
anchorage. This t ype of movement is know n as s liding mechanics and is
more applicable t o pre-adjust ed appliances w here a st raight archw ire is
used. I n t he edgew ise appliance t he f irst -, second-, and t hird-order bends
necessary in t he archw ire make sliding t eet h along it diff icult .
Fig. 17. 27. A sect ional archw ire t o ret ract / 3.

Fig. 17. 28. Sliding t eet h along t he archw ire using a nickel t it anium coil
spring.

Fig. 17. 29 show s t he st eps involved in t he t reat ment of a maximum anchorage


Class I I division 1 malocclusion w it h f ixed appliances.

Fig. 17.29. (a) The right buccal view of a 12-year-old


patient with a Class II division 1 malocclusion and
previous extraction of all first premolars. It was decided
to gain space for reduction of the overjet by using
headgear to 6/6. (b) Retraction of 3/3 with a sectional
archwire, whilst a lower fixed appliance is used to align
the lower arch and reduce the overbite. (c) The molars
and canines are now Class I, with the overbite reduced.
(d) Retraction of 21/12 with a looped archwire to reduce
the overjet. (e) At the completion of treatment.

(a)

(b)

(c)

(d)
(e)

Adjust ment s t o t he appliance need t o be made on a regular basis, usually every


6 w eeks. O nce space closure is complet e and incisor posit ion correct ed, some
operat ors w ill place a more f lexible f ull-sized archw ire, of t en in conjunct ion w it h
vert ical elast ic t ract ion, t o help s ock-in t he buccal occlusion.
The subject of ret ent ion is covered in more det ail in t he chapt er on ret ent ion.
How ever, in order t o t ry and overcome t he great er t endency f or relapse of
rot at ional or apical movement s, some ort hodont ist s overcorrect t hese aspect s of
a malocclusion.

17.6. FIXED APPLIANCE SYSTEM S


17.6.1. Pre-adjusted appliances
Because of t heir advant ages t hese syst ems are now universally accept ed. The
need f or f irst -, second-, and t hird-order bends in t he archw ire during t reat ment
is considerably reduced because t he bracket s are manuf act ured w it h t he slot cut
in such a w ay t hat t hese movement s are built in. Theref ore plain pref ormed
archw ires can be used so t hat t he t eet h are moved progressively f rom t he very
st art of t reat ment t o t heir ideal posit ion. Hence t hey are also know n as t he
st raight w ire appliance.
As individual t oot h posit ions are built int o t he bracket , it is necessary t o produce
a bracket f or each t oot h, but t he t ime saved in w ire bending and t he superior
result s achieved more t han compensat e f or t he increased cost of purchasing a
great er invent ory of bracket s. How ever, a pre-adjust ed bracket syst em w ill not
eliminat e t he need f or w ire bending as only average values are built int o t he
appliance, and of t en addit ional individual bends need t o be placed in t he
archw ire.
Not surprisingly, t here are many diff erent opinions as t o t he correct posit ion of
each t oot h, and many manuf act urers keen t o join a lucrat ive market . The result is
an almost bew ildering array of pre-adjust ed syst ems, all w it h slight ly diff ering

degrees of t orque and t ip. O f t hese perhaps t he best know n are t he Andrew s
prescript ion, developed by Andrew s, t he f at her of t he st raight w ire appliance
(see Table 17. 2) and t he Rot h syst em.

Table 17. 2 Typical pre-adjusted values for tip and torque (at mid-point of
facial surface)

Torque (deg) Tip (deg)

Maxilla

Central incisor 7 5

Lateral incisor 3 9

Canine 7 11

First premolar -7 2

Second premolar -7 2

First molar -9 5

Second molar -9 5

Mandible

Central incisor -1 2

Lateral incisor -1 2

Canine -11 5

First premolar -17 2


Second premolar -22 2

First molar -26 2

Second molar -31 2

Fig. 17. 30. A f low diagram show ing t he sequence of t reat ment w it h a 022
pre-adjust ed bracket syst em.

Fig. 17. 30 is a f low diagram illust rat ing one approach t o using a pre-adjust ed
appliance syst em.
17.6.2. Begg appliance
Named af t er it s originat or, t he Begg appliance (Fig. 17. 31) is based on t he use
of round w ire w hich f it s f airly loosely int o a channel at t he t op of t he bracket .
Apical and rot at ional movement is achieved by means of auxiliary springs or by
loops placed in t he archw ire. Begg used d iff erent ial f orce syst ems t o accomplish
t oot h movement , claiming t hat t he int ra-oral f orces w ere adjust ed so t hat t hey
w ere opt imal f or movement of t he ant erior segment t eet h w hilst ensuring t hat t he
post erior segment t eet h act ed as an anchorage unit . The Begg appliance w as
of t en used in conjunct ion w it h ext ract ions t o provide int ra-oral anchorage, so t hat
reliance w as not placed on t he pat ient w earing headgear. How ever, pat ient
compliance w it h w earing elast ics f or t he durat ion of t reat ment w as required
inst ead.

Fig. 17. 31. This show s t he problems posed f or t oot hbrushing by t he Begg
appliance.

Fig. 17. 32. A Tip Edge bracket .


Apart f rom t he problems experienced by pat ient s cleaning around t he auxiliary
springs f avoured in t he Begg t echnique, t he main draw back t o t his appliance is
t hat it is diff icult t o posit ion t he t eet h precisely at t he end of t reat ment .

17.6.3 Tip Edge appliance


This appliance w as designed w it h t he aim of combining t he advant ages of bot h
t he st raight w ire and t he Begg syst ems. O rt hodont ist s disagree as t o t he ext ent
t o w hich t he Tip Edge t echnique achieves t his. The Tip Edge bracket (Fig.
17. 32), allow s t ipping of t he t oot h in t he init ial st ages of t reat ment w hen round
archw ires are employed, as in t he Begg t echnique, but w hen f ull-sized
rect angular archw ires are used in t he lat t er st ages, t he built -in pre-adjust ment s
help t o give a bet t er degree of cont rol of f inal t oot h posit ioning.

17.7. DECALCIFICATION AND FIXED APPLIANCES


Placement of a f ixed at t achment upon a t oot h surf ace leads t o plaque
accumulat ion. I n addit ion, if a diet rich in sugar is consumed, t his result s in
demineralizat ion of t he enamel surrounding t he bracket and occasionally f rank
cavit at ion. The incidence of decalcif icat ion (Fig. 17. 33) w it h f ixed appliances has
been variously report ed as bet w een 15 and 85 per cent . As any decalcif icat ion is
undesirable, considerable int erest has f ocused on w ays of reducing t his problem.
The main approaches t hat have been used are as f ollow s:

Fig. 17. 33. Pict ure show ing severe decalcif icat ion f ollow ing f ixed appliance
t reat ment (nat urally t his pat ient w as not t reat ed by t he aut hor! )

1. Fluoride mout h rinses f or t he durat ion of t reat ment . The problem w it h t his
approach is t hat t he individuals most at risk of decalcif icat ion are t hose least
likely t o comply f ully w it h a rinsing regime.
2. Local f luoride release f rom f luoride-cont aining cement s and bonding
adhesives. Variable result s have been report ed f or t hose composit es w hich
have been market ed f or t heir f luoride-releasing pot ent ial. G lass ionomer
cement s have been show n t o be eff ect ive at reducing t he incidence of
decalcif icat ion around bands, w hilst achieving equal or bet t er ret ent ion
result s t han convent ional cement s. Alt hough glass ionomer cement s appear
eff ect ive at reducing decalcif icat ion around bonded at t achment s, t his is at
t he expense of poorer ret ent ion rat es (see Sect ion 17. 3. 3).

3. Diet ary advice. This import ant aspect of prevent ive advice should not be
f orgot t en. Pat ient s are of t en advised t o avoid chew y sw eet s during
t reat ment , but t he import ance of avoiding sugared beverages and f izzy
drinks, part icularly bet w een meals, should not be overlooked.

17.8. STARTING WITH FIXED APPLIANCES


I t is ext remely unw ise t o embark on t reat ment w it h f ixed appliances w it hout f irst
gaining some expert ise in t heir use. This is best achieved by a longit udinal
course in t he f orm of an apprent iceship w it h a skilled operat or. I t is mandat ory
t hat t his is supplement ed by a t horough appreciat ion of ort hodont ic diagnosis
and t reat ment planning, so t hat t he novice ort hodont ist realizes his or her
limit at ions and is select ive in t he t ype of case t ackled. The 2 or 3 day courses
comprising a pract ical t ypodont w it h a small t heoret ical element are alw ays
heavily oversubscribed, but most serve t o put off t he general dent al pract ioner
(perhaps not unint ent ionally). They do not provide an adequat e basis f or
launching int o f ixed appliances, unless a more experienced ort hodont ist is readily
available f or advice.
Some ort hodont ic supply companies off er t he pract ioner a kit cont aining
bracket s, bands, and a f ew archw ires in ret urn f or an impression and a f ee. O f
course, t his is an expensive alt ernat ive and, in addit ion, bands select ed f rom an
impression are unlikely t o be a good f it . Those int erest ed in gaining f urt her
ort hodont ic skills are advised t o gain adequat e experience on a longit udinal basis
and t o buy an adequat e st ock of pliers, bands, and bracket s t o make f ixed
appliance t reat ment rew arding and successf ul f or bot h t he pract it ioner and
pat ient .

PRINCIPAL SOURCES AND FURTHER READING


How els, D. J. (1986). The st raight -w ire appliance. Dental Update, 13, 367 7 6.

T he background t o, and use of , t he f irst pre-adjust ed syst em.

Williams, J. K. , I saacson, K. G . , and Cook, P. A. (1995). Fi xed orthodonti c


appl i ances. Pri nci pl es and practi ces. But t erw ort h Heinemann, London.
An excellent book, w hich should be read by anyone using f ixed appliances.

Kapila, S. and Sachdeva, R. (1989). Mechanical propert ies and and clinical
applicat ions of ort hodont ic w ires. Ameri can Journal of O rthodonti cs and
Dentof aci al O rthopedi cs, 96, 100 9 .

An excellent , and readable, account of archw ire mat erials.

Kusy, R. P. (1997). A review of cont emporary archw ires: t heir propert ies and
charact erist ics. Angl e O rthodonti st, 67, 197 2 07.

Millet t , D. T. and G ordon, P. H. (1994). A 5-year clinical review of bond f ailure


w it h a no-mix adhesive (Right -on). European Journal of O rthodonti cs, 16,
203 11.
This paper provides scient if ic just if icat ion f or all t he old w ives t ales about bond
f ailure rat es.

Rock, P. (1995). A pract ical int roduct ion t o f ixed appliances: t he st raight w ire
appliance. Dental Update, 22, 18 2 1, 61 5 .

O Higgins, E. A. et al . (1999). The inf luence of maxillary incisor inclinat ion on


arch lengt h. Bri ti sh Journal of O rthodonti cs, 26, 97 1 02.

A f ascinat ing art icle a m ust read f or t hose pract it ioners using f ixed
appliances.

Shaw, W. C. (ed. ) (1993). O rthodonti cs and occl usal management. Wright ,


Brist ol.

Chapt er 15 on f ixed appliances is w ell w rit t en and inf ormat ive and is
complement ed by t he chapt er on common t reat ment procedures.
Authors: Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> Table of C ontents > 18 - Func tional applianc es ( N. E . C ar ter )

18
Functional appliances (N. E. Carter)

18.1. INTRODUCTION
The f unct ional appliances are a group of ort hodont ic appliances w hich are quit e
dist inct in t he w ay t hat t hey w ork. I n general t hey have no act ive component s
such as springs or elast ics, but inst ead harness f orces generat ed by t he
mast icat ory and f acial musculat ure (t hey are of t en called myof unct ional
appliances). This is achieved by const ruct ing t he appliance such t hat it holds t he
mandible in a post ured posit ion aw ay f rom it s posit ion of rest , and, w hilst t here
are many designs of f unct ional appliance, t hey all engage bot h dent al arches and
cause mandibular post uring w it h displacement of t he condyles w it hin t he glenoid
f ossae. Funct ional appliances of all t ypes are most eff ect ive during act ive
grow t h.
The purpose of f unct ional appliances is t o alt er t he ant eropost erior occlusion
bet w een t he t w o dent al arches, and t hey cannot on t heir ow n t reat irregularit ies
of arch alignment such as crow ding. The t emporomandibular joint s primarily
permit opening and prot rusion of t he mandible, and t he vast majorit y of f unct ional
appliances are made t o a f orw ard post ured w orking bit e. Thus t hey are most ly
used in t he t reat ment of Class I I malocclusions, part icularly Class I I division 1
w here t he overjet is increased.
Bef ore discussing f unct ional appliances in det ail, Fig. 18. 1 gives an overview of
t his t ype of f unct ional appliance in clinical use. This pat ient has a Class I I
division 1 malocclusion of t he t ype f or w hich f unct ional appliances are very
suit able, and f or w hich t hey have been used f or many years.
There are a number of import ant f eat ures t o not e w hich w ill be discussed f urt her
lat er in t he chapt er. First , t he pat ient is st ill grow ing and t he signs are t hat her
pat t ern of f acial grow t h is likely t o be f avourable. Alt hough t he skelet al pat t ern is
Class I I , t he vert ical relat ionships are close t o average and t he direct ion of
mandibular grow t h is likely t o be a mild f orw ard rot at ion (see Chapt er 4) w hich is
f avourable t o t he correct ion of a Class I I malocclusion. Second, t he sof t t issue
morphology is f avourable despit e t he lips being incompet ent , w it h t he low er lip
rest ing behind t he upper incisors. The low er lip line is above t he level of t he
upper incisal edges, and af t er t he overjet has been reduced t he low er lip w ill
rest labially t o t he upper incisors, so helping t o resist any t endency f or relapse
of t he overjet . Third, t he arches are w ell aligned f unct ional appliances have no
mechanism f or t reat ing irregularit ies of alignment of t he t eet h.
The appliance holds t he mandible in a f orw ard post ured posit ion, in t his case
w it h t he incisors edge t o edge (Fig. 18. 1(f )). The f acial musculat ure is t hus
st ret ched, and applies a post erior f orce t o t he upper arch and an ant erior f orce
t o t he low er arch. The low er incisors have acrylic capping t o prevent excessive
labial t ilt ing of t he low er incisors, and t his also serves as a bit e-plane t o reduce
t he overbit e (Chapt er 10). The appliance must be w orn f or at least 14 1 6 hours
each day, but once t he overjet has been reduced f ully t he amount of daily w ear
can gradually be reduced t o sleeping hours only. The pat ient should cont inue t o
w ear t he appliance overnight in t his w ay as a ret ainer, at least unt il t he period of
rapid pubert al grow t h is complet e. Figures 18. 1(g) and 18. 1(h) show t he dent al
and f acial changes w hich occurred during t reat ment .
A f unct ional appliance can be used as t he f irst part of a t w o-st age t reat ment , in
w hich t he overjet is reduced, f ollow ed by a second phase of t reat ment w it h f ixed
appliances t o deal w it h crow ding or ot her irregularit ies of dent al alignment .

Fig. 18.1. (a) This 12-year-old girl had a skeletal II


facial pattern and average facial proportions. The lips
were incompetent with the lower lip lying below the
upper incisors at rest. (b), (c) She had a Class II
division 1 malocclusion with an overjet of 10 mm, the
overbite was increased and complete, and the molar
relationship was Class II on both sides. (d), (e) The
upper and lower arches were well aligned. (f) A
functional appliance (an activator) was fitted. (g) The
corrected occlusion with Class I incisor and molar
relationships. (h) The patient's facial profile at the end
of treatment.
(a)

(b)

(c)
(d)

(e)

(f)

(g)
(h)

18.2. M ODE OF ACTION


The w ay t hat f unct ional appliances w ork is not f ully underst ood, but t hey are
t hought t o achieve t heir eff ect by t he post uring of t he mandible causing
st ret ching of t he f acial musculat ure. This generat es f orces w hich are delivered
primarily t o t he t eet h, and t here is no doubt t hat a post eriorly direct ed f orce act s
upon t he upper arch and an ant eriorly direct ed f orce must t heref ore act upon t he
low er. How ever, it is t he clinical impression of many ort hodont ist s t hat t here are
more w idespread eff ect s upon t he f acial skelet on as w ell as upon t he dent it ion.
The sit es w here f unct ional appliances might induce f acial changes are t he
maxillary complex, t he mandible, and t he glenoid f ossa.

The ext ent of t hese changes has become somet hing of a cont roversy w it hin
ort hodont ics. There are t hose w ho claim t hat f unct ional appliances alt er t he
environment of t he grow ing f acial skelet on enough t o bring about signif icant
changes in t he grow t h pat t ern. The alt ernat ive point of view is t hat grow t h of t he
f acial skelet on is under close genet ic cont rol and t heref ore ort hodont ic
appliances can have lit t le eff ect ot her t han t o move t he t eet h w it hin t he alveolar
bone. The t rut h probably lies somew here in bet w een. How ever, one import ant
principle is clear: f unct ional appliances only w ork in grow ing children and have
t heir great est eff ect w hen grow t h is most rapid.
Much research eff ort is direct ed at t rying t o det ermine w hat impact f unct ional
appliances have upon f acial grow t h, but st udies in t his f ield f ace problems and
limit at ions. The main t ypes of research have been animal experiment s and
cephalomet ric st udies of human subject s.
Animal studies allow great er cont rol of t he experiment al condit ions t han is
possible w it h human clinical st udies. For example, variables such as t he genet ic
background of t he animals can be cont rolled and operat ive t echniques can be
st andardized. Precise measurement s of t he jaw s can be made af t er sacrif ice,
and st udies at a cellular level can demonst rat e changes indicat ive of act ive
grow t h, f or inst ance in t he mandibular condyle. These st udies have involved
various species but primat es are most relevant t o t he human sit uat ion. How ever,
primat e st udies are very expensive and t heref ore t he numbers of animals
involved are small. There are also t he obvious limit at ions t hat species ot her t han
t he human are being invest igat ed and t hat t he regime of appliance w ear is
diff erent . Appliances t o produce mandibular post uring in animals have usually
been f ixed, unlike t he f unct ional appliances f or humans w hich are removable and
are w orn only part -t ime. Animal f acial morphology is very diff erent and t he f acial
skelet al discrepancies seen in humans are almost unknow n in animals; t heref ore
t he appliances are usually making normal occlusions become abnormal. Thus t he
changes seen in animals do not compare direct ly w it h humans and t he result s
must be applied t o human clinical pract ice w it h caut ion.
Human studies of necessit y are non-invasive, and cephalomet ric radiography
has proved t o be a usef ul t ool in t he measurement of human f acial grow t h.
How ever, it does have signif icant limit at ions in t erms of t echnique error, w hich
are discussed in Chapt er 6. Measurement s are made f rom landmarks ident if ied
on t he radiographs, and it is not alw ays possible t o select a landmark w hich is
bot h easy t o ident if y reliably and t ruly represent at ive of t he st ruct ure being
measured. The measurement errors w hich are inherent w it hin t he t echnique may
be as large as t he changes w hich are being examined, and t here is also
considerable variat ion among pat ient s in t heir responses t o appliances. These
diff icult ies do not invalidat e cephalomet ry as a research t ool but , if t he f indings
of a cephalomet ric st udy are t o have any real meaning, proper experiment al
design and t he inclusion of suff icient ly large numbers of pat ient s are essent ial.
Many report ed st udies are ret rospect ive, t hat is subject s are select ed f or
inclusion in t he st udy af t er complet ion of t he ort hodont ic t reat ment . These t end
t o have an element of bias as, f or various reasons, st udies have of t en only
included pat ient s w ho have achieved a successf ul result f rom t he t reat ment being
examined, but very f ew have also looked at t hose in w hom t he t reat ment f ailed.
Thus t he st udy sample may be biased in t hat t hese successf ul pat ient s may have
inherent ly f avourable grow t h pat t erns w hile t he unsuccessf ul ones, w hich
perhaps w ere not included in t he st udy, w ere t hose w it h unf avourable grow t h.
The changes induced by t he t reat ment need t o be dist inguished f rom t hose w hich
occur during normal grow t h, and in t heory t his can be done by comparing t he
group of t reat ed pat ient s w it h an unt reat ed cont rol group w hich is mat ched f or
age, sex, and malocclusion. I n pract ice t his is also diff icult , as very f ew pat ient s
w it h malocclusions of any severit y decline t reat ment and yet have serial
ort hodont ic records t aken over a period of years.

Prospect ive randomly allocat ed clinical t rials give much bet t er evidence by
eliminat ing select ion bias. I n t hese st udies, subject s are select ed f or inclusion
bef ore t he t reat ment begins and are allocat ed randomly t o one of t he t reat ment
met hods being examined. Such st udies have t o be large t o allow f or pat ient s
abandoning t he t reat ment being st udied or being lost t o f ollow -up, and t hey have
t o ext end over several years t o allow t he long-t erm eff ect s of t reat ment t o be
assessed. Several prospect ive clinical st udies of f unct ional appliances are
current ly under w ay but so f ar only preliminary result s have been report ed.
I n summary, t he quest ion of t he precise mode of act ion f unct ional appliances is
not easily resolved and it cont inues t o be cont roversial. At present , t he evidence
of t he bet t er scient if ic st udies suggest s t he f ollow ing changes w hen a f orw ard
post ured f unct ional appliance is used:

Dento-alveolar changes There is no doubt t hat f unct ional appliances move


t he upper t eet h post eriorly. Ant erior movement of t he low er arch may also
occur but is a less consist ent f inding.
Changes in maxillary growth There is rest rict ion of f orw ard grow t h of t he
maxilla, similar t o t he eff ect of headgear. How ever, t his change may not be
permanent as t here is evidence t hat c at ch-up grow t h of t he maxilla occurs
af t er t reat ment .
Changes in mandibular growth There is evidence t hat f unct ional appliances
may induce on average an ext ra 1 2 mm of grow t h of t he mandible. How ever,
t here appears t o be considerable variat ion in t his response, and it is
possible t hat some pat ient s exhibit signif icant accelerat ion of mandibular
grow t h during f unct ional appliance t reat ment , alt hough such eff ect s may be
only be t ransit ory, and ot hers do not . The direct ion of mandibular grow t h may
also be improved by f unct ional appliance t herapy. Unf ort unat ely, at present ,
reliable predict ion of pat ient response is not possible, but on average t he
changes are modest .
Changes in the glenoid fossae Remodelling of t he glenoid f ossa more
ant eriorly has been seen in animal experiment s and t here is some evidence
t hat it may occur in humans. I f t his does happen, t he t emporomandibular joint
and t he mandible w ould become reposit ioned slight ly f urt her f orw ard.

18.3. INDICATIONS FOR FUNCTIONAL APPLIANCES


All pat ient s must meet t he f ollow ing general crit eria f or a f unct ional appliance t o
be appropriat e:

The pat ient must st ill be grow ing, pref erably approaching a phase of rapid
grow t h.
The pat t ern and direct ion of f acial grow t h should be reasonably f avourable.
While f unct ional appliances may have a small eff ect on grow t h, t his must be
regarded as being limit ed and it is not possible t o make a dramat ic
improvement upon a very unf avourable grow t h pat t ern.
The pat ient must be w ell mot ivat ed. These appliances are bulky and must be
w orn f or a subst ant ial amount of t ime. This requires a considerable eff ort
and commit ment by t he pat ient and t he f amily, part icularly in t he early st ages
of t reat ment .

The timing of treatment needs caref ul considerat ion. These appliances only
w ork in pat ient s w ho are grow ing, and t heir eff ect is great est w hen grow t h is
most rapid. The t iming of dent al development correlat es poorly w it h t hat of
skelet al grow t h and t he pubert al grow t h spurt , and some children est ablish t he
permanent dent it ion at a relat ively early age w hile ot hers are st ill in t he lat e
mixed dent it ion at pubert y. I t is common pract ice t o f it f unct ional appliances in
t he mixed dent it ion st age, but some designs of f unct ional appliance become
diff icult

t o manage w hen many primary t eet h are mobile and exf oliat ing. The appliance
should be w orn unt il t he end of t he pubert al grow t h spurt , and if t reat ment is
st art ed early in a young child it is likely t o be very lengt hy. The pat ient 's
ent husiasm f or t reat ment may w ell w ane in t hese circumst ances. How ever, in
many cases t he advant ages of early t reat ment may be f elt t o out w eigh t he
disadvant ages, such as w here t he overjet is very large and causing concern
because of t easing or risk of t rauma t o t he upper incisors.
Theref ore it can be quit e diff icult in some cases t o decide w hen t o begin
t reat ment , part icularly w hen t he f unct ional appliance is t o be used in conjunct ion
w it h ot her t reat ment such as f or crow ding. I t is usef ul t o record t he pat ient 's
st anding height over a period bef ore and during t reat ment , as t his gives some
indicat ion of t he rat e of grow t h. Alt hough it is not possible t o predict t he onset of
t he pubert al grow t h spurt precisely, t his inf ormat ion may help t o det ermine w hen
t he t reat ment should st art .

18.3.1. Class II division 1


Funct ional appliances are most of t en used in Class I I division 1 malocclusions.
They are part icularly appropriat e w here t he arches are w ell aligned as t hey
cont ain no mechanism f or aligning irregular arches (Fig. 18. 1). I t is possible t o
use a f unct ional appliance w here t here is crow ding w it hin t he arches, but t hese
cases are of t en more easily t reat ed in ot her w ays. Where a f unct ional appliance
is t o be used, arch alignment is carried out eit her bef ore or af t er t he f unct ional
appliance phase of t reat ment .
The f unct ional appliance may be f it t ed during t he mixed dent it ion st age t o
achieve ant eropost erior correct ion of t he malocclusion, and t he crow ding t reat ed
lat er in a second phase of t reat ment af t er t he f irst premolar t eet h have erupt ed.
This usually requires ext ract ions and eit her removable or f ixed appliances t o
align t he arches. This sequence of t reat ment has t he advant age of achieving
early overjet reduct ion, but overall t reat ment t ime is of t en long. There is also a
risk of some relapse of t he overjet w hen t he f unct ional appliance has been
st opped t o make w ay f or t he appliances needed t o align t he arches. I t may be
necessary t o reinsert a f unct ional appliance as a ret ainer af t er t he t eet h have
been aligned, but t his must be done bef ore t he grow t h spurt is f inished.

Fig. 18.2. (a) ( c) Class II division 1 malocclusion with


lower arch crowding; (d) a combination of removable
and fixed appliances to align the arches prior to fitting
the functional appliance; (e) activator appliance
modified to fit over the fixed appliance; (f) the occlusion
at the end of treatment.

(a)

(b)
(c)

(d)

(e)

(f)

Where t he premolars erupt bef ore t he pubert al grow t h spurt t akes place, t he
sequence of t reat ment can be reversed. The crow ding is relieved by ext ract ing
premolar t eet h, and t hen t he arches are aligned using f ixed or removable
appliances, or a combinat ion of t he t w o, but making no at t empt t o correct t he
incisor or molar relat ionships (Fig. 18. 2). The f unct ional appliance is f it t ed w hen
t he arches have been aligned, and some designs can be made t o f it over a f ixed
appliance. I t should be w orn unt il t he grow t h spurt is complet e, and can serve as
a ret ainer af t er t he bracket s have been removed.
The degree of overbit e should be considered w hen select ing t he design of
f unct ional appliance. Low er incisor capping act s as an ant erior bit e-plane t o
reduce an increased overbit e, limit ing low er incisor erupt ion and allow ing molar
erupt ion. Conversely, w here t he overbit e is reduced, a design w hich incorporat es
molar capping, such as t he t w in-block appliance (see Sect ion 18. 5. 6), w ill help
t o prevent an ant erior open-bit e f rom developing.

18.3.2. Class II division 2


Treat ment of a Class I I division 2 malocclusion can be prolonged and diff icult
because correct ion of t he incisor relat ionship requires reduct ion of t he overbit e
and reduct ion of t he int er-incisal angle t o ensure st abilit y of t he result (Chapt er
10). This can be done w it h f ixed appliances, but t he t reat ment is ext ensive as it
involves correct ing t he ret roclinat ion of t he upper incisors by moving t heir apices
palat ally, t hus reducing t he int er-incisal angle.
An alt ernat ive approach is t o correct t he upper incisor angulat ion by moving t heir
crow ns labially, w hich is of t en st raight f orw ard using a removable appliance. The
result ing increased overjet and t he deep overbit e can t hen be correct ed using a
f unct ional appliance. This met hod is part icularly appropriat e w here t he low er
arch is w ell aligned. The ret roclined upper incisors are of t en crow ded, but t his
resolves as t hey are t ilt ed labially int o a larger arc. The malocclusion has t hen
been changed f rom Class I I division 2 t o a Class I I division 1 w it h aligned
arches, w hich is ideal f or t reat ment w it h a f unct ional appliance (Fig. 18. 3).

Fig. 18.3. (a) Class II division 2 malocclusion with well-


aligned lower arch; (b) upper removable appliance to
expand the arch and procline the upper incisors; (c)
activator appliance in place; (d) some overcorrection
was achieved.
(a)

(b)

(c)

(d)
18.3.3. Class III
The problem f aced by f unct ional appliances designed t o correct Class I I I
malocclusion is t hat only minimal post erior post uring of t he mandible is possible.
Thus t hey are limit ed in t he degree of act ivat ion w hich can be achieved, and t he
w orking bit e is usually open rat her t han f orced post eriorly. The pat t ern of
mandibular grow t h is also less likely t o be f avourable f or correct ion of a Class
I I I malocclusion. O ne of t he more popular designs of Class I I I f unct ional
appliances is a variant of t he Frankel appliance, t he FR3 (Fig. 18. 4). This
includes w ires lying labial t o t he low er incisors and palat al t o t he upper incisor
w hich, t oget her w it h t he acrylic shield in t he upper labial sulcus, induce slight
lingual movement of t he low er incisors and labial movement of t he upper
incisors. Thus t he eff ect is a dent o-alveolar correct ion of t he Class I I I incisor
relat ionship, and at present t here is no evidence t hat f unct ional appliances
achieve any clinically signif icant skelet al correct ion in Class I I I cases.

Fig. 18. 4. Frankel appliance f or Class I I I correct ion.

18.4. M ANAGEM ENT OF FUNCTIONAL APPLIANCES


I t is essent ial t hat adequat e records, comprising st udy models and panoramic
and lat eral skull radiographs, are t aken bef ore t reat ment begins. Phot ographs
and a not e of t he pat ient 's st anding height are also usef ul.
Well-ext ended upper and low er impressions are needed t oget her w it h a w orking
bit e. The exact nat ure of t he bit e depends on t he t ype of f unct ional appliance t o
be used, but all of t hem require t he mandible t o be post ured f orw ard, usually by
no more t han about 8 mm or t o edge-t o-edge, w hichever is less. The upper and
low er cent relines should be coincident , and a degree of opening is usually
necessary, w it h t he exact amount depending upon t he over-bit e and design of
appliance t o be used.
When t he appliance is f it t ed, t he pat ient should f ind it comf ort able, if st range, t o
st art w it h. These appliances are demanding t o w ear and t he pat ient needs t o be
w ell mot ivat ed. Wit h t his t ype of t reat ment , almost more t han any ot her, t he
ort hodont ist must ent huse t he pat ient and f amily. The appliance should be w orn
f or at least 14 hours out of every 24, and pref erably more. Clinical experience
has show n t hat , w hile some pat ient s may achieve some improvement w it h less
w ear t han t his, many do not , and it cert ainly seems t hat t he more t he appliance
is w orn each day, t he f ast er w ill be t he response. As w it h all ort hodont ic
appliances, t he pat ient w ill f ind t hat t he f irst f ew days af t er f it t ing are t he most
diff icult , and t hey w ill need t ime t o become accust omed t o w earing it . I nit ially, it
should be w orn f or a f ew hours each day as a t raining period, gradually
increasing t he amount of w ear over t he f irst w eek or t w o unt il t he minimum of 14
hours is being achieved. For most children t his t ime is f ound bet w een coming
home f rom school and get t ing up next morning. Appliance w ear does not need t o
be cont inuous as long as t he t ot al t ime is achieved, and most designs of
f unct ional appliance have t o be removed f or meals. Children can increase t he
amount of w ear by t aking t he f unct ional appliance t o school, provided t hat t hey
can be t rust ed t o t ake care of it w hen it is out of t he mout h. I t is helpf ul t o give
pat ient s a t ime chart so t hat t hey can record f or t hemselves how t hey are
get t ing on.
The pat ient should be seen af t er 2 w eeks t o ensure t hat t he appliance is
comf ort able and t o encourage adequat e w ear. During act ive t reat ment , review
appoint ment s should be every 6 t o 8 w eeks. Progress is assessed by measuring
t he overjet and observing correct ion of t he buccal segment relat ionship, ensuring
t hat t he mandible is f ully ret ruded and t hat t he pat ient is not post uring f orw ards.

The f it of t he appliance should be checked and adjust ed f or obvious reasons it


must be as comf ort able as possible. I t is import ant t o check t hat t he appliance is
not causing unw ant ed int erf erence w it h t he erupt ion of permanent t eet h, and it
should be t rimmed as appropriat e. The act ivat ion of t he appliance should be
checked, and in cases w here t he init ial overjet w as large it may be necessary t o
react ivat e or replace it . Finally, it is w ort h recording t he st anding height , as slow
progress w it h t he appliance may be because t he pat ient is not in a rapid grow t h
phase.
O ne of t he main t asks at review appoint ment s is t o encourage and mot ivat e t he
pat ient , and t his is made much easier if t he pat ient and f amily can see an
improvement f or t hemselves. The pat ient 's t ime chart should be looked at and
discussed it is import ant t o remember t o t ake an int erest in t his. The rat e of
response w ill vary, but if progress is slow or non-exist ent t he problem should be
t alked t hrough w it h t he pat ient and parent . I f grow t h in height is rapid t his should
be point ed out f orcibly, as t he overjet should be reducing rapidly and t here is no
second chance once t he grow t h spurt has f inished.
When t he overjet has been reduced f ully, or pref erably overcorrect ed slight ly, t he
amount of t ime t hat t he appliance is w orn each day can be reduced progressively
t o 12 hours, t hen 10 hours, and f inally dow n t o sleeping hours only. This
reduct ion should be very gradual, over about a year, and t he overjet and buccal
segment correct ion must be monit ored t o ensure t hat t hey remain st able. The
pat ient should cont inue t o w ear t he appliance at night unt il t hey are w ell t hrough
t he pubert al grow t h spurt , as clinical experience has show n t hat gradual relapse
may occur during t he lat e st ages of grow t h if t he appliance is w it hdraw n t oo
soon. Wearing t he appliance in bed at night is not a problem f or most t eenagers.

18.5. TYPES OF APPLIANCE


There are many designs of f unct ional appliance, but t hey all share t he common
f eat ure t hat t he mandible is held in a post ured posit ion. O ne of t he earliest
designs w as Pierre Robin's monobl oc w hich w as designed t o hold t he mandible
f orw ard in inf ant s w it h ext reme mandibular ret rognat hism (Pierre Robin
syndrome). Andresen originally developed his appliance as a ret ainer f or use
af t er f ixed appliances had been removed and f ound t hat it cont inued t o reduce
increased overjet s.
Six popular designs of f unct ional appliance w ill be described brief ly here, but
t here are many adapt at ions and most ort hodont ist s have developed t heir ow n
variant s. Some designs are w orn w it h headgear w hich f urt her helps t he Class I I
correct ion.

18.5.1. The Andresen activator


There are many variat ions upon Andresen's original design. An Andresen
act ivat or is show n in Fig. 18. 5. I t is a monoblock design, t hat is t o say it
comprises upper and low er acrylic appliances f used t oget her. The original design
had a solid palat e, but t hat show n has been made w it h an open palat e t o reduce
it s bulk. The low er incisors are capped t o minimize t he t endency f or t hem t o
procline during overjet reduct ion, and w hich also serves as a bit e-plane t o
reduce t he overbit e. The capping resist s t ipping of t he t eet h so t hat any labial
movement w ill have t o be bodily t ranslat ion and is t heref ore minimized. The labial
bow lies passively against t he upper incisors, and t he palat al w ire is again
int ended t o minimize palat al t ilt ing of t he upper incisors.
Fig. 18. 5. Andresen act ivat or used t o t reat t he pat ient show n in Fig. 18. 1.

The int erdent al acrylic in t he buccal segment s has been t rimmed t o make a
series of inclined planes w hich guide t he erupt ion of t he upper molars and
premolars buccally and dist ally. The dist al movement is int ended t o help correct
t he Class I I buccal segment relat ionship. The buccal movement is needed
because, as t he buccal segment relat ionship correct s, t he upper post erior t eet h
occlude against a w ider part of t he low er arch. Wit h low er incisor erupt ion
rest rict ed by t he capping, erupt ion of t he molars brings about reduct ion of t he
overbit e. Where t he overbit e is normal at t he st art of t reat ment , t he molar
capping should be t rimmed t o allow expansion but not erupt ion, so t hat t he
molars cannot erupt more t han t he incisors and cause an ant erior open bit e t o
develop (Fig. 18. 6).
Fig. 18. 6. Andresen act ivat or w it h buccal capping t o prevent excessive
reduct ion of overbit e.

The appliance has no clasps; t he int ent ion is t hat t he looseness in t he mout h
causes t he pat ient t o bit e int o it . Many pat ient s f ind t his diff icult t o t olerat e in
t he early st ages of t reat ment , f inding t hat t he appliance of t en comes out during
t he night , and a common modif icat ion is t o clasp t he upper f irst molars alt hough
t his prevent s spont aneous expansion.

18.5.2. The medium opening activator


The acrylic in t his variant of t he act ivat or has been kept t o a minimum t o make it
bet t er t olerat ed (Fig. 18. 7). The low er acrylic ext ends lingually t he labial
segment only, and t he upper and low er part s are joined by t w o st out acrylic
post s, leaving a breat hing hole ant eriorly. The appliance has clasps in t he upper
buccal segment s. There is no molar capping, and t his design is t hus not suit able
w here t he init ial overbit e is normal or reduced.

Fig. 18. 7. Medium opening act ivat or.


Where t he upper molars are clasped, t here can be no spont aneous expansion of
t he upper arch w hile t he act ivat or is being w orn. Theref ore it is necessary t o f it
an expansion appliance f irst , such as t hat show n in Fig. 18. 8. This gives t he
pat ient an easy int roduct ion t o appliance w ear, and it may also include springs t o
improve t he alignment of t he upper incisors. I n cases w here a f ixed appliance
has been used t o align t he arches bef ore f it t ing t he f unct ional appliance, t he
medium opening act ivat or design can be modif ied t o f it around f ixed at t achment s
(Fig. 18. 2).

Fig. 18. 8. Expansion appliance f it t ed prior t o t he f unct ional appliance.

18.5.3. The Harvold activator


The most obvious diff erences bet w een t he Harvold and Andresen act ivat ors are
t hat t he Harvold appliance is made t o a w idely open w orking bit e so as t o gain
maximum eff ect f rom st ret ching t he muscles and has occlusal shelves w hich
cont act t he upper but not t he low er post erior t eet h (Fig. 18. 9). As t he low er
post erior t eet h erupt t hey move f orw ards slight ly, and t he t heory is t hat using
occlusal shelves t o prevent erupt ion of t he upper post erior t eet h and encourage
erupt ion of t he low er post erior t eet h helps t o correct t he molar relat ionship f rom
Class I I t o Class I . How ever, w here t he overbit e is normal and does not need t o
be reduced, t he shelves should cont act bot h upper and low er post erior t eet h.
The appliance has no clasps and can be used in conjunct ion w it h f ixed
appliances.
Fig. 18. 9. Harvold act ivat or (court esy of Mr T. G . Bennet t ).

18.5.4. The bionator


The bionat or w as originally designed t o modif y t ongue behaviour on t he basis
t hat t he t ongue w as t he main cause of increased overjet . I t is now recognized
t hat t his is only very rarely t he case, if at all, but t he bionat or design has proved
t o a be a usef ul f unct ional appliance w it h a minimal bulk of acrylic w hich makes it
easy t o w ear. A heavy w ire loop t akes t he place of t he palat al acrylic and buccal
ext ensions of t he labial bow hold t he cheeks out of cont act w it h t he

buccal segment t eet h t o allow some arch expansion (Fig. 18. 10). I t is usually
made t o an edge-t o-edge w orking bit e w hich is opened up as lit t le as possible.
The original bionat or design has no low er incisor capping but does have
post erior capping, w hich pot ent ially causes problems w it h excessive proclinat ion
of t he low er incisors and w it h management of a deep overbit e. The appliance
can be modif ied t o include low er incisor capping and omit post erior capping, and
in t his f orm it becomes anot her variant of t he act ivat or.
Fig. 18. 10. Bionat or appliance (court esy of Mr T. G . Bennet t ).

18.5.5. The Frankel appliance


Frankel originally called t his t he f unct ion regulat or (FR). I t looks very diff erent ,
having acrylic shields in t he buccal sulci and lit t le or no acrylic lingually, but in
common w it h all f unct ional appliances it induces mandibular post uring. The
buccal shields are int ended t o cause expansion of t he arches by holding t he
cheeks aw ay f rom t he t eet h and also t o enlarge t he alveolar process by
st ret ching t he periost eum in t he dept h of t he sulcus, t hus causing bone t o be laid
dow n on t he buccal aspect . There is lit t le evidence t o support t his t heory, but t he
appliance is very eff ect ive f or ant eropost erior correct ion.
Frankel described t hree main variant s of t he appliance. The FR1 (Fig. 18. 11) is
f or t reat ment of Class I I division 1 malocclusions and incorporat es lip pads labial
t o t he low er incisors t o allow f orw ard development of t he mandibular alveolar
process. Where t he low er lip is t rapped behind t he upper incisors, t he lip pads
help t he low er lip t o unf url and f unct ion in f ront of t he upper incisors. O verbit e
cont rol is less easy because of t he lack of low er incisor capping, but variant s
have been described w hich incorporat e capping.

Fig. 18. 11. Frankel appliance f or correct ion of Class I I division 1


malocclusion.

The FR2 has in addit ion a palat al w ire t o procline t he upper incisors and is
int ended f or Class I I division 2 malocclusions.
The FR3 (Fig. 18. 4) is f or t reat ment of Class I I I malocclusions, having acrylic
shields labial t o t he upper incisors w hich, t oget her w it h a palat al arch, procline
t hem, and a low er labial bow w hich ret roclines t he low er incisors. Thus t he FR3
achieves only a dent o-alveolar correct ion of t he incisor relat ionship, but it is t he
best of t he f unct ional appliance designs f or Class I I I malocclusions. There is
lit t le evidence t hat any skelet al correct ion is achieved.
Frankel appliances are complex and must be made t o a very high st andard if
t hey are t o be t olerat ed an ill-f it t ing Frankel appliance is ext remely
uncomf ort able, part icularly w here t he acrylic shields ext end deeply int o t he
buccal sulci. How ever, a keen pat ient w it h a w ell-f it t ing appliance can w ear it
virt ually f ull-t ime, except f or eat ing, and induce rapid changes. The complex
design makes t he appliance expensive t o make and vulnerable t o dist ort ion of
t he w ires, and it can be diff icult or impossible t o correct a dist ort ed or damaged
appliance.

18.5.6. The twin-block appliance


The unique f eat ure of t his appliance is t hat it is const ruct ed in t w o part s, as
separat e upper and low er appliances (Fig. 18. 12). Forw ard mandibular post uring
is achieved by incorporat ing buccal blocks w it h int erlocking inclined planes, w it h
t he low er blocks engaging in f ront of t he upper ones. The appliance is of t en used
w it h headgear t o t he upper arch. The t w o-part const ruct ion makes it w ell
t olerat ed, even during eat ing, and many operat ors inst ruct t he pat ient t o w ear
t heir t w in blocks f ull t ime. I t w ill t heref ore of t en produce rapid changes.

Fig. 18. 12. Tw in-block appliance, show ing t he low er buccal block engaging
ant eriorly t o t he upper buccal block.

This appliance's main diff icult y is management of deep overbit e, because of t he


buccal blocks. As t he overjet reduces, lat eral open bit es develop w hich are t hen
closed by progressively t rimming t he blocks in such a w ay as t o allow t he
post erior t eet h t o erupt but at t he same t ime maint ain t he f orw ard post uring.

This can be very f iddly and as a result many operat ors f ind t he appliance most
usef ul w here t he overbit e is normal or reduced, rat her t han increased.

PRINCIPAL SOURCES AND FURTHER READING


Bart on, S. and Cook, P. A. (1997). Predict ing f unct ional appliance t reat ment
out come in Class I I malocclusions a review. Ameri can Journal of
O rthodonti cs and Dentof aci al O rthopedi cs, 112, 282 6 .

A concise summary of t he evidence about t he use and eff ect s of f unct ional
appliances.

Clark, W. J. (1988). Tw in block t echnique. A f unct ional ort hopedic appliance


syst em. Ameri can Journal of O rthodonti cs and Dentof aci al O rthopedi cs, 93,
1 1 8.

The t w in block appliance described by it s originat or.

I saacson, K. G . , Reed, R. T. , and St ephens, C. D. (1990). Functi onal


orthodonti c appl i ances. Blackw ell, O xf ord.

The use and eff ect s of f unct ional appliances, including an ext ensive lit erat ure
review.

Mills, J. R. E. (1983). Clinical cont rol of craniof acial grow t h: a skept ic's
view point . I n Cl i ni cal al terati ons of the growi ng f ace. (ed. J. A. McNamara,
K. A. Ribbons, and R. P. How e), Monograph 14, . Cent er f or Human G row t h
and Development , Universit y of Michigan.
An exhaust ive appraisal of t he evidence concerning t he eff ect s of f unct ional
appliances.

O rt on, H. S. (1990). Functi onal appl i ances i n orthodonti c treatment.


Q uint essence, London.

A manual of laborat ory const ruct ion of t he appliances.


Authors: Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> Table of C ontents > 19 - Adult or thodontic s

19
Adult orthodontics

As dent al aw areness is grow ing and ort hodont ic appliances are now becoming
more socially accept able, a increasing number of adult pat ient s are seeking
ort hodont ic t reat ment . At t he same t ime, a great er proport ion of t he general
public are keeping t heir t eet h f or longer, w hich is result ing in an increasing
demand f or ort hodont ic t reat ment t o f acilit at e rest orat ive and periodont al care.

19.1. DIFFICULTIES POSED BY ORTHODONTIC


TREATM ENT FOR ADULTS
O rt hodont ic t reat ment is usually carried out in children around t he t ime of t he
pubert al grow t h spurt and/ or soon af t er erupt ion of t he permanent dent it ion. Bot h
spont aneous and dynamic t oot h movement are accomplished more readily at t his
age, and act ive grow t h f acilit at es t he correct ion of skelet al discrepancies. I n
cont rast , if ort hodont ic t reat ment is delayed unt il adult hood t reat ment may be
complicat ed by t he f ollow ing:

Negligible growth Alt hough recent st udies indicat e t hat grow t h does
cont inue t hroughout adult hood, t his is at a much diminished rat e compared
w it h childhood. This means t hat t he t hreshold f or surgery is low er in adult
pat ient s w it h skelet al discrepancies or increased overbit e.
Reduced tissue blood supply and cell turnover As a result t he response
t o ort hodont ic f orce is more sluggish (in children t he init ial react ion t o
ort hodont ic f orce occurs w it hin 24 hours, w hereas in adult s it can t ake up t o
3 w eeks) and t issue reorganizat ion f ollow ing t oot h movement t akes longer.
Reduced periodontal attachment The incidence and severit y of periodont al
at t achment loss increases w it h age, and t he load upon a reduced
periodont ium can be f urt her exacerbat ed by t oot h loss. I n some cases t he
t eet h are less able t o resist sof t t issue and occlusal f orces, leading t o
migrat ion and drif t ing of part icularly t he incisors. Where ort hodont ic
t reat ment is planned f or t eet h w it h reduced periodont al support , t he f orces
applied t o t he t eet h need t o be decreased accordingly, and pat ient s w it h
gingival recession should be counselled t hat ort hodont ic t reat ment may
accelerat e t his problem.
Missing and heavily restored teeth Toot h loss may lead t o migrat ion and/ or
t ilt ing of t he adjacent t eet h and t o over-erupt ion of t he opposing t eet h, t hus
cont ribut ing t o disrupt ion of t he occlusion. I n addit ion, at rophy of t he alveolar
bone f ollow ing ext ract ion can lead t o necking (Fig. 19. 1). I nadequat e
rest orat ions w it h poor cont act point s, def icient occlusal st ops, or premat ure
cont act s may also lead t o occlusal disharmonies and/ or mandibular
displacement . The choice of t eet h f or ext ract ion in adult s is of t en det ermined
by t he prognosis of individual t eet h.
Adults are less able to adapt to discrepancies in the occlusion Theref ore
even more care is required t o ensure t hat a good f unct ional occlusion is
achieved at t he end of t reat ment .

Fig. 19. 1. Necking.

19.2. PRACTICAL ORTHODONTIC M ANAGEM ENT IN


ADULTS
A t horough ort hodont ic assessment (Chapt er 5) should be carried out prior t o
planning t reat ment , and t his should include a caref ul examinat ion of t he condit ion
of t he t eet h, bot h periodont ally and rest orat ively. I n some adult s t his may involve
t aking f ull-mout h radiographs. I f t he pat ient has several missing t eet h it is
import ant t o observe t he pat h of closure of t he mandible on t he hinge axis,
looking part icularly f or displacement s. As w it h children, good dent al care is a
prerequisit e t o ort hodont ic t reat ment , but in t he adult it is even more import ant
t hat any periodont al disease is cont rolled bef ore ort hodont ic appliances are
placed. I n many adult pat ient s assessment and t reat ment planning should be
carried out joint ly w it h ot her disciplines, part icularly if periodont al disease is
present and/ or rest orat ive w ork is necessary.
Management of Class I , Class I I , and Class I I I malocclusions in t he adult w ill
generally run along t he lines discussed in Chapt ers 8, 9, 10, 11. How ever, ow ing
t o t he lack of grow t h t here is a low er t hreshold f or surgery in t he management of
skelet al discrepancies and increased overbit e. Treat ment planning in t he adult ,
including anchorage requirement s, may be compromised by previous t oot h loss
and t he condit ion of t he remaining t eet h, and in some cases a compromise may
have t o be accept ed as a result .
Where possible, overbit e reduct ion should be achieved by int rusion, as ext rusion
of t he molars t ends t o relapse once appliances are removed. O n occasion,
limit ed crow n reduct ion can be considered w hen over-erupt ion has occurred.
Rarely, t his may involve elect ive devit alizat ion t o prevent pulpal problems,
f ollow ed by crow ning w hen t reat ment is complet e. Alt ernat ively, surgery may be
required.
Light er f orces should be used in t he adult , part icularly init ially and w here
periodont al support is reduced. A slow er rat e of t oot h movement can be
expect ed in t he older pat ient , part icularly init ially. Spont aneous t oot h movement
and space closure is also much reduced in t he adult dent it ion. Dist al movement
of t he upper buccal segment s is not really an opt ion in t he mat ure dent it ion,
alt hough ext raoral anchorage can be used provided t hat t he pat ient is prepared
t o accept it . Despit e t he increased accept ance of ort hodont ics, adult pat ient s
are usually keen f or appliances t o be as unobt rusive as possible. Toot h-coloured
bracket s (Fig. 19. 2) lingual or minibracket s can be used, and t hese improve t he
aest het ics of a f ixed appliance. Crow ned or heavily rest ored t eet h of t en pose a
problem f or bonded at t achment s. Silane coupling agent s can be used in
conjunct ion w it h a composit e ort hodont ic adhesive f or bonding t o porcelain
veneers or crow ns, but t he ret ent ion rat es are of t en disappoint ing. I f much of t he
labial surf ace is involved in a met al rest orat ion, t here may be no alt ernat ive but
t o use a band around t he t oot h. Pat ient s should be w arned prior t o st art ing
t reat ment if t here is a risk of a rest orat ion being dislodged w hen t he appliance is
removed, and if complex rest orat ive t reat ment is required t his is of t en best
delayed unt il af t er t he ort hodont ic phase is complet e.
Fig. 19. 2. Toot h-coloured plast ic bracket used t o align t his pat ient 's upper
labial segment .

Because of t he slow er rat e of t issue reorganizat ion, ret ent ion f ollow ing
ort hodont ic t reat ment in t he adult may need t o be prolonged or even permanent .

19.3. ORTHODONTICS AS AN ADJUNCT TO


RESTORATIVE WORK
As t he proport ion of t he populat ion w it h some nat ural t eet h increases, so does
t he need f or joint management of adult s w it h m ut ilat ed dent it ions due t o t oot h
loss and periodont al disease. Where collaborat ion bet w een ort hodont ist and

rest orat ive dent ist is required in t he management of a case, it is pref erable t o
see t he pat ient joint ly t o f ormulat e a int egrat ed t reat ment plan. The f ollow ing are
examples of problems t hat benef it f rom a joint rest orat ive o rt hodont ic approach:

Redistribution/ closing of space Follow ing unplanned t oot h loss, space


closure or movement of a proposed abut ment t oot h int o t he middle of an
edent ulous span may be indicat ed t o f acilit at e f abricat ion of a durable
prost hesis.
Uprighting of tilted bridge abutments I f , f ollow ing t he loss of a permanent
t oot h, t he adjacent t eet h t ilt int o t he space, replacement of t he missing unit
w it h bridgew ork may be complicat ed by a lack of parallelism of t he abut ment
t eet h. O ne possible opt ion is t o upright t he adjacent t eet h prior t o
bridgew ork.
Intrusion of over-erupted teeth I nt rusion of over-erupt ed t eet h may be
required prior t o rest orat ive w ork in t he opposing arch.
Extrusion of fractured teeth This is usually required w here t he f ract ure line
ext ends below t he gingival margin. Alt hough ext rusion brings t he margin
supragingivally and f acilit at es placement of a crow n or rest orat ion, it must
be remembered t hat ext rusion w ill also adversely aff ect t he crow n-t o-root
rat io.

Where a combined approach is indicat ed, it is of t en w ise t o allow a period of


st abilizat ion bet w een t he phases of t reat ment of diff ering specialit ies.

19.4. M IGRATION OF PERIODONTALLY INVOLVED


INCISORS
Migrat ion of periodont ally compromised incisors is an increasingly common
problem and t heref ore is considered separat ely in t his sect ion.

19.4.1. Aetiology
Pat ient s w it h loss of periodont al at t achment may experience labial drif t ing of t he
t eet h, most commonly t he upper incisors, alt hough ot her t eet h can be aff ect ed.
This may be due t o a number of f act ors, and one or more may be operat ing in an
individual case:

Reduced bony support means t hat t he t eet h are less able t o w it hst and
adverse sof t t issue and occlusal f orces, and t oot h movement occurs.
Periodont al inf lammat ion leads t o ext rusion of t he t eet h, bringing t hem int o
t raumat ic occlusion. I f t he periodont al support is also reduced, t he t eet h may
drif t as a result (Fig. 19. 3).
I f a premat ure cont act w hich result s in a f orw ard slide of t he mandible on
closure occurs in a pat ient w it h periodont ally involved upper incisors,
proclinat ion of t he upper labial segment may occur as a result .
Lack of post erior support due t o t oot h loss places undue pressures on t he
incisors, leading part icularly t o proclinat ion of t he upper incisors.
Fig. 19. 3. Periodont al disease and lack of post erior support cont ribut ed t o
t he proclinat ion and spacing of t his pat ient 's upper labial segment (see also
Fig. 19. 2 w hich show s t he appliance used t o align t he upper labial segment ).

19.4.2. Management
I nit ial management has t o include st abilizat ion of t he periodont al condit ion and
an assessment of t he prognosis of t he aff ect ed t eet h. I f t he prognosis is
sat isf act ory and ort hodont ic alignment is planned, t he most diff icult aspect is
of t en over-bit e reduct ion. I f t he overbit e is not markedly increased, a removable
bit e-plane appliance can be used (Fig. 19. 4), but it should be remembered t hat
t his w ill
lead t o overbit e reduct ion by ext rusion of t he molars w hich w ill t end t o relapse
post -t reat ment . Fixed appliances are required if incisor int rusion is indicat ed.
How ever, t here is a limit t o t he amount of overbit e reduct ion t hat can be
at t empt ed, and eit her crow n height reduct ion or surgery may be indicat ed.

Fig. 19.4. Adult with migration of /1 secondary to


advanced periodontal disease and a combined perio-
endo lesion of /1. Following control of the periodontal
disease and root canal therapy, an upper removable
appliance in conjunction with a single bracket was used
to align /1: (a) prior to orthodontic treatment; (b)
appliance used to align /1.

(a)

(b)

Fig. 19.5. Adult patient with migration of the upper


incisors secondary to periodontal disease. An upper
fixed appliance was used to close the upper labial
spacing and to retract the maxillary incisors: (a) pre-
treatment: (b) fixed appliance.

(a)

(b)
Fig. 19. 6. Met al splint t o provide ret ent ion and support f ollow ing ret ract ion
of periodont ally involved incisors.

I f a f orw ard slide f rom a premat ure cont act is an aet iological f act or, t his should
be eliminat ed t o allow t he pat ient t o at t ain t heir t rue int ercuspal posit ion (cent ric
relat ion). This of t en necessit at es a course of splint t herapy, w hich is best
carried out by t he rest orat ive member of t he t eam w ho can t hen advise on
eliminat ion of any premat ure cont act s revealed by t his process.
Reduct ion of t he increased overjet is usually relat ively st raight f orw ard w it h a
f ixed appliance in most cases (Fig. 19. 5). How ever, permanent ret ent ion is
usually necessary f ollow ing t reat ment . This can most easily be accomplished
w it h a convent ional bonded ret ainer, alt hough in some cases a met al splint
(similar t o t he ret ent ion w ings of an acid-et ch ret ained bridge), at t ached t o t he
palat al aspect of t he t eet h w it h composit e, may be indicat ed t o provide
addit ional support t o periodont ally involved t eet h (Fig. 19. 6).

PRINCIPAL SOURCES AND FURTHER READING


Heasman, P. A. and Millet t , D. T. (1996). The peri odonti um and orthodonti cs
i n heal th and di sease. O xf ord Universit y Press, O xf ord.

How at , A. P. and Warren, K. (1991). A rest orat ive o rt hodont ic approach in t he


older pat ient . Bri ti sh Journal of O rthodonti cs, 18, 195 2 01.

An int erest ing case report w hich illust rat es t he t eamw ork required in a
combined periodont al o rt hodont ic r est orat ive t reat ment f or a 60-year-old pat ient .

Kahl-Nieke, B. (1996). Ret ent ion and st abilit y considerat ions f or adult
pat ient s. Dental Cl i ni cs of North Ameri ca, 40, 961 9 4.

Khan, R. S. and Horrocks, E. N. (1991). A st udy of adult ort hodont ic pat ient s
and t heir t reat ment . Bri ti sh Journal of O rthodonti cs, 18, 183 9 4.

Melsen, B. , Agerbaek, N. , Eriksen, J. , and Terp, S. (1988). New at t achment


t hrough periodont al t reat ment and ort hodont ic ext rusion. Ameri can Journal of
O rthodonti cs and Dentof aci al O rthopedi cs, 94, 104 1 6.
A t hought -provoking art icle.

Melsen, B. , Agerbaek, N. , and Markenst am, G . (1989). I nt rusion of incisors in


adult pat ient s w it h marginal bone loss. Ameri can Journal of O rthodonti cs and
Dentof aci al O rthopedi cs, 96, 232 4 1.
Nat t rass, C. and Sandy, J. R. (1995). Adult O rt hodont ics a review. Bri ti sh
Journal of O rthodonti cs, 22, 331 7 .

Nort on, I . A. (1988). The eff ect of ageing cellular mechanisms on t oot h
movement . Dental Cl i ni cs of North Ameri ca, 32, 437 4 6.
Authors: Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> Table of C ontents > 20 - O r thodontic s and or thognathic s ur ger y

20
Orthodontics and orthognathic surgery

O rt hognat hic surgery is concerned w it h t he correct ion of dent o-f acial def ormit y.
I n t he vast majorit y of cases a combined surgical and ort hodont ic approach is
required t o achieve an opt imum result .

20.1. INDICATIONS
Pat ient s w it h a craniof acial def ormit y, f or example clef t lip and palat e, may
require ort hognat hic surgery t o correct or mask t heir underlying abnormalit y.
O rt hognat hic surgery may be necessary f or t hose cases w it h a skelet al
discrepancy out side t he limit s of ort hodont ic t reat ment eit her because of t heir
severit y or a lack of grow t h. Examples include t he f ollow ing:

severe Class I I malocclusions


severe Class I I I malocclusions
vert ical discrepancies
ant erior open bit e
markedly increased overbit e
skelet al asymmet ry.

20.2. DIAGNOSIS AND TREATM ENT PLANNING


An int egrat ed t eam approach is essent ial as t his allow s t he surgeon and
ort hodont ist t o produce a coordinat ed t reat ment plan t ailored t o an individual
pat ient 's needs. This is best achieved by holding joint clinics w here t reat ment
can be discussed w it h t he prospect ive pat ient . I n some cent res a psychologist is
also a member of t he t eam, helping t o ident if y t hose pat ient s w it h unrealist ic
expect at ions of t reat ment . There should also be access t o speech and language
t herapy.

20.2.1. The patient's perception of the problem


Pat ient s seek ort hognat hic surgery f or a number of reasons. The most common
are t he f ollow ing:

appearance
mast icat ory diff icult ies
speech
t raumat ic overbit e
t emporomandibular joint dysf unct ion.

Treat ment should alw ays at t empt t o address t he pat ient 's concerns. How ever, it
is import ant t o assess w het her an individual's percept ion of t he problem is
realist ic.

A small number of pat ient s project t heir diff icult ies in f orming relat ionships or
f riendships ont o a part icular f acial f eat ure. Their expect at ions are unrealist ic, as
t hey expect surgery t o provide an inst ant solut ion t o t heir problems and t hey may
react unf avourably post -operat ively.

20.2.2. Clinical examination


A syst emat ic approach is required w hich should include t he w hole of t he pat ient 's
f ace including t he f orehead and neck. The dat a given in Table 20. 1 can be used
as a guide.

Fig. 20.1. Patient with mild facial asymmetry: (a) extra-


oral; (b) intra-oral.
(a)

(b)

Table 20. 1 Useful measurements for dentofacial assessment

Males 66 Females 60
Mid-facial third
mm mm

Males 66 Females 60
Lower facial third
mm mm
Subnasale to vermilion Males 33 Females 30
lower lip mm mm

Vermilion lower lip to Males 33


menton (ST) mm

Intercanthal width 34 ą 4 mm
Females 30
Alar base width 34 ą 4 mm mm

Interpupillary width 65 ą 4 mm

W idth of mouth 65 ą 4 mm

Males 22 Females 20
Length of upper lip
mm mm

Exposure of upper incisor Males 0


at rest mm

Exposure of upper incisor


7 1 0 mm
smiling

Projection of supra-orbital
5 1 0 mm Females 3
ridge:
mm
Nasolabial angle 110° ą 9°

Labiomental angle 124° ą 10°

Neck c hin angle 135°


Full face
This should include an assessment of t he symmet ry and balance of t he f ace f rom
t he f ront al view. Alt hough no f ace is complet ely symmet rical, obvious deviat ions
f rom normal bet w een lef t and right should be not ed. This examinat ion should
include t he level of t he orbit s and also t he cont our of t he maxilla and mandible,
part icularly any deviat ion of t he chin point (Fig. 20. 1). I n an aest het ically
pleasing f ace t he upper, middle, and low er f acial t hirds are nearly equal in height
(Figs. 20. 2 and Fig. 20. 3), and t he f ace also divides int o f if t hs vert ically.

Fig. 20. 2. An aest het ic f ace w ill divide int o t hirds vert ically. The dist ance
f rom st omion t o ment on is t w o-t hirds of t he low er f acial t hird.
Fig. 20. 3. A pat ient w it h a long low er t hird of t he f ace, w it h a proport ionat ely
increased dist ance bet w een st omion and ment on.

Profile
The upper, middle, and low er f acial t hirds should be considered in t urn, so t hat
t he f orehead and t he neck t hroat angle are assessed as w ell as t he relat ionship
of t he maxilla t o t he mandible. Maxillary ret rognat hia is more easily diagnosed
f rom t his perspect ive, as t he prof ile appears concave. The shape of t he nose
and t he nasolabial angle are also import ant , as ret ract ion of t he upper incisors
w ill lead t o an increase in obliquit y of t he nasolabial angle, making t he nose
more prominent (Fig. 20. 4). Conversely, proclinat ion of t he upper incisors or
f orw ard movement of t he maxilla w ill make t he angle f ormed bet w een t he nose
and t he upper lip more acut e.
Fig. 20. 4. A pat ient w it h a Class I I division 1 incisor relat ionship on a Class
I I skelet al pat t ern and a good nasolabial angle. Ret ract ion of t he upper
incisors w ould lead t o a f lat t ening of t he upper lip and make t he nose appear
more prominent .

The eff ect on t he prof ile of surgery t o advance t he mandible can be judged by
asking t he pat ient t o post ure f orw ards t he desired amount . Advancement of t he
maxilla can also be evaluat ed by placing cot t on w ool rolls under t he pat ient 's
upper lip.

Soft tissues
The f orm and t one of t he sof t t issues should be recorded. The f ullness of t he lips
and t he amount of t oot h show, part icularly t he upper incisors, at rest and during
f unct ion should be assessed (Fig. 20. 5). Liposuct ion and/ or plat ysma plicat ion
can somet imes be used t o improve t he neck t hroat angle.

Fig. 20.5. (a) A patient with a Class II division 1


malocclusion with an excessive amount of upper incisor
show; (a) the same patient following segmental surgery
in the upper arch and a mandibular advancement. The
lips are now competent.
(a)

(b)

Temporomandibular joints
The presence of any signs or sympt oms of t emporomandibular joint dysf unct ion
should be included in t he examinat ion of a pat ient f or ort hognat hic surgery. The
role of t he occlusion in t he aet iology of t emporomandibular dysf unct ion is
discussed in more det ail in Chapt er 1. I deally, any sympt oms should be t reat ed
conservat ively prior t o t reat ment . How ever, in pat ient s w it h grossly deranged
occlusions and/ or mult iple non-w orking side int erf erences, it may be necessary
t o commence t reat ment w hich w ill address t hese occlusal problems.

Dental health
G ood dent al healt h is a prerequisit e t o a successf ul out come. The long-t erm
prognosis of all rest ored t eet h should be t aken int o considerat ion w hen
ext ract ions are planned. O n occasion t his can compromise t he t reat ment plan
(Fig. 20. 6).

Fig. 20. 6. The DPT radiograph of a pat ient f or w hom it w as decided t o avoid
presurgical ort hodont ic alignment in t he low er arch.

Occlusal assessment
A t horough examinat ion of t he occlusion should be carried out by an ort hodont ist
(see Chapt er 5). I t is import ant t o check w het her t he cent relines of t he upper
and low er arches are coincident w it h each ot her and t he cent re of t he f ace, and
t o not e t he direct ion and nat ure of any discrepancies.

20.2.3. Radiographic examination


This usually includes t hose radiographs t aken as part of t he rout ine ort hodont ic
assessment of a pat ient w it h a skelet al discrepancy, namely a panoramic dent al
view (DPT), a lat eral cephalomet ric radiograph, and, if indicat ed, a view of t he
upper incisors. O n occasion, ot her view s may be indicat ed, f or example a
post eroant erior skull f or asymmet ry or a subment overt ex t o assess mandibular
f lare prior t o a mandibular set back.

20.2.4. Cephalometric assessment


I n addit ion t o a rout ine cephalomet ric analysis (Chapt er 6), many surgeons and
ort hodont ist s w ill carry out more specialized analyses t o help det ermine t he
underlying aet iology of a part icular problem. Many such analyses exist , and f or
det ails of t hese t he reader is ref erred t o t he sect ion on f urt her reading. O ne
commonly used approach is t o compare t he pat ient 's cephalomet ric values w it h
t he norm by means of a s t andard t racing. Perhaps t he most w idely used of
t hese is t he Bolt on st andard (Fig. 20. 7). The Bolt on st andard is a composit e
t racing derived f rom t he lat eral cephalomet ric radiographs t aken every year f or a
group of individuals f ollow ed f rom birt h t o mat urit y. An a verage t racing is
available f or each year of age, w hich can be compared against a pat ient 's
t racing t o help det ermine areas of discrepancy. How ever, care is required, as
t he discrepancies w ill alt er depending on w hich st ruct ures t he t racings are
superimposed upon. Also, t he Bolt on t racings are det ermined f rom a relat ively
small group of individuals of bot h sexes, and t heref ore should only be used as a
guide and not a t reat ment goal.

Fig. 20. 7. Comput er print -out t o show superimposit ion of a Bolt on composit e
f or an 18-year-old (bold out line) upon t he t racing of a pat ient w it h a severe
Class I I I malocclusion on t he sella nasion line at sella.

20.2.5. Planning
The f ollow ing are essent ial f or t he purposes of planning and audit :

1. Study models I n addit ion t o a ngled st udy models, it is of t en helpf ul t o have


at least one set of duplicat e models f or model surgery, usually mount ed on a
plane line art iculat or (Fig. 20. 8). How ever, if it is t hought t hat t reat ment is
likely t o involve bimaxillary surgery and/ or aut orot at ion of t he mandible, a set
of models should be mount ed on a semi-adjust able art iculat or.
2. Photographs Most ort hodont ist s have a rout ine set of ext ra-oral and
int raoral view s t aken bef ore ort hodont ic t reat ment . I n addit ion t o t hese,
some surgeons f ind it helpf ul t o have a negat ive of t he pat ient 's prof ile
enlarged t o f it 1: 1 t o t heir lat eral cephalomet ric radiograph so t hat t he t w o
are superim-posed allow ing bot h sof t and bony t issues t o be seen. This can
t hen be cut up t o help det ermine t he eff ect s of diff erent surgical opt ions
upon t he pat ient 's prof ile and can be used t o give t he pat ient an idea of his
appearance post -surgery. How ever, care is required not t o inst ill unrealist ic
expect at ions, as alt hough some allow ance can be made f or t he responses of
t he sof t t issues t o diff erent surgical procedures, t here is w ide individual
variat ion.

Fig. 20. 8. Model surgery.

Where a skelet al discrepancy exist s, t he act ion of t he sof t t issues can lead t o
t ilt ing of t he t eet h w hich compensat es f or t he underlying skelet al problem t o
varying degrees. This is know n as dent o-alveolar compensat ion. I t is most
commonly seen in Class I I I malocclusions w here proclinat ion of t he upper
incisors and ret roclinat ion of t he low er incisors occurs ow ing t o t he act ion of t he
lips and t ongue st riving t o f orm an ant erior oral seal (Fig. 20. 9). I f an
ort hodont ics-only approach is t o be undert aken f or a skelet al discrepancy, t his
usually involves a degree of dent o-alveolar compensat ion, w hereas if
ort hognat hic surgery is t o be carried out , ideally any dent o-alveolar
compensat ion needs t o be eliminat ed prior t o surgery in order t hat a f ull
correct ion of t he underlying skelet al discrepancy can be carried out . O bviously,
in pat ient s w it h a marked skelet al discrepancy, considerat ion should be given t o
t he need f or surgery bef ore embarking on ort hodont ic t reat ment alone as t he
t oot h movement s required are in t he opposit e direct ion.

Fig. 20. 9. Dent o-alveolar compensat ion.

O ccasionally it is not f easible or desirable t o correct t he incisor angulat ions t o


t heir ideal values, f or example a narrow mandibular symphysis and/ or t hin labial
periodont al t issues may preclude complet e decompensat ion of ret roclined low er
incisors in a Class I I I malocclusion. Theref ore it is imperat ive t hat t he surgeon
and ort hodont ist w ork closely t oget her at t he planning st age t o ensure t hat a co-
ordinat ed approach is employed and t he desired skelet al changes can be
correlat ed w it h t he planned occlusion.
A number of met hods are used t o det ermine t he eff ect of diff erent t reat ment
plans upon t he pat ient 's f ace and occlusion. There are several manual met hods
w here a g uesst imat e of t he eff ect of ort hodont ics and surgery is const ruct ed
f rom t he lat eral cephalomet ric t racing. The met hod described previously, w hich
ut ilizes a 1: 1 phot ograph superimposed upon a lat eral cephalomet ric radiograph
is a variat ion on t his t heme. I ncreasingly, specially designed comput er programs
(Fig. 20. 10) can be ut ilized t o evaluat e t he eff ect s of diff erent ort hodont ic and
surgical approaches on a part icular malocclusion. Use of t hese sophist icat ed
programs saves considerable t ime over t he manual met hod, allow s t he
invest igat ion of an almost endless range of t reat ment permut at ions, and also
provides a dat a-base f or t he subsequent analysis of t he result s of t reat ment .
How ever, a degree of

caut ion is required w hen using t hese programs so t hat only t hose approaches
t hat are t echnically f easible f or a part icular pat ient are select ed f or f urt her
considerat ion.
Fig. 20. 10. Print -out of t he t reat ment planned (dashed line) f or a pat ient w it h
a Class I I I malocclusion using a comput er planning program (CO G sof t ).

Fig. 20.11. A patient in her


early twenties with a Class III
malocclusion who refused to
wear orthodontic appliances.
She was treated by a maxillary
advancement alone, and whilst
there is an obvious aesthetic
improvement the resulting
buccal occlusion is not ideal:
(a), (b) pre-operatively; (c), (d)
post-operatively.
(a)
(b)

(c)

(d)

Follow ing t his process it should be possible t o det ermine w here t he discrepancy
lies and w het her, and t o w hat degree, it can be correct ed. O f t en, more t han one
opt ion can be present ed t o t he pat ient show ing varying levels of complexit y and
f inal result . Pat ient s of t en f ind it helpf ul t o meet a previous (successf ul! )
candidat e t o discuss t he eff ect s of t reat ment .
A proport ion of pat ient s w ill ref use t o consider w earing ort hodont ic appliances.
Rarely, a reasonable occlusion may be possible w it h surgery alone and perhaps
a lit t le judicious occlusal grinding (Fig. 20. 11). I n t he majorit y a very poor
occlusion w ill result f ollow ing surgery w it hout ort hodont ic preparat ion and if
dent oalveolar compensat ion is not reduced t hen t he f acial result may also be
prejudiced. I n t hese cases it may be advisable not t o proceed unless t he pat ient
accept s ort hodont ic appliances.

20.3. SEQUENCE OF TREATM ENT


Except f or some of t he craniof acial anomalies, ort hognat hic surgery is usually
carried out w hen t he pat ient has f inished grow ing so t hat a good result is not
spoiled by f urt her grow t h. How ever, t he presurgical ort hodont ic preparat ion can

be commenced earlier, so t hat it s conclusion is t imed t o coincide w it h t he


complet ion of grow t h.

20.3.1. Extractions
Ext ract ions may be necessary t o relieve crow ding and t o provide space in order
t o align t he t eet h over t heir skelet al bases (i. e. reduce any dent o-alveolar
decompensat ion). I n addit ion, it is import ant f or t he surgeon t o decide w het her
any impact ed t hird molars should be removed prior t o t he st art of t reat ment or
during surgery it self , part icularly if mandibular ramus surgery is planned.

20.3.2. Presurgical orthodontics


A phase of presurgical ort hodont ics is usually necessary t o est ablish t he desired
ant eropost erior and vert ical posit ion of t he incisors, and t o align and coordinat e
t he arches so t hat t he t eet h do not int erf ere w it h placing t he jaw s in t heir
planned relat ionship. I f a segment al procedure is t o be carried out , space w ill
need t o be creat ed int erdent ally f or t he surgical cut s. How ever, it is ineff icient t o
carry out t oot h movement s t hat can be accomplished more readily at or af t er
surgery, f or example levelling of t he low er arch in a Class I I division 2
malocclusion. As w it h any ort hodont ic or surgical procedure, some relapse can
be ant icipat ed. Theref ore it is helpf ul if t he ort hodont ics can be planned so t hat
t he ort hodont ic relapse is in t he opposit e direct ion t o t he expect ed surgical
relapse, so t hat t hey t end t o cancel each ot her out . I t is import ant t o f orew arn
t he pat ient t hat t he presurgical ort hodont ic phase may make t heir appearance
w orse as any dent o-alveolar compensat ion is reduced (Fig. 20. 12).
Presurgical ort hodont ics is carried out using f ixed appliances, w hich are lef t in
place during surgery. The pre-adjust ed appliances (see Chapt er 17) make t his
phase of t reat ment much easier. Rigid rect angular archw ires are usually required
t o complet e presurgical alignment . How ever, it is import ant t hat t hese are
passive bef ore surgery is carried out , part icularly if int er-occlusal w af ers are t o
be used during surgery. I n most cases t he rigid archw ires are lef t i n si tu and
hooks are added f or int ermaxillary f ixat ion during surgery. Some ort hodont ist s
choose a f ixed appliance syst em w it h a hook on each bracket f or ort hognat hic
cases t o save having t o place hooks ont o t he archw ire w hich can be a f iddly
and t ime-consuming exercise (Fig. 20. 13).
Presurgical ort hodont ics usually t akes bet w een 12 and 18 mont hs depending
upon t he complexit y of t he case. At t his st age new st udy models, radiographs,
and phot ographs are recorded t o check w hat has been achieved during t his
phase so t hat t he surgical plan can be modif ied or conf irmed as indicat ed. Model
surgery is of t en carried out t o det ermine t he amount and sit e of bone removal
and t o f abricat e int er-occlusal w af ers (or splint s) used t o locat e t he bony
segment s t o t he planned posit ion during surgery, prior t o f ixat ion.

20.3.3. Surgery
A brief descript ion of t he common surgical procedures is given in Sect ion 20. 4.
I n t he past , w ires w ere used t o locat e and f ix t he bony segment s in t heir
correct ed posit ion. This necessit at ed t he use of int ermaxillary f ixat ion (i. e. t he
upper and low er t eet h w ere w ired t oget her) f or about 6 w eeks unt il bony union
had occurred. Apart f rom being unpleasant f or t he pat ient , t here w as a great er
morbidit y in t he immediat e post -operat ive period, of t en necessit at ing admit t ance
t o an int ensive-care bed f or t he f irst 24 hours.
The int roduct ion of small bone plat es t o f ix t he posit ion of bony segment s
semirigidly in t he maxilla and t he use of plat es and/ or screw s in t he mandible has
complet ely revolut ionized ort hognat hic surgery. This means t hat it is not
necessary

t o rely only on int ermaxillary f ixat ion f ollow ing surgery. This approach, t oget her
w it h advances in t he use of st eroids t o reduce sw elling and modern ant ibiot ic
regimens, means t hat pat ient s can of t en be released f rom hospit al w it hin 2 or 3
days of t heir operat ion. More recent ly, resorbable plat es and screw s have been
int roduced.

Fig. 20.12. Patient aged 16 years with a Class III


malocclusion: SNA = 84°, SNB = 91.5°, ANB = -7.5°,
UInc to MxPl = 123°, LInc to MnPl = 76°, MMPA = 21°
and FP = 55 per cent. Following the extraction of all
four second premolars and presurgical orthodontics,
the patient had bimaxillary surgery; (a), (b)
pretreatment; (c), (d) at the end of presurgical
alignment; (e), (f) at the end of treatment.

(a)

(b)
(c)

(d)

(e)
(f)

Fig. 20.13. (a) Ball hooks crimped onto archwire for the
application of intermaxillary fixation during surgery. (b)
Bracket system with hook incorporated into each
bracket.

(a)

(b)

20.3.4. Post-surgical orthodontics


Alt hough int ermaxillary elast ic t ract ion can be st art ed immediat ely post -
operat ively t o help guide t he arches int o t he desired posit ion, act ive t oot h
movement is not usually commenced unt il approximat ely 4 w eeks af t er surgery.
Light er round w ires, and elast ic t ract ion are ut ilized t o det ail t he occlusion int o a
good int erdigit at ion. This phase of ort hodont ics should last f or about 6 mont hs.
I f t he bony segment s are not correct ly posit ioned during surgery, a limit ed
amount of movement t ow ards t he desired posit ion is possible using int ermaxillary
elast ics in t he immediat e post -operat ive period. This problem occurs most
commonly w hen t he condyles have been displaced f rom t he glenoid f ossa during
surgery, w it h t he result t hat w hen t hey ret urn t o t heir correct art iculat ion post -
operat ively t he occlusion is w rong.

20.3.5. Retention
This is usually along similar lines as f or convent ional f ixed appliance t herapy
(see Chapt er 17), namely an upper removable ret ainer and eit her a low er
removable or bonded (lingual t o t he low er incisors) ret ainer as indicat ed.

20.4. COM M ON SURGICAL PROCEDURES


O nly a brief overview of some of t he more popular surgical t echniques is
included here. Addit ional inf ormat ion is available in t he lit erat ure cit ed in t he
sect ion on f urt her reading.
As aest het ics are of major import ance, w here possible an int ra-oral approach
should be used t o avoid unsight ly scars. Segment al procedures have an
increased morbidit y, as damage t o t he t eet h or disrupt ion of t he blood supply t o
a segment is more likely.

20.4.1. Maxillary procedures


Segmental procedures
O ne or more t eet h and t heir support ing bone can be moved as a segment al
procedure. The Wassmund t echnique involves movement of t he upper
premaxillary segment of incisors and canines as a block, eit her dist ally t o reduce
an increased overjet or upw ards t o reduce excessive upper incisor show.
Now adays a Le Fort I procedure is more f requent ly carried out and t he maxilla
divided f rom above int o segment s.

Le Fort I (Fig. 20.14)


This is t he most w idely used t echnique. The st andard approach is a horseshoe
incision of t he buccal mucosa and underlying bone, w hich result s in t he maxilla
being pedicled on t he palat al sof t t issues and blood supply. The maxilla can t hen
be moved upw ards (af t er removal of t he int ervening bone), dow nw ards (w it h
int erposit ional bone graf t ), or f orw ards. Movement of t he maxilla backw ards is
not f easible in pract ice. Where t here is concern regarding t he blood supply
provided by t he palat al vessels, t he buccal approach can be made via small
vert ical incisions and t unnelling of t he mucosa, but t his makes plat ing diff icult
and may increase t he likelihood of relapse.
A t ranspalat al approach is f avoured in a small number of cent res.

Le Fort II
This is employed t o achieve mid-f ace advancement .

Le Fort III
This usually necessit at es raising of a bicoronal f lap f or access and is commonly
used in t he management of craniof acial anomalies.

20.4.2. Mandibular procedures


Ramus procedures
The most commonly used ramus t echniques are t he f ollow ing.

Vertical subsigmoid osteotomy


This is used f or mandibular prognat hism and involves a bone cut f rom t he
sigmoid not ch t o t he low er border. This can be perf ormed int ra-orally using

special inst rument s or ext ra-orally using st andard inst rument s at t he expense of
a scar.

Fig. 20. 14. Diagram t o show t he posit ion of t he surgical cut s (dashed lines)
f or a Le Fort 1 procedure.

Sagittal split osteotomy (Fig. 20.15)


This procedure can be used t o advance or push back t he mandible or t o correct
mild asymmet ry. The bony cut ext ends obliquely f rom above t he lingula, across
t he ret romolar region, and vert ically dow n t he buccal plat e t o t he low er border.
The main complicat ion is damage t o t he inf erior alveolar nerve.

Body osteotomy
This operat ion is usef ul if t here is a nat ural gap in t he low er arch ant erior t o t he
ment al f oramen in a pat ient w it h mandibular prognat hism. Now rarely used.

Genioplasty (Fig. 20.16)


The t ip of t he chin can be moved in almost any direct ion, limit ed by sliding bony
cont act and t he muscle pedicle. This t echnique can somet imes be usef ully
employed as a masking procedure, t hus avoiding more complex t reat ment (f or
example, mild asymmet ry).

Post-condylar cartilage graft


This t echnique diff ers f rom t hose discussed previously, as it is usually ut ilized f or
t he correct ion of severe mandibular ret rognat hia in grow ing children. I nsert ion of
a block of cadaveric or aut ologous cart ilage behind t he condylar head can
produce result s analogous t o inst ant aneous f unct ional appliance t reat ment in
Class I I division 1 malocclusions, w it h remodelling of t he condylar f ossa and
surprisingly f ew adverse react ions. How ever, t his approach may require mult iple
int ervent ions t o achieve an adequat e result and def init ive ort hognat hic surgery
may st ill be required.

20.4.3 Bimaxillary surgery


Many pat ient s require surgery t o bot h jaw s t o correct t he underlying skelet al
discrepancy (Fig. 20. 17).

20.4.4 Distraction Osteogenesis


O ne of t he diff icult ies posed by t he t reat ment of congenit al craniof acial
def ormit ies, is t he limit at ions placed by t he sof t t issues on t he amount of
movement t hat is achievable. Alt hough t his problem has been addressed t o an
ext ent by t he use of t issue expanders, t he int roduct ion of s low dist ract ion
ost eogenesis in t he management of limb def ormit y has opened up a w ealt h of
opport unit y f or t he management of craniof acial anomalies. Basically t his process
involves t he applicat ion of increment al t ract ion t o ost eot omized bone ends. As a
result t ension arises in t he healing callus and new bone is st imulat ed in t he
direct ion of t he t ract ion. Thus t his t echnique avoids t he problems of harvest ing
and maint aining a viable bone graf t in t he t reat ment of def iciencies and, in
addit ion, t he f orces also act upon t he surrounding sof t t issues leading t o
adapt ive changes t ermed dist ract ion hist ogenesis. Dist ract ion ost eogenesis is
usef ul f or t he correct ion of severe def ormit y in t he grow ing child and it is hoped
w ill help t o reduce t he number of surgical procedures previously required t o t reat
t hese children.

Fig. 20. 15. Diagram t o show t he posit ion of t he surgical cut s (dashed/ dot t ed
lines) f or a sagit t al split ost eot omy.

Fig. 20.16. (a) A genioplasty being carried out; (b) a


lateral cephalometric radiograph of a patient who had a
genioplasty carried out in addition to a sagittal split
ramus procedure (note the plates securing the
genioplasty).
(a)

(b)

Fig. 20.17. A 16-year-old patient with a Class III


malocclusion: SNA = 72.5°, SNB = 79°, ANB = -7.5°,
UInc to MxPl = 112.5°, LInc to MnPl = 81°, MMPA =
26.5° and FP = 59 per cent.
Following presurgical orthodontics, the patient had a
maxillary advancement and a mandibular set-back: (a),
(b) pretreatment; (c) during orthodontic preparation;
(d), (e) at the end of treatment.
(a)

(b)

(c)

(d)
(e)

Whilst t his syst em is st ill in t he process of being developed up t o 20 mm of


addit ional mandibular lengt h has been gained by some w orkers and t he t echnique
can also be used f or t he correct ion of midf ace and cranial def ormit ies. Most
w orkers have ut ilized ext ernal f ixat ors, w hich are manually cont rolled; how ever,
t his approach of t en leads t o signif icant scarring. I nt ra-oral mechanisms are now
commercially available and f ut ure possibilit ies include implant ed t elemet rically
cont rolled devices.

20.5. RELAPSE
Wit h biological syst ems t here is alw ays a t endency f or any changes t o regress.
Theref ore t he pot ent ial f or relapse should be assessed at t he t reat ment planning
st age and if necessary st eps should be t aken t o limit or compensat e f or it . A
number of f act ors can lead t o relapse and t hese are broadly classif ied as
f ollow s:

1. Surgical f act ors


Poor planning.
The size of t he movement required. Movement of t he maxilla by more
t han 5 6 mm in any direct ion is more suscept ible t o relapse, as is
movement of t he mandible by more t han 8 mm.
Direct ion of movement required (see Table 20. 2)
Dist ract ion of t he condylar heads out of t he glenoid f ossa during surgery.
I nadequat e f ixat ion.
2. O rt hodont ic f act ors
Poor planning.
Movement of t he t eet h int o zones of sof t t issue pressure w ill lead t o
relapse w hen appliances are removed. Theref ore t reat ment should be
planned t o ensure t hat t he t eet h w ill be in a zone of sof t t issue balance
post -operat ively and t hat t he lips w ill be compet ent .
Ext rusion of t he t eet h during alignment t ends t o relapse post -t reat ment .
Sof t t issue habit s, f or example a t ongue t hrust , may persist , leading t o a
recurrence of an ant erior open bit e.

3. Pat ient f act ors


The nat ure of t he problem; f or example, ant erior open bit es associat ed
w it h abnormal sof t t issue behaviour are not oriously diff icult t o t reat
successf ully and have a marked pot ent ial t o relapse, and pat ient s should
be w arned of t his prior t o t reat ment .
Movement s w hich put t he sof t t issues under t ension, as in t he correct ion
of def iciencies, are more suscept ible t o relapse.
I n pat ient s w it h clef t lip and palat e advancement of t he maxilla is diff icult
and prone t o relapse because of t he scar t issue of t he primary repair.
Failure t o comply w it h t reat ment ; f or example, pat ient does not w ear
int ermaxillary elast ic t ract ion as inst ruct ed.

Table 20. 2 Stability of orthognathic surgery

Most stable
Maxillary impaction
Mandibular advancement
Genioplasty (any direction)
Maxillary advancement
Correction of maxillary asymmetry
Maxillary impaction with mandibular advancement
Maxillary advancement with mandibular setback
Correction of mandibular asymmetry
Mandibular setback
Movement of maxilla downwards
Surgical expansion of maxilla
Least stable
Based on the article by Proffit et al. (1996) .
PRINCIPAL SOURCES AND FURTHER READING
Barnard, D. and Birnie, D. (1990). Scope and limit at ions of ort hognat hic
surgery. Dental Update, 17, 63 9 .
A w ell-illust rat ed easy-t o-read art icle int roducing t he reader t o ort hognat hic
surgery.

Cope, J. B. , Samchukov, M. D. , and Cherkashin, A. M. (1999). Mandibular


dist ract ion ost eogenesis: A hist oric perspect ive and f ut ure direct ions.
Ameri can Journal of O rthodonti cs and Dentof aci al O rthopedi cs, 115, 448 6 0.

Cunningham, S. J. and Feinmann, C. (1998). Psychological assessment of


pat ient s requiring ort hognat hic surgery and t he relevance of body dysmorphic
disorder. Bri ti sh Journal of O rthodonti cs, 25, 293 8 .

Epker, B. N. and Fish, L. C. (1986). Dentof aci al def ormi ti es i ntegrated


orthodonti c and surgi cal correcti on. Mosby, St Louis, MO .

A st andard t ext of it s t ime.

Harris, M. and Reynolds, I . R. (1991). Fundamental s of orthognathi c surgery.


Saunders, London.

A concise but complet e account of t he subject f or t hose w it h lit t le background


in t he f ield.

Hunt , N. P. and Rudge, S. J. (1984). Facial prof ile and ort hognat hic surgery.
Bri ti sh Journal of O rthodonti cs, 11, 126 3 6.

A det ailed account of assessment of a pat ient f or ort hognat hic surgery.

Lee, R. T. (1994). The benef it s of post -surgical ort hodont ic t reat ment . Bri ti sh
Journal of O rthodonti cs, 21, 265 7 4.

Proff it , W. R. , Turvey, T. A. , and Phillips, C. (1996). O rt hognat hic surgery: a


hierarchy of st abilit y. Internati onal Journal of Adul t O rthodonti cs and
O rthognathi c Surgery, 11, 191 2 04.

Proff it , W. R. and Whit e, R. R. (1991). Surgi cal o rthodonti c treatment. Mosby


Year Book, St Louis, MO .
A comprehensive w ell-w rit t en t ext w hich is highly recommended.
Tuinzing, D. B. , G reebe, R. B. , Dorenbos, J. , and van der Kw ast , W. A. M.
(1993). Surgi cal orthodonti cs di agnosi s and treatment. VU Universit y Press,
Amst erdam.

This book provides a int erest ing insight int o an ingenious met hod of planning
ort hognat hic management . I t also cont ains a usef ul sect ion on areas requiring
f urt her invest igat ion f or t hose looking f or ideas f or research project s.
Authors: Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> Table of C ontents > 21 - C left lip and palate and other c r aniofac ial anom alies

21
Cleft lip and palate and other craniofacial
anomalies

21.1. PREVALENCE
Clef t lip and palat e is t he most common craniof acial malf ormat ion, comprising 65
per cent of all anomalies aff ect ing t he head and neck. There are t w o dist inct
t ypes of clef t anomaly, clef t lip w it h or w it hout clef t palat e and isolat ed clef t
palat e, w hich result f rom f ailure of f usion at t w o diff erent st ages of dent of acial
development .

21.1.1. Cleft lip and palate


The prevalence of clef t lip and palat e varies geographically and bet w een
diff erent racial groups. Amongst Caucasians, t his anomaly occurs in
approximat ely 1 in every 750 live birt hs. How ever, t he prevalence is increasing. A
f amily hist ory can be f ound in around 40 per cent of cases of clef t lip w it h or
w it hout clef t palat e, and t he risk of unaff ect ed parent s having anot her child w it h
t his anomaly is 1 in 20. Males are aff ect ed more f requent ly t han f emales, and
t he lef t side is involved more commonly t han t he right . I nt erest ingly, t he severit y
of t he clef t is usually more marked w hen it arises in t he less common variant .

21.1.2. Isolated cleft of the secondary palate


I solat ed clef t occurs in around 1 in 2000 live birt hs and aff ect s f emales more
of t en t han males. Clef t s of t he secondary palat e have a lesser genet ic
component , w it h a f amily hist ory in around 20 per cent and a reduced risk of
f urt her aff ect ed off spring t o normal parent s (1 in 80).
I solat ed clef t palat e is also f ound as a f eat ure in a number of syndromes
including Dow n, Treacher C ollins, Pierre R obin, and Klippel F iel syndromes.

21.2. AETIOLOGY
I n normal development f usion of t he embryological processes t hat comprise t he
upper lip occurs around t he sixt h w eek of int ra-ut erine lif e. F lip-up of t he palat al
shelves f rom a vert ical t o a horizont al posit ion f ollow ed by f usion t o f orm t he
secondary palat e occurs around t he eight h w eek. Bef ore f usion can t ake place
t he embryological processes must grow unt il t hey come int o cont act . Then
breakdow n of t he overlying epit helium is f ollow ed by invasion of mesenchyme. I f
t his process is t o t ake place successf ully, a number of diff erent f act ors need t o
int eract at t he right t ime. An inherit ed t endency t ow ards short palat al shelves,
f or example, can be compensat ed (t o a degree) by overdevelopment of ot her
f act ors. I f one of t hese f act ors is also aff ect ed or an environment al insult occurs
at t he

t ime t hat palat e f ormat ion is t aking place, a clef t may result . Theref ore clef t lip
and palat e is described as exhibit ing polygenic inherit ance w it h a t hreshold.
Environment al f act ors (f or example ant iconvulsant drugs, f olic acid def iciency, or
st eroid t herapy) may t hus precipit at e a suscept ible f et us t ow ards t he t hreshold.
I t is post ulat ed t hat isolat ed clef t palat e is more common in f emales t han males
because t ransposit ion of t he palat al shelves occurs lat er in t he f emale f et us.
Thus great er opport unit y exist s f or an environment al insult t o aff ect successf ul
elevat ion, w hich is f urt her hampered by w idening of t he f ace as a result of
grow t h in t he int ervening period.

21.3. CLASSIFICATION
A number of classif icat ions exist but , given t he w ide variat ion in clinical
present at ion, in pract ice it is of t en pref erable t o describe t he present ing
def ormit y in w ords (Fig. 21. 1). How ever, in medicine in general, moves t o
st andardize nomenclat ure have result ed in t he int roduct ion of nat ional and
int ernat ional classif icat ions w hich aim t o embrace all medical condit ions, t hus
f acilit at ing epidemiology and management . O f t hese, t he most w idely accept ed in
t he UK is t he Read coding syst em. Table 21. 1 gives t he relevant Read and
I nt ernat ional Classif icat ion of Diseases (I CD) codes f or clef t lip and palat e
anomaly.

Fig. 21.1. (a) Baby with a complete unilateral cleft lip


and palate on the left side; (b) baby with a bilateral
incomplete cleft lip.
(a)

(b)

Table 21. 1 Codes for cleft lip and palate anomalies

Anom aly Read ICD

Cleft lip + palate (unspecified) P9 749

Cleft lip P91 749.1

Cleft palate P90 749.0


Cleft lip + palate P92 749.2

Unilateral complete cleft lip + palate P921 749.21

Bilateral complete cleft lip + palate P923 749.23

21.4. PROBLEM S IN M ANAGEM ENT


21.4.1. Congenital anomalies
The dist urbances in dent al and skelet al development caused by t he clef t ing
process it self depend upon t he sit e and severit y of t he clef t .

Lip only
There is lit t le eff ect in t his t ype, alt hough not ching of t he alveolus adjacent t o t he
clef t lip may somet imes be seen.

Lip and alveolus


A unilat eral clef t of t he lip and alveolus is not usually associat ed w it h segment al
displacement . How ever, in bilat eral cases t he premaxilla may be rot at ed
f orw ards. The lat eral incisor on t he side of t he clef t may exhibit some of t he
f ollow ing dent al anomalies:

congenit al absence
an abnormalit y of t oot h size and/ or shape

enamel def ect s


t w o conical t eet h, one on each side of t he clef t .

Lip and palate


I n unilat eral clef t s rot at ion and collapse of bot h segment s inw ards ant eriorly is
usually seen, alt hough t his is usually more marked on t he side of t he clef t (t he
lesser segment ). I n bilat eral clef t s bot h lat eral segment s are of t en collapsed
behind a prominent premaxilla (Fig. 21. 2).
Fig. 21. 2. Upper model of a bilat eral complet e clef t lip and palat e show ing
t he inw ard collapse of t he lat eral segment s behind t he premaxillary segment .

Palate only
A w idening of t he arch post eriorly is usually seen.
I t has been show n t hat individuals w it h a clef t have a more concave prof ile, and
w hilst a degree of t his is due t o a rest rict ion of grow t h (see below ), research
indicat es t hat clef t pat ient s have a t endency t ow ards a more ret rognat hic maxilla
and mandible and also a reduced upper f ace height compared w it h t he normal
populat ion.

21.4.2. Post-surgical distortions


St udies of individuals w it h unoperat ed clef t s (usually in Third World count ries)
show t hat t hey do not experience a signif icant rest rict ion of f acial grow t h,
alt hough t here is a lack of development in t he region of t he clef t it self , possibly
because of t issue hypoplasia. I n cont rast , individuals w ho have undergone
surgical repair of a clef t lip and palat e exhibit marked rest rict ion of mid-f ace
grow t h ant eropost eriorly and t ransversely (Fig. 21. 3). This is at t ribut ed t o t he
rest raining eff ect of t he scar t issue, w hich result s f rom surgical int ervent ion. I t
has been est imat ed t hat approximat ely 40 per cent of clef t pat ient s suff er severe
maxillary ret rusion. Limit at ion of vert ical grow t h of t he maxilla coupled w it h a
t endency f or an increased low er f acial height result s in an excessive f reew ay
space, and f requent ly overclosure (Fig. 21. 4).
Fig. 21. 3. Pat ient w it h a repaired unilat eral clef t lip and palat e of t he lef t
side show ing mid-f ace ret rusion.

21.4.3. Hearing and speech


Speech development is adversely aff ect ed by t he presence of f ist ulae in t he
palat e (Fig. 21. 5) and by velopharyngeal insuff iciency (w here t he sof t palat e is
not able t o make an adequat e cont act w it h t he back of t he pharynx t o close off
t he nasal airw ay).

Fig. 21. 4. Pat ient w it h a repaired clef t lip and palat e of t he right side w ho
had a degree of overclosure, believed t o be due t o t he rest rict ing eff ect of
t he primary repair on vert ical grow t h.
Fig. 21. 5. Residual palat al f ist ula.

A clef t involving t he post erior part of t he hard and sof t palat e w ill also involve
t he t ensor palat i muscles, w hich act on t he Eust achian t ube. This predisposes
t he pat ient t o problems w it h middle-ear vent ilat ion (know n colloquially as g lue
ear ) . O bviously, hearing diff icult ies w ill also ret ard a child's speech
development . Theref ore management of t he child w it h a clef t involving t he
post erior palat e must include audiological assessment s and myringot omy w it h or
w it hout grommet s as indicat ed.

21.4.4. Other congenital abnormalities


Around 20 per cent of babies w it h clef t anomalies, part icularly w it h isolat ed clef t
palat e, have associat ed abnormalit ies, more f requent ly of t he heart and
ext remit ies.

21.4.5. Dental anomalies


I n addit ion t o t he aff ect s on t he t eet h in t he region of t he clef t discussed above,
t he f ollow ing anomalies are more prevalent in t he remainder of t he dent it ion:

delayed erupt ion (delay increases w it h severit y of clef t )


hypodont ia
general reduct ion in t oot h size
abnormalit ies of t oot h size and shape (Fig. 21. 6)
enamel def ect s.
Fig. 21. 6. Repaired bilat eral clef t lip and palat e w it h absent upper right
lat eral incisor and hypoplasia of t he upper right cent ral incisor.

21.5. COORDINATION OF CARE


I n order t o minimize t he number of hospit al visit s and t o ensure int egrat ed
int erdisciplinary management , it is essent ial t o employ a t eam approach w it h
joint clinics. The core members usually include t he f ollow ing:

ort hodont ist


maxillof acial surgeon
plast ic surgeon
speech t herapist
ear, nose, and t hroat (ENT) surgeon.
healt h visit or

21.6. M ANAGEM ENT


21.6.1. At birth
The birt h of a child w it h a clef t anomaly w ill come as a shock and a
disappoint ment f or t he parent s. I t is common f or t hem t o experience f eelings of
guilt and t hey w ill need t ime t o grieve f or t he emot ional loss of t he normal child
t hat t hey ant icipat ed. I t is import ant t o provide support f or t he mot her at t his
t ime t o ensure t hat bonding develops normally and t hat help w it h f eeding is
readily available f or t hose inf ant s w it h a clef t palat e. Because a child w it h a clef t

w ill have diff icult y in sucking, a bot t le and t eat w hich help direct t he f low of milk
int o t he mout h is helpf ul, f or example a sof t bot t le w hich can be squeezed (Fig.
21. 7). Det ails of a range of usef ul bot t les and t eat s can be obt ained f rom t he
support group CLAPA (t he Clef t Lip and Palat e Associat ion) (Fig. 21. 8). This
group also provides support and counselling, w hich is usually great ly appreciat ed
by t he parent s of a clef t baby. An explanat ion f rom a member of t he clef t t eam
of probable f ut ure management and t he possiblit ies of modern t reat ment ,
t oget her w it h a cont act person f or advice, is also recommended.

Fig. 21. 7. Suit able bot t les and t eat s f or f eeding clef t babies.

Some cent res st ill advocat e t he use of acrylic plat es designed t o help w it h
f eeding or t o move t he displaced clef t segment s act ively t ow ards a more normal
relat ionship t o aid subsequent surgical apposit ion. This approach, w hich is know n
as presurgical ort hopaedics, is becoming less f ashionable because of a lack of
evidence of it s eff icacy and t he good result s produced by some clef t t eams (f or
example O slo) w ho do not employ presurgical plat es.

21.6.2. Lip repair


There is a w ide variat ion in t he t iming of primary lip repair, depending upon t he
pref erence and prot ocol of t he surgeon and clef t t eam involved. Neonat al repair
is st ill being evaluat ed. I n t he UK primary lip repair is, on average, carried out
around 3 mont hs of age. A number of diff erent surgical t echniques have been
described (f or example Millard, Delaire, and st raight line). The best t echniques
aim t o dissect out and re-oppose t he muscles of t he lip and alar base in t heir
correct anat omical posit ion. How ever, t here is some cont roversy as t o w het her
t issue movement should be achieved by subperiost eal dissect ion or
supraperiost eal dissect ion and skin-lengt hening cut s. The degree t o w hich t he
alar cart lidge is dissect ed is also cont ent ious, as is t he use of a vomer f lap.
Fig. 21. 8. CLAPA leaf let s.

Most cent res repair bilat eral clef t lips at t he same procedure, but some st ill
carry out t w o separat e operat ions. Primary bone graf t ing of t he alveolus at t he
t ime of lip repair has f allen int o disreput e ow ing t o t he adverse eff ect s upon
subsequent grow t h.

21.6.3. Palate repair


I n many European cent res closure of t he hard palat e is delayed unt il 5 years of
age or older in an eff ort t o reduce t he unw ant ed eff ect s of early surgery upon
grow t h. There is some evidence t o suggest t hat t ransverse grow t h of t he maxilla
is improved. How ever, t he adverse eff ect upon speech development has been
w ell document ed. I n t he UK hard and sof t palat e repair is undert aken, on
average, bet w een 9 and 12 mont hs of age w it h t he philosophy t hat any unw ant ed
eff ect s upon grow t h caused by repair at t his st age (w hich can be compensat ed
f or t o a degree by ort hodont ics and surgery) are pref erable t o f ost ering t he
development of poor art iculat ory habit s, w hich can be ext remely diff icult t o
eradicat e af t er t he age of 5.

21.6.4. Primary dentition


The f irst f ormal speech assessment is usually carried out around 2 years of age,
depending upon t he needs of t he child. Monit oring of a pat ient 's speech should
cont inue t hroughout childhood, pref erably at joint clinics, t o pick up any
developing problems t hat may arise w it h grow t h. An assessment w it h an ENT
surgeon should also be arranged if t his specialt y has not been not involved at t he
t ime of primary repair.
I t is import ant t o minimize surgical int erf erence w it h t he clef t child's lif e and
m inor t ouch-ups should be avoided. Lip revision, prior t o t he st art of schooling,

should be perf ormed only if clearly indicat ed. Closure of any residual palat al
f ist ulae may also be considered t o help speech development . I n a proport ion of
cases t he repaired clef t palat e does not complet ely seal off t he nasopharynx
during speech and nasal escape of air may occur, result ing in a nasal int onat ion
t o t he child's speech. I f indicat ed by evidence f rom invest igat ions such as
speech assessment , videof luroscopy, and nasoendoscopy, a pharnyngoplast y
may help. These operat ions, w hich involve moving mucosal or musculomucosal
pharyngeal f laps t o augment t he shape and f unct ion of t he sof t palat e, can
reduce velopharngeal incompet ence. I f indicat ed, t his should be carried out
around 4 t o 5 years of age.
O rt hodont ic t reat ment in t he primary dent it ion is not w arrant ed. How ever, during
t his st age it is import ant t o develop good dent al care habit s, inst it ut ing f luoride
supplement s in non-f luoridat ed areas.

21.6.5. Mixed dentition


During t his st age t he rest raining eff ect of surgery upon grow t h becomes more
apparent , init ially t ransversely in t he upper arch and t hen ant eropost eriorly as
grow t h in t he lat t er dimension predominat es. Wit h t he erupt ion of t he permanent
incisors, def ect s in t oot h number, f ormat ion, and posit ion can be assessed.
O f t en t he upper incisors erupt int o lingual occlusion and may also be displaced
or rot at ed (Fig. 21. 9).

Fig. 21. 9. A repaired unilat eral clef t lip and palat e in t he mixed dent it ion.

I n order t o avoid st raining pat ient cooperat ion, it is bet t er if ort hodont ic
int ervent ion is concent rat ed int o t w o phases. The f irst st age is usually carried
out during t he mixed dent it ion w it h t he specif ic aim of preparing t he pat ient f or
alveolar or secondary bone graf t ing, and it is pref erable, if possible, t o delay t he
correct ion of t he upper incisors unt il t hen. The second st age is discussed in
Sect ion 21. 6. 6.

Alveolar (Secondary) bone grafting


This t echnique has signif icant ly improved t he ort hodont ic care of pat ient s w it h an
alveolar clef t as it involves repairing t he def ect w it h cancellous bone w hich
conf ers t he f ollow ing advant ages:

provision of bone t hrough w hich t he permanent canine (or lat eral incisor) can
erupt int o t he arch (Fig. 21. 10);
t he possibilit y of providing t he pat ient w it h an int act arch;
improved alar base support ;
aids closure of residual oronasal f ist ulae;
st abilizat ion of a mobile premaxilla in a bilat eral clef t .

Fig. 21.10 Radiographs of a patient who had an


alveolar bone graft: (a) prior to bone grafting; (b) a
month after bone grafting.

(a)
(b)

For opt imal result s t his procedure should be t imed bef ore t he erupt ion of t he
permanent canines, at around 8 9 years, part icularly as erupt ion of a t oot h
t hrough t he graf t helps t o st abilize it .
Bef ore bone graf t ing is carried out , any t ransverse collapse of t he segment s
should be correct ed t o allow complet e exposure of t he alveolar def ect and t o
improve access f or t he surgeon. This is most commonly carried out by using t he
f ixed expansion appliance called t he quadhelix (see Sect ion 13. 4. 4). This
appliance has t he advant age t hat addit ional arms or springs can be at t ached, if
indicat ed, t o procline t he upper incisors, but in cases w it h more severe
displacement and/ or rot at ion of t he incisors a simple f ixed appliance can be used
concurrent ly (Fig. 21. 11). How ever, care is required t o ensure t hat t he root s of
t he t eet h adjacent t o t he clef t are not moved out of t heir bony support , and it
may be necessary t o def er t heir complet e alignment t o t he post -graf t ing st age.
The expansion achieved should be ret ained, f or example w it h a palat al arch,
w hilst bone graf t ing is carried

out (Fig. 21. 12). Removing deciduous t eet h and erupt ed supernumerary t eet h in
t he region of t he clef t prior t o graf t ing subst ant ially improves f lap qualit y.

Fig. 21.11. Patient with a repaired unilateral cleft of the


lip and palate of the left side: (a) pretreatment; (b)
following expansion and alignment of the rotated upper
left central incisor.
(a)

(b)

Fig. 21.12. The same patient as in Fig. 21.11: (a)


palatal arch and sectional archwire to retain position of
the upper central incisors, prior to bone grafting; (b)
after bone grafting, showing the upper left canine
erupting.

(a)
(b)

I n pat ient s w it h a bilat eral complet e clef t lip and palat e it may be necessary t o
st abilize t he mobile premaxillary segment af t er bone graf t ing in order t o ensure
t hat t he graf t t akes. This can be accomplished by placement of a relat ively rigid
buccal archw ire prior t o bone graf t ing, w hich is lef t i n si tu f or at least 3 mont hs
af t er t he operat ion. I f space closure on t he side of t he clef t is planned,
considerat ion should be given t o t he need t o ext ract t he deciduous molars on
t hat side prior t o graf t ing in order t o f acilit at e f orw ard movement of t he f irst
permanent molar. How ever, any ext ract ions should be carried out at least 3
w eeks prior t o bone graf t ing in order t o allow healing of t he kerat inized mucosa.
Cancellous bone is current ly used f or bone graf t ing because it assumes t he
charact erist ics of t he adjacent bone; how ever, t his may change in t he f ut ure as
bone morphogenesis prot eins become cheaper and more readily available.
Cancellous bone can be harvest ed f rom a number of sit es, but t he iliac crest or
t he chin are current ly most popular. Kerat inized f laps should be raised and
ut ilized f or closure, as mucosal f laps may int erf ere w it h subsequent t oot h
erupt ion. Unerupt ed supernumerary t eet h are commonly f ound in t he clef t it self ,
and t hese can be removed at t he t ime of operat ion. There is no subst ant ive
evidence t o support t he cont ent ion t hat simult aneous bone graf t ing of bilat eral
alveolar clef t jeopardizes t he int egrit y of t he premaxilla.
The complicat ions of t his t echnique include t he f ollow ing:

granuloma f ormat ion in t he region of t he graf t t his of t en resolves w it h


increased oral hygiene, but surgical removal may be required;
f ailure of t he graf t t o t ake t his usually only occurs t o a part ial degree;
root resorpt ion relat ively rare;
around 15 per cent of canines require exposure.

21.6.6. Permanent dentition


O nce t he permanent dent it ion has been est ablished, but bef ore f urt her
ort hodont ic t reat ment is planned, t he pat ient should be assessed as t o t he need
f or ort hognat hic surgery t o correct mid-f ace ret rusion (see Chapt er 20). The
degree of maxillary ret rognat hia, t he magnit ude and eff ect of any f ut ure grow t h,
and t he pat ient 's w ishes should all be t aken int o considerat ion. I f surgical
correct ion is indicat ed, t his should be def erred unt il grow t h is complet e
(f ollow ing any presurgical ort hodont ic alignment ).
I f ort hodont ics alone is indicat ed, t his can be commenced once t he permanent
dent it ion is est ablished. Usually f ixed appliances are necessary (Fig. 21. 13). I f
space closure in t he region of t he clef t is not f easible, t reat ment planning should
be carried out in collaborat ion w it h a rest orat ive opinion regarding t he design of
t he prost hesis required.

Fig. 21.13. (a) Patient with a repaired unilateral left


cleft lip and palate. The diminutive upper right lateral
incisor was extracted and the canine brought forward
adjacent to the upper right central incisor: (b)
pretreatment; (c) post-treatment.

(a)
(b)

(c)

At t he end of ort hodont ic t reat ment , ret ent ion w ill be required. I f t he maxillary
arch has been expanded, t his w ill be part icularly prone t o relapse, and ret ent ion
of t he arch w idt h w it h eit her a removable ret ainer w orn at night or a part ial
dent ure (if indicat ed f or prost het ic reasons) is advisable.

21.6.7. Completion of growth


A f inal surgical revision of t he nose (rhinoplast y) may be carried out at t his
st age. How ever, if ort hognat hic surgery is planned, t his should be carried out
f irst , as movement of t he underlying bone w ill aff ect t he cont our of t he nose.

21.7. AUDIT OF CLEFT PALATE CARE


Audit of clef t palat e management is diff icult because of t he diff erent disciplines
involved in providing care and t he range of clinical present at ions. I n order t o t ry
t o evaluat e t he eff ect s of t reat ment , caref ul records t aken bef ore and af t er any
int ervent ion (surgical or ort hodont ic) must be a priorit y. These should include
st udy models and phot ographs of t he clef t prior t o primary closure, so t hat t he
size and morphology of t he original clef t can be t aken int o considerat ion. I n
addit ion, a clef t t eam should concent rat e on a part icular t reat ment prot ocol in
order t o gain t he necessary expert ise and experience t o achieve successf ul
result s and t o collat e a meaningf ul amount of usef ul dat a. I f t he result s of one
surgical t eam carrying out a part icular t reat ment prot ocol are t o be compared
w it h anot her t reat ment regimen carried out at a diff erent cent re, some
st andardizat ion of t hese records is required. I n t he UK t he Cranio-f acial Societ y
of G reat Brit ain is at t empt ing t o st andardize record collect ion w it h t he Cranio-
f acial Anomalies REgist er (CARE).
As in all branches of medicine, concent rat ion of expert ise and experience at a
cent re of excellence produces superior result s t o t hose obt ained by a lone
pract it ioner carrying out small numbers of a part icular procedure each year.
Theref ore t here is pressure t o concent rat e clef t palat e care at regional cent res.
How ever, t his approach has t he disadvant age t hat t he majorit y of pat ient s w ill
have t o t ravel great er dist ances t o receive t heir t reat ment . I n ot her count ries
t his problem is addressed by great er availabilit y of cent ral f unding t o t ransport
pat ient s and t heir f amilies t o receive t reat ment ; accommodat ion cost s are also
included.

21.8. OTHER CRANIOFACIAL ANOM ALIES


21.8.1. Hemifacial microsomia
This is t he second most common craniof acial anomaly, w it h a prevalence of 1 in
5000 birt hs. I t is a congenit al def ect charact erized by a lack of bot h hard and
sof t t issue on t he aff ect ed side of t he f ace, usually in t he area of t he mandibular
ramus and ext ernal ear (i. e. in t he region of t he f irst and second branchial
arches, hence it s older name of f irst arch syndrome). This anomaly usually
aff ect s one side of t he f ace (Fig. 21. 14), but does present bilat erally in around
20 per cent of cases. A w ide spect rum of ear and cranial nerve def ormit ies are
f ound. G oldenhar syndrome or oculo-auriculovert ebral dysplasia (t he lat t er name
neat ly explains t he aff ect ed sit es, but is more diff icult t o remember and spell) is
a variant of hemif acial microsomia.

Fig. 21.14. Patient with hemifacial microsomia.


(a)

(b)

Management usually involves a combinat ion of surgery and ort hodont ic


t reat ment . How ever, milder cases can somet imes be managed w it h ort hodont ic
appliances alone. O rt hodont ic t reat ment usually involves t he use of a specialized
t ype of f unct ional appliance know n as a hybrid appliance, so called because
component s are select ed according t o t he needs of t he individual malocclusion,
f or example encouraging erupt ion of t he buccal segment t eet h on t he aff ect ed
side. The degree and t ype of surgery depends upon t he severit y of t he def ect ,
but t hree phases are recognized:

Early reconst ruct ion (5 t o 8 years of age), commonly w it h cost ochondral rib
graf t s, is usually reserved f or severe cases w it h no f unct ioning TMJ.
At t he end of t he adolescent grow t h spurt (around 12 1 5 years of age)
dist ract ion ost eogenesis (see sect ion 20. 4. 4).
Lat e t eens, t o enhance t he cont our of t he skelet on and sof t t issues
convent ional ort hognat hic and reconst ruct ive t echniques.

21.8.2. Treacher C ollins syndrome


This syndrome is also know n as mandibulof acial dysost osis. I t is inherit ed in an
aut osomal dominant manner and consist s of t he f ollow ing f eat ures, w hich are
present bilat erally:

dow nw ard sloping (ant i-mongoloid slant ) palpebral f issures and colobomas
(not ched iris w it h a displaced pupil);
hypoplast ic malars;
mandibular ret rognat hia;
def ormed ears, including middle and inner ear w hich can result in deaf ness;
hypoplast ic air sinuses;
clef t palat e in 30 per cent of cases;
most have complet ely normal int ellect ual f unct ion.

The specif ics of management depend upon t he f eat ures of t he case, but usually
st aged craniof acial surgery is required. I f a clef t palat e is present , t his is
handled as described above.

21.8.3. Pierre Robin anomaly


This anomaly consist s of ret rognat hia of t he mandible, clef t palat e, and
glossopt osis, w hich t oget her cause airw ay problems in t he inf ant . Alt hough
originally t hought t o be due t o raised int ra-ut erine pressure causing t he head of
t he f et us t o be compressed against t he chest , t hus rest rict ing normal
development of t he

mandible, recent research w ould suggest a met abolic aet iological f act or. The
f irst priorit y at birt h is t o maint ain t he airw ay; in a proport ion of cases it is
necessary t o use an endot racheal t ube f or t he f irst f ew days, but once t he child
is older, or in less severe cases, prone nursing w ill suff ice. Rarely, t racheost omy
f or medium-t erm airw ay prot ect ion is required. Subsequent management is as f or
clef t palat e (see above). I n a proport ion of Pierre Robin children cat ch-up
grow t h of t he mandible does occur, but paediat ric dist ract ion ost eogenesis (see
sect ion 20. 4. 4) or convent ional ort hognat hic surgery can be planned f or t hose
w it h a markedly ret rognat hic mandible.
21.8.4. Craniosynostoses
I n craniosynost osis and craniof acial synost oses, premat ure f usion of one or
more of t he sut ures of t he bones of t he cranial base or vault occurs. The eff ect s
depend upon t he sit e and ext ent of t he premat ure f usion, but all have a marked
eff ect upon grow t h. I n some cases rest rict ion of skull vault grow t h can lead t o an
increase in int racranial pressure w hich, if unt reat ed, can lead t o brain damage. I f
raised int racranial pressure is det ect ed, release of t he aff ect ed sut ure(s) bef ore
6 mont hs of age is indicat ed. This may be t he only int ervent ion needed in
isolat ed craniosynost oses. Combined craniof acial synost oses (e. g. Crouzon
syndrome, Apert syndrome) require subsequent st aged ort hodont ic and surgical
int ervent ion. This may become t he prime indicat ion f or t elemet ric dist ract ion
ost eogenesis.

PRINCIPAL SOURCES AND FURTHER READING


Bergland, O . , Semb, G . , and Abyholm, F. E. (1986). Eliminat ion of t he
residual alveolar clef t by secondary bone graf t ing and subsequent ort hodont ic
t reat ment . Cl ef t Li p and Pal ate Journal, 23, 175 2 05.

This paper is now a classic. I t describes t he pioneering w ork by t he O slo clef t


t eam on alveolar bone graf t ing.

Bhat ia, S. N. (1972). G enet ics of clef t lip and palat e. Bri ti sh Dental Journal,
132, 95 1 03.
G ives an int erest ing hypot hesis regarding t he inherit ance of clef t anomalies,
but also includes insight on t he genet ics of ot her dent al anomalies.

Clinical St andards Advisory G roup (1998). Cl ef t l i p and/ or pal ate. St at ionery


O ff ice, London.

Cousley, R. R. J. (1993). A comparison of t w o classif icat ion syst ems f or


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78 8 2.

Edw ards, J. R. G . and New all, D. R. (1985). The Pierre Robin syndrome
reassessed in t he light of recent research. Bri ti sh Journal of Pl asti c Surgery,
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Rant a, R. (1986). A review of t oot h f ormat ion in children in clef t lip/ palat e.
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St einberg, M. D. et al . (1999). St at e of t he art in oral and maxillof acial


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An easy-t o-read paper emphasizing t he int egrat ion of prevent ive care in t he
overall management of t he clef t palat e pat ient .
Authors: Mitchell, Laura
T itle: A n I ntroducti on to O rthodonti cs , 2nd Edi ti on
Copyright Š2001 O xf ord Universit y Press
> B ac k of B ook > D efinitions

Definitions
ANCHO RAG E
The source of resist ance t o t he f orces generat ed in react ion t o t he act ive
component s of an appliance.
ANT ERIO R O PEN BIT E
There is a space vert ically bet w een t he incisors w hen t he buccal segment t eet h
are in occlusion.
BALANCING EXT RACT IO N
Ext ract ion of t he same (or adjacent ) t oot h on t he opposit e side of t he arch t o
preserve symmet ry.
BIMAXILLARY PRO CLINAT IO N
Bot h upper and low er incisors are proclined relat ive t o t heir skelet al bases.
BO DILY MO VEMENT
Equal movement of t he root apex and crow n of a t oot h in t he same direct ion.
BUCCAL CRO SSBIT E
The buccal cusps of t he low er premolars and/ or molars occlude buccally t o t he
buccal cusps of t he upper premolars and/ or molars.
CING ULUM PLAT EAU
The convexit y of t he cervical t hird of t he lingual/ palat al aspect of t he incisors
and canines.
CO MPENSAT ING EXT RACT IO N
Ext ract ion of t he same t oot h in t he opposing arch.
CO MPET ENT LIPS
Upper and low er lips cont act w it hout muscular act ivit y at rest .
CO MPLET E O VERBIT E
The low er incisors occlude w it h t he upper incisors or palat al mucosa.
CRO WDING
Where t here is insuff icient space t o accommodat e t he t eet h in perf ect alignment
in an arch, or segment of an arch.
DENT O -ALVEO LAR CO MPENSAT IO N
The inclinat ion of t he t eet h compensat es f or t he underlying skelet al pat t ern, so
t hat t he occlusal relat ionship bet w een t he arches is less marked.
HYPO DO NT IA
This t erm is used w hen one or more permanent t eet h (excluding t hird molars) are
congenit ally absent . The equivalent American nomenclat ure is oligodont ia.
IDEAL O CCLUSIO N
Anat omically perf ect arrangement of t he t eet h. Rare.
IMPACT IO N
I mpeded t oot h erupt ion usually because of displacement of t he t oot h or
mechanical obst ruct ion (e. g. a supernumerary t oot h).
INCO MPET ENT LIPS
Some muscular act ivit y is required f or t he lips t o meet t oget her.
INCO MPLET E O VERBIT E
The low er incisors do not make cont act w it h t he opposing upper incisors or
palat al mucosa w hen t he buccal segment t eet h are in occlusion.
LEEWAY SPACE
The diff erence in diamet er bet w een t he deciduous canine, f irst molar, and
second molar, and t heir permanent successors (canine, f irst premolar, and
second premolar).
LING UAL CRO SSBIT E
The buccal cusps of t he low er premolars and/ or molars occlude lingually t o t he
lingual cusps of t he upper premolars or molars.
MALO CCLUSIO N
Variat ion f rom ideal occlusion w hich has dent al healt h and/ or psychosocial
implicat ions f or t he individual. NB The borderline bet w een normal occlusion and
malocclusion is cont ent ious (see Chapt er 1).
MANDIBULAR DEVIAT IO N
The pat h of closure of t he mandible st art s f rom a post ured posit ion.
MANDIBULAR DISPLACEMENT
When closing f rom t he rest posit ion t he mandible displaces (eit her lat erally or
ant eriorly) t o avoid a premat ure cont act .
MIDLINE DIAST EMA
A space bet w een t he cent ral incisors. Most common in t he upper arch.
MIG RAT IO N
Physiological (minor) movement of a t oot h.
NO RMAL O CCLUSIO N
Accept able variat ion f rom ideal occlusion.
O VERBIT E
Vert ical overlap of t he upper and low er incisors w hen view ed ant eriorly: one-
t hird t o one-half coverage of t he low er incisors is normal; w here t he overbit e is
great er t han one-half it is described as being increased; w here t he overbit e is
less t han one-t hird it is described as being reduced.
O VERJET
Dist ance bet w een t he upper and low er incisors in t he horizont al plane. Normal is
2 4 mm.
RELAPSE
The ret urn, f ollow ing correct ion, of t he f eat ures of t he original malocclusion.
REVERSE O VERJET
The low er incisors lie ant erior t o t he upper incisors. When only one or t w o
incisors are involved t he t erm ant erior crossbit e is commonly used.
RO TAT IO N
A t oot h is t w ist ed around it s long axis.
SPACING
Where t he t eet h do not t ouch int erproximally and t here are gaps bet w een
adjacent t eet h. Can be localized or generalized.
T ILT ING MO VEMENT
Movement of t he root apex and crow n of a t oot h in opposit e direct ions around a
f ulcrum.
T O RQ UE
Movement of t he root apex buccolingually, eit her w it h no or minimal movement of
t he crow n in t he same direct ion.
T RAUMAT IC O VERBIT E
The occlusion of t he low er incisors w it h t he palat al mucosa has led t o ulcerat ion.
UPRIG HT ING
Mesial or dist al movement of t he root apex so t hat t he root and crow n of t he
t oot h are at an ideal angulat ion.