3) Primary dentition. Formation, stages, and characteristics.

1. Normal terms of eruption of primary teeth:

- 1st primary incisors - 6-8 months
- 2nd primary incisors - 8-12 months
- 1st primary molars - 12-16 months
- primary canines - 16-20 months
- 2nd primary molars - 20-30 months
The eruption of the 1st primary incisors is called early eruption if it happens before the 4th
month and late eruption if it is after the 12th month!
Regarding all primary teeth the eruption is called LATE when it is 6 months later than the initial
term and 2 months later than the final term!
2. Formation of the primary dentition :
This stage continues until 2.5 - 3 years of age, I. e. all primary teeth should be erupted till this
age!
3. Formation of the roots of the primary teeth:
The completion of the development of the roots of the primary teeth is up to 2 years after
their eruption and the resorption of the roots starts 1-2 years after the development of the
roots is finished.
4. Normal shape of the dental arches:
Both upper and lower dental arches in primary dentition have a semicircle shape,unlike the
dental arches in permanent dentition - the upper arch has a semi-ellipse shape and the lower
arch - parabola shape.
In the primary dentition the curve of Spee is almost absolutely missing.
5. Deviation from the norm regarding the existing spaces
between the teeth in primary dentition:
The primary dentition normally develops with diastemas and tremmas and their presence is
very important, because they compensate the difference between the mesiodistal widths of
the primary teeth and the permanent teeth which replace them. So we assume as a deviation
from the normal development of the dental arches a primary dentition without diastemas and
tremmas ( according to Vladislavov ), whereupon in 3/4 of the clinical cases irregular
alignment of the permanent incisors is observed. If the primary teeth are rotated and crowded
the prognosis is for unfavorable alignment of the permanent incisors in almost 100% of the
cases (a symptom of teeth size - jaw size discrepancy )!
6. Stage of stable primary dentition :
This stage is between 2,5 -3 years of age and 5,5 - 6 years of age, I. e. until the first primary
incisor exfoliates!
7. Preventive procedures during primary dentition; elimination of
bad oral habits; control of the eruption of the primary teeth :
- The 1st appointment of the child at the dentist's office is before the 3rd month after birth
and it is very important to advise the mother about the most physiological way of feeding the
baby.
- 2nd visit of the child at the dentist's office - at 1-1,5 year of age - the eruption of the primary
teeth should be monitored and it is important for the child to be fed with a spoon, to drink
liquids from a cup in order not to hold food under the tongue and also the child should eat
natural and solid food not soft and squashy food and so the persistence of the " infantile
swallowing "after the development of the primary dentition can be eliminated!
- The next dental examination of the child is usually after the full eruption of all primary teeth
at the age of 2,5-3 years and afterwards at least every 6 months !
- The stage of stable primary dentition is exclusively favorible for prevention of the
malocclusions ,because :
􀌤the primary dentition is absolutely formed and stable
􀌤the mental development of the child allows us to have the necessary contact with her/him
and so we can expect a collaboration
􀌤in this age most of the etiological factors,responsible for the development of the
malocclusions, are acting
􀌤if the etiological factors are eliminated a self correction of some of the present malocclusions
can be expected
􀌤the stage of the primary dentition is long enough for conducting of an effective preventive
measures and realization of orthopedic effect- namely to create the appropriate conditions for
normal development and interrelation of the jaws
􀌤the main purpose of the general practitioner is to find and eliminate the basic etiological
factors for development of the malocclusions with the help of the parents and other relatives
- BAD ORAL HABITS :
!Finger or thumb sucking :
Most often the parents find this habit;it's necessary to determine the cause for it's presence
and to decide how we will manage this problem and eliminate it without burdening the
child.The approach depends on the age - when a baby is trying to put it's finger in the mouth
we simply need to pay more attention to the child and to gently remove the finger from the
mouth or to replace it with a pacifier (NUK type).After the age of 3 years we can make contact
with the child
and we must try to persuade him or her that the thumb sucking is deleterious so we can
expect a collaboration in the elimination of the bad habit.We can use rough woolen
mitts,sewn to the sleeves of child's pajamas ,that are really unpleasant for sucking or some
kind of mechanical barrier that stops the finger and the recurrence of the habit - different
prefabricated interceptive appliances (trainers) or oral screen, according to Kraus.
●MOUTH BREATHING :
Again we receive the information for the presence of this habit from the parents, but it is our
obligation to find out if this mouth breathing is due to obstruction of the nasal breathing or it
is simply a habit without any morphological obstructions in the airways. In our office we can
ask the child to put some water in the mouth and to hold it for 1 minute.If the child can't
breathe through the nose due to some obstructions ,she/he will open the mouth, because
mouth breathing is a
necessity in this cases.For elimination of this bad habit we can use again the prefabricated
interceptive appliances (trainers ( or oral screen, according to Kraus.
●TONGUE THRUSTING AND PERSISTENT INFANTILE SWALLOWING :
After the birth the baby swallows as he/she places the tongue between the edentate alveolar
crests.This type of swallowing is called "infantile" passes into swallowing with teeth in contact
after the development of the primary dentition. This incorrect swallowing after 3 years of age
is recognized by the dentist. Clinically we can put our fingers under the lower border of the
mandible or index fingers of both hands over m.masseters in the angles of the mandible so we
can fell the contraction of muscles during swallowing ( normal swallowing is with teeth in
contact ).We can determine if there is a contraction of m.mentalis during swallowing by
placing our thumbs on the chin. Simultaneously with the examination of the muscles we must
retract the lip corner so as to assess the interrelation between the tongue and the teeth.
Incorrect swallowing can be
accompanied by so called "specific facial expression/grimace ". The elimination of the
incorrect swallowing should be performed after the primary dentition is fully
developed and when infantile swallowing drops out.There are 3 basic and effective excersises:
a) we must show the place of the incisive papilla to the child where he/she should place the tip
of the tongue .And he/she must practice to hold the tip of the tongue there simultaneously
with opening and closing the mouth in order to get used to the normal position of the tongue.
b) the 2nd exercise for the child is to swallow with teeth in contact(clinched teeth) without
seeing the tongue between the teeth as he/she control himself /herself in a mirror. With the
1st and the 2nd excersise the voluntary swallowing is normalized.
c) in order to normalize the reflex swallowing the child places a mint candy on the back of the
tongue near it's tip and after that she/he presses the candy against the palate .Mint candy
stimulates the secretion of saliva ,which the child must swallow without dropping the candy
until it is fully melted.

4) Mixed dentition. Formation, stages, and characteristics. Transitory discrepancies in the

dental arches during mixed dentition.

Basic features of the early mixed dentition :

- Early mixed dentition is the 1st stage of the development of the mixed dentition (eruption if
the 1st permanent molars and the permanent incisors ) and it consists of 2 phases :
▪ 1st: between 6 - 7.5 years of age - during this phase there is active growth of the dental
arches ,associated with the tooth eruption
▪ 2nd : between 7.5 - 9 years of age - we don't expect so active growth of the dental arches
during the formation of the dental roots
Transitional deviations during the development of the dental
arches in mixed dentition :
♡ upper central incisors may erupt with divergent axis and a diastema of 1mm or less in 30% of
the cases.A self correction can be expected due to the eruption of the posterior teeth if there
is enough space for them in the arch
♡ upper lateral incisors can have DV rotation and distal inclination with enough space in the
arch for them ( "ugly duckling"stage).This can be a transitional deviation ,caused by the
eruption of the permanent canines
♡ lower incisors may erupt lingually to the primary incisors. Usually they are corrected by the
function of the tongue if there is enough space in the arch for them. If 1-2 mm of space is are
missing in the arch and there is normal overbire (not deep bite ) a normal alignment in the
arch is expected during the transverse growth of the dental arch that normally occurs with the
eruption of the permanent incisors
♡ when there is a flush terminal plane in the region of the 2nd primary molars and I Angle class
in the region of the primary canines, a self correction of the distal bite in the region of the 1 st
permanent molars is expected
Basic symptoms of tooth size - jaw size discrepancies :
¤ they may affect the anterior or the posterior region of the dental arches
¤ they can be transitional (being compensated by the growth of the jaws and the eruption of
the permanent teeth ) and permanent (usually compensatory tooth extractions are needed)
¤ early symptoms of tooth size - jaw size discrepancies :
~ crowded and rotated primary anterior teeth without diastemas and tremmas
~ resorption of two primary anterior teeth by one permanent tooth
~ lingually erupted lateral incisor and deviation of the other incisors to it's place in the arch
~ early crowding of the incisors, accompanied by protrusion or vestibular inclination of a single
tooth and a recession of the same tooth
~ resorption of the 2nd primary molars by the 1st permanent molars and premature loss of the
primary 2nd molar
~ vestibular eruption of the 2nd upper permanent molars or their retention in the bone
~ mesial inclination of the posterior teeth
Preventive procedures during mixed dentition:
- systematic control of the replacement of teeth - especially the eruption of the permanent
incisors
- early or late eruption; irregular eruption due to lack of enough space in the arch; persistent
primary tooth; irregular resorption of two primary teeth by one permanent tooth
- elimination of the bad oral habits and the causes for their presence
- the myotherapy as a part of the treatment of the malocclusions
- extraction of persistent teeth if there is enough space in the arch for the permanent tooth
and if is not a persistent tooth due to hypodontia
- placement of a space maintainers in cases with premature loss of primary teeth
- if there is a tendency to edge to edge bite or crossbite during the eruption of the permanent
incisors - it can be useful to make excersises with spatula
Late mixed dentition:
- Late mixed dentition is the 2nd stage of the development of the mixed
dentition( replacement of the primary canines and primary molars with the permanent
canines and premolars) and also consists of two phases:
- 1st : between 9 -10,5 years of age - at the time that premolars erupt there is no active growth
of dental arches
- 2nd : between 10.5 - 12 years of age - there is active growth of the dental arches during the
formation of the roots of the premolars and the eruption of the permanent canines. The basic
factors that determine the growth of the dental arches are the eruption of teeth and the
formation of their roots.
Growth of the dental arches in the three dimensions of
space:
< TRANSVERSAL GROWTH - the biggest growth of the dental arch in this direction is carried out
when the permanent incisors are erupting and this is the basic physiological expansion of the
dental arch. According to Vladislavov at this time the width of the arch, measured between the
primary canines, increases with 2.6 - 2.7mm. Between 4 - 13 years of age a 3mm expansion of
the arch between the canines is estimated, and 2 mm between the premolars and molars. The
transverse growth of the dental arch continues until 13 - 15 years of age in the upper arch and
until 10 - 12 years of age in the lower.
< SAGGITAL GROWTH - according to Baume the length of the line, drawn from the vestibular
surfaces of the incisors to the distal surfaces of the canines, increases with 2.2 mm in the
upper arch and with 1.3 mm in the lower when the permanent teeth are erupting. This growth
is important because the wider permanent incisors need increased size of the arch. The
average difference between the mesiodistal widths of the primary and permanent incisors in
the upper jaw
is ~6.5 mm and in the lower jaw ~4.5 mm.But the difference between the mesiodistal widths
of the interchangeable five permanent and primary teeth according to Vladislavov is 4mm in
the upper jaw and 0.36 mm in the lower. Therefore the whole length of the dental arche
during the replacement of the primary by the permanent teeth between 3 -18 years of age is
DECREASING!The reason for this change is the mesial movement of the posterior teeth during
the replacement of the wider primary molars with the narrower premolars. This difference is 2
- 2.5 mm in the upper arch and 2.5 - 3 mm in the lower arch.

5) Permanent dentition, formation, stages, and characteristics. Transitory discrepancies in

the dental arches during mixed dentition.
Normal terms of eruption of the permanent teeth and some
important features:
- 1st permanent molars and central incisors - 6 years
- lateral incisors - 7 years
- 1st premolars - 8 years
- permanent canines - 9 years
- 2nd premolars - 10 years
- 2nd permanent molars - 11 years
􀌤this is usually the order for the eruption of the permanent teeth but often in the mandible
the permanent canine is erupting after the incisors and before the 1st and the 2nd premolars.
􀌤the permanent incisors normally erupt in vestibular direction and thereby a space is gained
for their larger size.
􀌤 the upper permanent canines have wider crowns than the primary canines and they fill the "
primate tremmas" ,push the lateral incisors mesially and the 1st premolars distally.
􀌤the lower canines also fill the "primate tremmas " and if they erupt after the 1st premolars
they can shift them distally, but usually they erupt before them.
􀌤 the premolars are aligned in wider spaces in the arch, because the primary molars have
larger crowns.
(+ FROM QUESTION 4 )

6) Normal occlusion in primary, mixed and permanent dentition.

--Primary dentition:
The overbite in primary dentition varies from 10% to 40% . The fact that more than 60% of the
children have reduced overbite or an open bite is attributed to oral habits ( thumb sucking,
pacifiers ) that are common in this age.
Overjet : the normal overjet in primary dentition varies between 0 to 4 mm.
Spacing: generalized spacing occur to 2/3 of the children in primary dentition.
Molar relationship: ( 90 or 96 % ) of the cases have a flush terminal plane relationship, or
1mm or greater mesial step.
--Mixed dentition:
We may have a temporary open bite which is transitory in future. It may disappear when
incisors complete the eruption process.
Spacing: Presence of midline diastemas is of normal occurrence. It may vary from 1mm to
3mm. It usually closes when maxillary canine erupts.
What considered good in mixed dentition stage is:
- Class 1 molar and canine relationship.
- positive leeway space
- minor or no rotations or incisor crowding.
- normal bucolingual axial inclination.
- normal mesiodistal axial inclination.
- tight proximal contacts.
- even marginal ridges vertically.
- flat occlusal plane or a mild curve of spee.
--Permanent dentition:
What is considered good in permanent dentition is :
Overlap: The maxillary teeth are buccal to the mandibular.
Angulation: In primary dentition, teeth are positioned vertically to the alveolar bone. In
permanent the teeth have bucolingual and mesiodistal angulations.
Occlusion: Except the mandibular central incisors and maxillary second molar, each tooth
occludes with two teeth from the opposite arch.
Arch curvature:
The arch curvature of the mandible is called the curve of spee.
The arch curvature of the maxilla is called the compensating curve.
The bucolingual curve from one side to another is called Wilson curve or Monson curve.

14) Orthodontic anamnesis and status

The anamnesis is the first step of diagnostic process.The patient/ parent interview is a direct
contact with the patient.It provides:
The origin of the malocclusion and how it developed.
The inheritable nature of the orthodontic problem and how to assess it.
The clinical and para clinical evaluation that needs to be implemented.
The patients attitude and expectations.
In early childhood the parents are interviewed.
The anamnesis consists:
Identification data.
History of present malocclusion (anamnesis morbi).
History of life (anamnesis vitae).
Family history.
Identification data:
name,date of birth, age, address and telephone number
History of present malocclusion:
Chief complain and reason of visit.
When was the onset of malocclusion.
What is the reason to seek orthodoontic treatment.
Were there previous consultations with an orthodontic specialist.
Was the patient previously treated orthodontically.
If previous orthodontic treatment was conducted, but discoontinued what was the reason.
History of life:
We need to find pathological reasons that lead to malocclusion.
Maternal pregnancy- maternal diseases, medications.
Childbirth -labor and complications.
Neonatal nutrition- breastfeeding, duration of the used pacifiers.
Eruption time of teeth.
Onset of speech.
Oral habits- pacifiers, digit or lip sucking, mouthbreathing.
Systemic conditions: allergies, respiratory diseases.
Family history:
hereditary malocclusions: diastema, hyperdontia, hypodontia, impacted maxillary canines,cleft
lip and palate.
Horizontal inheritance pattern- clinical examination of brothers and cousins.
Vertical inheritance pattern- clinical examination of parents and grandparents.
Clinical examination of patient (status)
General status addresses the physiological condition of the patient appearance,body
constitution and musculature, according to age, posture hygiene.
Status localis there is intraoral and extraoral.
Frontal view
Symmetry of the face accrding to the midline.
Proportinality of the face-it is divided to three vertical facial heights
a) trichion to soft tissue nasion.
b)nasion to subnasale.
c)subnasale to gnathion.
The lower facial third is 5-10mm higher than the middle face heigh.
The horizontal line tha pass through the pupils and the corners of the mount should be
parallel.
Contact point between upper and lower lip should be in contact ideally.
Profile view
Facial profile is estimated by its appearance depending on the correlation of position of the
pints:tip of the nose, upper lip and chin prominence. It can be can be
concave(prognathic),straight and convex (retrgognathic).
Mandibular angle is examinedby positioning 2 rulers one on the ramus and one on the
mandibular body. Facial profile photograph is performed.
Intraoral status
They are examined present teeth, dental arch form,tongue size and position,periodontal
status,oral hygiene and oral frenula.
Functional evaluation
Evaluation of oral functions, related to condition of muscle groups snd the temporomandibular
joint in physiologic rest position of the mandible. Swallowing is examined as the clinician
placeshis index finger and middle finger after the inner margin of the mandibular body and
invites the patient to swallow saliva. It is important to differentiate mouth-breathing from
nasal breathing.
Diagnostic clinical tests
By visible facial symmetry the movement of the mandible should be examined.
The patient is advised to fully open his mouth and then slowly start closing it.
If facial symmetry is observed during openign and closing, there is morphological discrepancy
of mandible otherwise its functional deviation of mandible.
Class 2
By prognathic profile, class 2 and severe overjet patient protrudes the mandible to class 1
molar relationships. Then the change in the patients profile is observed.
If the profile improves, the maxilla is in correct position and normal development of the
mandible is returded.
If the profile worsens the maxilla is protruded and has excessive growth.
If during the test the profile initially improves but then worsens then both maxilla and the
mandible have sagittal discrepancies.
Class 3
By class 3 the clinician manually retrudes the mandible n distal position. If this movement is
obtainable and the patient occludes in edge to edge in the anterion area then its anterior cross
bite. If distal movementof the mandible is impossible, then its prognathic and additional
evaluation of the jaw relationships is necessary.
Deep bite
Clinical test for assessing supraerupted frontal segment or infrapositioned posterior segment
is applied. The distance between mandibular and maxillary teeth is measured. If the distance is
2mm the frontal segment is supraerupted and if the distance is 4mm posterior segments are
infrapositioned.

15 ) single arch analysis and evaluation of the occlusion in decidiuous teeth, mixed and
permanent dentition.

1. Mesiodistal width of permanent teeth

2. SI = Mesiodistal Width of Maxillary incisors

3. Transverse Discrepancies
 Anterior: Midline deviation ( left or right of Maxilla or Mandible in mm ) ( From
the contact between the central incisors )
 Posterior: 1) PP maxilla = fissure of first permanent premolars.
PP mandible = between first and second permanent premolars.

2) MM Maxilla = central fissure under the MV cusp of first permanent molars.

MM mandible = tip of distobuccal cusp of first permanent molars.
Compare with the values
Conclusion: if – constriction , if + expansion

4. Sagittal Discrepancies
 Anterior segment: Lo ( maxillary) = Distance from the first incisors up to the line
that connects ( in half) the first premolars.
Lu ( mandible) = Distance from the first incisors up to the line that connects the
aproximal contact between the first and second premolars.

Compare with the values

Conclusion: ( more)= protrusion , ( less)= retrusion
  Posterior Segment: compare the premolars and molars with perpendicular lines
from the middle line. (We always write mesial drift from which tooth in mm)
(except missing theeth)
5. Vertical Discrepancies
( occlusal plane)
 Supraposition ( higher than normal )
 Infraposition ( shorter than normal)

6. Mixed dentition analysis.

 Moyers: 1)count mesiodistal diameters of mandible permanent incisors (Si) , 2)

count from the middle line buccaly with the sum of the Si/2 ( Mandible) and SI/2
(Maxilla) , 3) from there counted to the mesial surface of first permanent molar.

We compare with the values of 75% ( according to si )

If we have + ( enough space)
If we have – ( not enough space)

7. Tonn index: Si/SI = ¾ or 0,74 ( variants from 0,72-0,77) . SI/si= 4/3 or 1,35.. At edge to
edge (1,22) , deep bite (1,42) (We also use it to find the SI)

8. If we do not have the lateral incisors, we use the Chateau method ( MDD 11 +16 )
( needed to find MM )

9. Bolton ratio: MDD of mandibular teeth / MDD of maxillary teeth X 100 = 91,3
FOR ANTERIOR: MDD of mandibular anterior teeth /MDD of maxillary anterior teeth
X 100 = 77,2 ( We can use it to see if the difference is in posterior or anterior segment)

16.Photographic analysis of the face

It provides preliminary and post-treatment evaluation of extraoral status/appearance of the
patient.Evaluation influences orthodontic diagnosis,treatment planning and treatment result
and helps avoid eventual orthodontic restorative or surgical diagnostic error.Printed
phptpgraph is at least 9x13 so the reference lines can be traced.Photographs may be colored
or black and white.
Routine photographs have one lateral view facing to the right and one frontal
view.Supplemental phptographs in frontal view with patient smiling ¾ profile view and lateral
view facing to the left may be included when diagnostically appropriate.Patient’s head is
orientated accurately in all three planes od space,lips relaxed and teeth in central
occlusion.Glasses are removed.By frontal photographs the camera is positioned parallel to the
median plane of the head.Patient’s head is orientated on Frankfurt horizontal,eyes are opened
looking straight ahead and ears exposed for purpose of orientation.Overall requirements for
and intraoral photographic records are: (extraoral)one lateral view facing to the right,two
frontal views-one with lips relaxed and one smiling,(intraoral)one frontal view in maximum
intercuspation,two lateral views(right and left) maxillary and mandibular occlusal views.
There are sveral techniques for photographic shooting:
Frontal and lateral views are taken as patient switches positions
Patient is simultaneously shot with one camera using the mirrors method.
Patient is simultaneously shot with two cameras from the front and lateral
Planes and lines
Frankfurt horizontal (H-line)-the line between the earlobe and orbit (P AND 0)
Nasal perpendicular according to Dreyfuss
Orbital perpendicular according to Simon
Mouth tangent T
Profile field of the jaws
Constructed by the Frankfurt horizontal(H-LINE),orbital perpendicular(Po) and the nasal
perpendicular (Pn).The normal width of PFJ is 13-14mm in children and 15-17mm in adults.
Variations of the profile according to Schwarz profile definition:
Straight face-Sn lies on the Dreyfuss perpendicular (Pn)
Forward face Sn lies before the Dreyfuss perpendicular(Pn)
Backward face-Sn lies behind the Dreyfuss perpendicular (Pn)
Frontal view analysis and facial symmetry
The frontal view photographic analysis of the face is used to evaluate disproportions and
asymmetry in the midsagittal and horizontal plane.Vertical and horizontal reference lines that
segment the face are applied in the analysis.Comparison of the symmetry of the derived
segmentsis then possible.Physiologically every face has some degree of reight-left half
asymmetry.Midsagittal line Tr-Me (Trichion-Menton).Vertical line from center point of the
pupils to orbital point O.
Facial width:upper face width ZA-ZA(zygoma prominence);lower face width Go-Go(Gonion-the
most lateral point on the mandibular angle)
Physiognomic face height:Tr-Me
Facial height:N-Gn
PP-line:Bipupillar line
H-line:Frankfurt horizontal
G:Glabella
Ns:tip of the nose
Sn:subnasale
Sto:stomion
Ls:abralle submentale
Pog:pogonion
Gn:gnathion
Me:menton
ULL:upper lip length
LLL:lower lip length
Facial index=Facial heght(N-Gn) X100
Facial width(ZA-ZA)
IFM(facial morphology)= Oph-Gn X100
Facial width(ZA-ZA)

19.Functional assessment of the orofacial system

Functional assessment-Mastication(suckling), Degultation, Respiration, Speech.
Clinical considerations: before any treatment all functions of stomatognathic system should be
checked because it can be primary etiologic factor in a malocclusion.
Musculature-Muscles are a potent force, they are in active function or rest. Resting muscle still
is performing a function that of maintaining posture. During mastication and degultation the
tongue may exert 2 or 3 times as much force on the dentition as the lips and cheeks.
Muscles of mastication:
Lateral pterygoid-depresses the mandible, side movements
Medial pterygoid-elevation and side to side movements
Masseter-elevation of mandible
Mastication is the process by which food is crushed and ground the teeth
The preparatory phase-food is ingested and positioned by tongue within oral cavity and the
mandible is moved towards chewing side.
Phases of deglutition : Preparatory, Oral phase, Pharyngeal phase, Esophageal phase.
Between 2-4 years of age mature swallow is seen in normal developmental patterns.
overretention of infantile swallowing causes lack of tooth support due to poor tooth position
or arch relationship. Discomfort during tooth contact due to caries.
Effects: Labial displacement of anterior teeth by the tongue, open bite
Characteristics of normal respiration:
Presence of normal seal
Normal TMJ
Normal atmospheric pressure
Normal anteroposterior relationships of maxilla and mandible
Tongue position
Mouth breathing: if the palate is high and narrow the dorsum of tongue does not fit against
palatal vault. if lips do not meet the oral airway is complete from open lips to oropharynx. So
air can be thrown in and expired just as easily through mouth cavity or through nasal cavities.
Etiology: nasopharyngeal obstruction due to nasal deformities, deviated nasal septum, nasal
polyps
Effects: Marked overbite, tongue position is low and forward to keep oral airway open.
Speech
Processes involved in speech: a)respiration, b)resonance, c)articulation
Lisping and stammering: Speech defect involves change of sound of letters. Main cause is
continuing of infantile mode of speech. If the tongue is moved forward without mandible and
lies on top of lower incisors lisping may result. Malocclusions like open bite, maxillary
protrusion, mandibular retrusion may cause lisping. Stammering if the child fails to produce
any sound

20.Organization of the primary orthodontic prevention from the prenatal and postnatal
period to primary dentition stage.
Preventive medicine is a medical term describing a complex of actions to avoid the occurrence,
development and increase of the diseases among humans.
Primary prevention aims to prevent disease before it occurs.
Secondary prevention attempts to identify a disease at its earlier stage so that management
can be initiated. It reduces impact of disease.
Tertiary focuses on reducing consequences of a disease
Prevention includes: assessment of malocclusion occurrence risk, application of prescribed
measures, health teaching, early diagnosis and treatment.

Prenatal care
1st consultation-1st month of pregnancy: education on the significance of teratogenic and
general factors causing maxillofacial deformities during pregnancy. a)infectious diseases-
(scarlet fever, rubella), b)medicament treatment, c)alcohol, d)ionizing radiation, e)nutritional
deficiency.
Teratogens  Effect
Aspirin  Cleft lip and palate
Tobacco  << >>
Valium  Craniofacial microsomia
X-radiation  Microcephaly
Hypovitaminos A  Affects calcification of teeth, retarded erruption
Vitamin B deficiency  Cheilosis, cleft lip and palate

Preventive care in infancy

1st visit-before 3rd month after birth (cleft lip and palate, tongue tie)
Prenatal care: Consultation 1st month of pregnancy. Education on significance of breastfeeding
and instructions on bottle feeding and use of pacifiers.
Babies are born with secondary embryonic maxillary prognathism, mandible is 5-6 mm distal
to maxilla and the vertical gap between the gum is 4-5mm. Mandible is stimulated to
protrusive movements with act of suckling, facilitating mandibular growth.
Suckling-the lips wrap around a wide area of breast. Perioral muscles are tightly holding the
breast nipple. Negative pressure is created into the oral cavity. Propulsion by the lateral
pterygoid muscles extracts milk. Milk is mixed with saliva. The tongue transports the mixture
into oropharynx .Food is swallowed.

21-Primary and secondary orthodontic prevention for malocclusions for children from 3-6
years of age
There are 2 stages of primary dentition :first stage 2,5-3 years of age when the primary teeth
eruption is completed .Second stage which is stable primary dentition 2,5-3 up to 5,5- 6 years
of age.
The stage of stable primary dentition is exclusively favorible for prevention of the
malocclusions ,because :
The primary dentition is absolutely formed and stable.
The mental development of the child allows us to have the necessary contact with her/him
and so we can expect a collaboration
In this age most of the etiological factors ,responsible for the development of the
malocclusions, are acting
If the etiological factors are eliminated a self correction of some of the present malocclusions
can be expected
The stage of the primary dentition is long enough for conducting of an effective preventive
measures and realization of orthopedic effect- namely to create the appropriate conditions for
normal development and interrelation of the jaws
The main purpose of the general practitioner is to find and eliminate the basic etiological
factors for development of the malocclusions with the help of the parents and other relatives.
Bad oral habits
Thumb sucking : After the age of 3 years we can make contact with the child and we must try
to persuade him or her that the thumb sucking is deleterious so we can expect a collaboration
in the elimination of the bad habit .We can use rough woolen mitts ,sewn to the sleeves of
child's pajamas ,that are really unpleasant for sucking or some kind of mechanical barrier that
stops the finger and the recurrence of the habit - different prefabricated interceptive
appliances (trainers) or oral screen, according to Kraus.
MOUTH BREATHING :Again we receive the information for the presence of this habit from the
parents, but it is our obligation to find out if this mouth breathing is due to obstruction of the
nasal breathing or it is simply a habit without any morphological obstructions in the airways. In
our office we can ask the child to put some water in the mouth and to hold it for 1 minute.If
the child can't breathe through the nose due to some obstructions ,she/he will open the
mouth, because mouth breathing is necessity in this cases.For elimination of this bad habit we
can use again the prefabricated
interceptive appliances (trainers or oral screen, according to Kraus).
Tongue thrusting and infantile swallowing : The elimination of the incorrect swallowing should
be performed after the primary dentition is fully
developed and when infantile swallowing drops out.There are 3 basic and effective excersises:
a) we must show the place of the incisive papilla to the child where he/she should place the tip
of the tongue .And he/she must practice to hold the tip of the tongue there simultaneously
with opening and closing the mouth in order to get used to the normal position of the tongue.
b) the 2nd exercise for the child is to swallow with teeth in contact(clinched teeth) without
seeing the tongue between the teeth as he/she control himself /herself in a mirror. With the
1st and the 2nd excersise the voluntary swallowing is normalized.
c) in order to normalize the reflex swallowing the child places a mint candy on the back of the
tongue near it's tip and after that she/he presses the candy against the palate .Mint candy
stimulates the secretion of saliva ,which the child must swallow without dropping the candy
until it is fully melted.
Hypotonia of orbicularis oris muscle:
It must be evaluated what part of the length of the clinical crown of the upper central incisors
is not covered by the upper lip at physiological rest position. When ½ or more of the length of
the clinical crown is visible, myotherapy is recommended in order to
increase the tonicity of orbicularis oris muscle /except in cases with deep bite with
overdevelopment of the upper anterior segment/. Most often, myogymnastic exercises
include a plastic disc with semilunar curve. When a child makes an exercise he/she must hold
the disk between lips with its curve touching the vestibular surfaces of upper
frontal teeth. Additional small weights of 10 gr may be loaded to the
disk.
Hypotonia of the muscles that move the mandible mesially, mostly lateral pterygoid muscle
;Hypotension of muscles that medialize mandible may be diagnosed indirectly when a distal
occlusion is present. In cases of distal occlusion with ½ and more canine width, myotherapy is
recommended. Myotherapy is contraindicated in cases when the mandible is blocked and
cannot move forward –deep bite, constriction of upper jaw. We apply the Rogers’ exercise.
The child stands straight with head and body, leaning against the wall. The head can be also
tilted backwards. In this position the child moves his/her mandible forward until the lower
anterior teeth come in front of the upper anterior teeth. The child holds that position for 10
seconds and after that must have a rest for 10 seconds. This makes 3 exercises per minute. At
the beginning we need 10 exercises twice a day, and gradually 30 exercises twice a day must
be reached.
3. Position of the head during sleep
In cases of distal occlusion - it’s desirable to sleep on a pillow
In cases of mesial occlusion - it’s desirable to sleep without a pillow or
on a low pillow.
Orthodontic treatment:
In some cases as a part of the secondary prevention we must treat the
present malocclusions. In primary dentition we must correct all single arch
or occlusion discrepancies that restrain the normal development of the jaws
The malocclusions that must be treated are:
- Anterior and/or posterior crossbite
- Mesial occlusion and laterodeviation of lower jaw that can worsen in the
future, because they interrupt the normal development of jaws and
occlusion
- Severe distal occlusion
- Traumatic deep bite combined with palatal inclination of upper anterior
teeth, that blocks the normal development of the mandible
- Severe open bite
6. Selective grinding of primary canines - indications and
contraindications:- in cases of incorrect teeth abrasion – most often this can lead to
unfavorable changes in the occlusion – usually crossbite which in turn
causes alterations in both mandibular position (mesial occlusion and
laterodeviation) and jaws development
- It is diagnosed by dentist or orthodontist
- Incorrectly abraded primary canines must be grinded until elimination of
premature contacts only in cases where we expect an improvement in the
normal development of the jaws
- Contraindications- crossbite and more severe malocclusions such as
laterognathia. In these cases grinding of primary canines is not
recommended, as after the orthodontic treatment of the malocclusion these
teeth will provide the necessary means for prevention of relapse.

22- Primary and secondary orthodontic prevention of the malocclusions in school age
children.
Early mixed dentition is the 1st stage of the development of the mixed dentition (eruption if
the 1st permanent molars and the permanent incisors ) and it consists of 2 phases :
▪ 1st: between 6 - 7.5 years of age - during this phase there is active growth of the dental
arches ,associated with the tooth eruption
▪ 2nd : between 7.5 - 9 years of age - we don't expect so active growth of the dental arches
during the formation of the dental roots.
Late mixed dentition:
- Late mixed dentition is the 2nd stage of the development of the mixed
dentition( replacement of the primary canines and primary molars with the permanent
canines and premolars) and also
consists of two phases:
- 1st : between 9 -10,5 years of age - at the time that premolars erupt there is no active growth
of dental arches
- 2nd : between 10.5 - 12 years of age - there is active growth of the dental arches during the
formation of the roots of the premolars and the eruption of the permanent canines.
The basic factors that determine the growth of the dental arches are the eruption of teeth and
the
formation of their roots.
Basic symptoms of tooth size - jaw size discrepancies :
they may affect the anterior or the posterior region of the dental arches
they can be transitional (being compensated by the growth of the jaws and the eruption of the
permanent teeth ) and permanent (usually compensatory tooth extractions are needed)
early symptoms of tooth size - jaw size discrepancies : crowded and rotated primary anterior
teeth without diastemas and tremmas
resorption of two primary anterior teeth by one permanent tooth
lingually erupted lateral incisor and deviation of the other incisors to it's place in the arch
early crowding of the incisors, accompanied by protrusion or vestibular inclination of a single
tooth and a recession of the same tooth
resorption of the 2nd primary molars by the 1st permanent molars and premature loss of the
primary 2nd molar
vestibular eruption of the 2nd upper permanent molars or their retention in the bone
mesial inclination of the posterior teeth
Preventive procedures during mixed dentition:
- systematic control of the replacement of teeth - especially the eruption of the permanent
incisors
- early or late eruption; irregular eruption due to lack of enough space in the arch; persistent
primary tooth; irregular resorption of two primary teeth by one permanent tooth
- elimination of the bad oral habits and the causes for their presence
- the myotherapy as a part of the treatment of the malocclusions
- extraction of persistent teeth if there is enough space in the arch for the permanent tooth
and ifis not a persistent tooth due to hypodontia
- placement of a space maintainers in cases with premature loss of primary teeth
- if there is a tendency to edge to edge bite or crossbite during the eruption of the permanent
incisors - it can be useful to make excersises with spatula

23- Myofunctional therapy

Orofacial myology evaluates and treats oral and facial postural and functional disorders and
habbit patterns thay may disrupt the normal dental development.
Myofunctional therapy often restores the normal teeth eruption
Orofacial muscles :
Masseter muscle
Orbicularis oris muscle
Lateral and medial pterygoid muscles
Temporalis muscle
Buccinator muscle
Intrinsic and extrinsic muscles of the tongue
Mentalis muscle
Common etiologies for orofacial myofunctional disorders: Tongue thrusting and persistent
infantile swallowing , finger sucking(coule be lower lip ,pacifier or other),mouth breathing.
Exercises for elimination for tongue thrusting and infantile swallowing:
Must show the place of incisive papilla to the child where he/she places the tongue and hold it
there while simultaneously opening and closing the mouth in order to get used to the normal
position .
The child should swallow with teeth in contact(clinched teeth) without seeing the tongue
between the teeth as the child control it in the mirror.
In order to normalize the reflex swallowing the child places a mint candy against the palate
.The candy stimulates the secretion of saliva ,which the child should swallow without the
candy until is fully melted.
Trainer system: Prefabricated oral appliances that are used for correction of bad oral habits
before ,during or after orthodontic treatment. It consists of a tooth positioner, jaw positioner
and myofunctional trainer.
It consists of canals for teeth and labial arches that exert a permanent force to the anterior
teeth when it is in the child’s mouth to cause their proper alignment.
The trainer has a free end called tongue tag that influences the proprioceptive positioning of
the tongue and lips. Tongue barriers prevent swallowing with the tongue between the teeth.
Lip bumper stretches and disables mentalis muscle contractions associated with infantile
swallowing.
Edge to edge occlusion as it is with most functional appliances.
Used for correction of breathing breathing standing and sleeping with his mouth open.
Types of trainer : T4K for 6-8 years old initial on made of soft silicone with blue or green
color ,which is worj for 6-8 months final one is made of hard polyurethane (pink or red). T4B it
is used simultaneously with fixed appliances and corrects muscle and teeth.
Infant trainer is for children between 2-5 years old .It provides normal development of teeth
and jaws.
Active trainer forces the child to chew normally by using chewing muscle ,eases breathing and
helps normalization of swallowing
TMJ system-relieves pain in TMJ problems and is used for bruxism .
Myobrace :Provides alignment of the teeth ,development of the dental arches and
myofunctional training.It mimicks the action of brackets and direct the eruption of the
teeth.Most effective in late mixed dentition -8 years old.
Variations : MBN for initial treatment of severe malocclusion when dental arches are well
developed it doesn’t expands dental arches.Has 7 different sizes.Can also be worn at night to
remove bad oral habits.This appliance includes the same elements as trainers associated with
the removal of bad oral habits lip bumper ,tongue tag ,barriers for tongue.
ACTIVE INTERCEPTIVE APPLIANCES - The principle of action of these
appliances is to create a dominant unconditional reflex that suppresses the conditional reflex
of the oral habit. They are patented by the Bulgarian authors Boyanov and Dekova. The
concept of the appliance is to eliminate the oral habit with a stimulus for an unconditional
reflex, caused by pricking the finger or lip.
24) Interceptive orthodontic appliances – passive, active and space maintainers.
Prefabricated interceptive appliances.
The interceptive appliances eliminate the abnormal oral habits like finger( thumb), lip and
object sucking, tongue thrusting and mouth-breathing.
In the primary and mixed dentition these oral habits affect the normal growth and
development of the dentition and result in malocclusion occurrence.
Interceptive devices are used effectively in the primary and secondary prevention
management of the orthodontic malocclusions.
Interceptive appliances ( classification) :
1) Passive interceptive appliances: Discontinue the oral habit recurrence without creating new
condition reflex. They set a physical barrier for the recurrence of an acquired and permanent
condition reflex ( oral habit). * reflex arch mediation is interrupted.
Types:
- oral screen according to Kraus,
- max plate with tongue bar??? According to Kraus,
- oral screen plate – type I and type II according to Dekova mond?? .
– plate with tongue barrier according to Krumova and ( 0 ) ?? ,
- prefabricated interceptive appliances.
2) Active interceptive appliances : create a dominant unconditioned reflex that suppress the
conditioned reflex of the oral habit.
The concept of the appliances is to eliminate oral habit with a stimulus for an unconditioned
reflex, caused by pricking the finger or lip.
Patent by Bulgarian authors Boyanov and Dekova.
Types: Appliance for dominant-reflex elimination of : - thumb (finger) sucking, - lower ( lip ? )
sucking.
3) Space maintainers : In premature loss of primary teeth, maintaining the space for
unerupted ( developing) permanent successor tooth. * anterior and posterior segment.
Types :
- Fixed space maintainers,
- fixed gap maintainer,
- removable space maintainers,
- partial denture Kemmeny-type,
- partial denture acrylic clasps.

48.PREVENTION AND TREATMENT OF MAXILLARY PROGNATISM

CLASS II DIVISION 1 • According to British Standards classification: “The lower incisor edges lie
posterior to the cingulum plateau of the upper incisors, there is an increase in overjet and the
upper central incisors are usually proclined.”
Aetiology : SKELETAL PATTERN, DENTAL FACTORS AETIOLOGY HABITS SOFT TISSUES
SKELETAL PATTERN • Usually associated with skeletal Class II pattern, due to retrognathic
mandible. • Proclination of the upper incisors &/or retroclination of the lower incisors by a
habit or the soft tissues can result in an increase in overjet on skeletal Class I or even a Class III
pattern.
SOFT TISSUES • Influence of soft tissue is mainly mediated by skeletal pattern, antero-
posteriorly & vertically. • Patient’s lips are incompetent, try to achieve anterior oral seal in one
of the following ways: – – – – – Circumoral muscular activity. Forward postured mandible.
Lower lip is drawn up behind the upper incisors. Tongue is placed forward between incisors to
contact lower lip. Combination of these.
HABITS • DIGIT SUCKING: – Proclination of the upper incisors. OVERJET – Retroclination of the
lower labial segment. – Incomplete overbite or localized anterior open bite. – Narrowing of
maxillary arch, Due to alteration in the balance between cheek & tongue pressure.
DENTAL FACTORS • Crowding in upper incisors out of the arch labially result in exacerbation of
the overjet.
OCCLUSAL FEATURES • • • • ANTERIOR Increased overjet. OPEN BITE Often increased
overbite. Incompetent lips. Class II molar, canine & incisor relationship.
CLASS II DIVISION 2 • According to British Standards classification: “The lower incisor edges lie
posterior to the cingulum plateau of the upper incisors. The upper central incisors are
retroclined, because of high lower lip line. Overjet is usually minimal or may be increased.”
o SKELETAL PATTERN AETIOLOGY DENTAL FACTORS SOFT TISSUES
SKELETAL PATTERN • Mild skeletal class II pattern. • Can also be present in association with a
class I or even a class III relationship. • Vertical dimension in class II division 2 malocclusion is
typically reduced, results in absence of occlusal stop to lower incisors, leading to increased
overbite.
. DENTAL FACTORS • Pre-existing crowding is exacerbated because retroclination of upper
central incisors.
. SOFT TISSUES • A high lower lip line will tend to retrocline the upper incisors. • It may also
occur from upper & lower retroclination caused by active muscular lips, irrespective of skeletal
pattern.
. OCCLUSAL FEATURES • Retroclined upper central incisors. • Upper lateral incisors are at an
average angulations or are proclined. • Overbite. • Lingual crossbite of the 1st and
occasionally 2nd premolar. • Class II molar, canine & incisor relationship.
DIAGNOSIS • • • • • History. Intra & extra-oral examination. Study models. Orthodontic
photographs. Radiographs. – Cephalometrics. – Orthopantomogram. – Hand wrist
radiographs.
LIKELY STABILITY OF OVERJET REDUCTION PATIENT’S AGE PATIENT’S FACIAL APPEARANCE
FACTORS INFLUENCING DEFINITIVE TREATMENT PLAN EITHER SKELETAL OR DENTAL
. TREATMENT OF CLASS II MALOCCLUSION
EARLY TREATMENT • Can be done in pre-adolescent children with the use of functional
appliances and then followed by fixed appliances in permanent dentition. – Overall longer
treatment time. – Little difference seen comparatively to children who didn’t undergo early
treatment. • At present, clinicians belief treatment is best deferred until eruption of
permanent dentition where space can be gained for relief of crowing & reduction of overjet by
extraction(if indicated) & till then soft tissue maturity increases likelihood of lip competence. –
In the interim custom made mouth-guard can be worn for sports.
MANAGEMENT OF CLASS II SKELETAL PATTERN • We have 3 options: – Growth modifications.
– Orthodontic camouflage. – Surgical correction.
GROWTH MODIFICATIONS • Can be achieved by: – Stimulation & enhancement of Mandibular
growth, through functional appliances: REMOVABLE FIXED Activator. Herbst appliance.
Bionator. Mandibular anterior repositioning appliance (MARA) Frankel. Cemented Twin-Block.
Twin-Block. Forsus appliance.
ACTIVATOR
BIONATAR
FRANKEL APPLIANCE
TWIN BLOCK FUNCTIONAL APPLIANCE
HERBST APPLIANCE
MANDIBULAR ANTERIOR REPOSITIONING APPLIANCE (MARA)
CEMENTED TWIN-BLOCK
GROWTH MODIFICATIONS • Can be achieved by: – Redirection of Maxillary growth by extra-
oral appliance, headgear.
HEADGEAR •FOR CLASS II SKELETAL PATTERN: •High pull/ parietal headgear. •Cervical
headgear. •Occipital pull (combination).
ORTHODONTIC CAMOUFLAGE • Orthodontic camouflage means that the jaw discrepancy is no
longer apparent. • Following three patterns of tooth movement can be used to correct class II
malocclusion: – Non-extraction treatment with class II elastics. – Retraction of maxillary
incisors into a premolar extraction space. – Distal movement of upper teeth.
NON-EXTRACTION TREATMENT WITH CLASS II ELASTICS • It’s a combination of retraction of
upper teeth and more forward movement of lower teeth comparatively to upper, without
tooth extractions. • After treatment, lip pressure moves lower incisors lingually leading to: –
Lower incisor crowding. – Return of overjet. – Return of overbite.

49.MANDIBULAR PROGNATISM
According to British standards Incisor classification, in class III malocclusion the lower incisor
edges lie anterior to the cingulum plateau of the upper incisors. The overjet is reduced or
reversed.
According to Angle’s classification, in class III the mesiobuccal cusp of the lower first molar
occludes mesial to the class I position.
Aetiology  Skeletal pattern  Dental factors  Soft tissues  Specific conditions  Familial
tendency
Skeletal Pattern  Most important aetiological factor  Skeletal pattern can be any of the
following:
1. Mandibular prognathism
2. Maxillary retrognathism
3. Combination of both
Features of class III malocclusion
A concave facial profile
A retrusive nasomaxillary area
Prominent lower third of the face
Narrow upper arch
Reduced or reversed overjet
Concave facial profile Reversed overjet
Diagnosis  A successful treatment plan depends on an accurate diagnosis  For treating class
III malocclusion a direct cause must be identified, that is, true class III should be differentiated
from pseudo class III malocclusion.
Pseudo Class III Malocclusion  Pseudo class III malocclusion is a habitual established cross
bite of all anterior teeth, without any skeletal discrepancy, resulting from functional forward
positioning/shift of the mandible on closure.  Causes include:  occlusal prematurity 
Enlarged adenoids
.  The final diagnosis of the type of class III malocclusion relies heavily on: (i) clinically
establishing the dual closure pattern by asking and guiding the patient to bite in normal centric
and habitual positions,
(ii) observing any familial tendency,
(iii) cephalometric parameters (iv) incisor relationships.
. Treatment objectives
 To achieve growth modulation in skeletal case
 To relieve crowding and produce alignment of teeth
 To correct incisor relationship to obtain normal overjet and overbite
 To achieve stable molar relationship
Factors considered while treatment planning  Patient’s opinion  Severity of skeletal pattern
 Amount and expected pattern of future growth  Degree of crowding  If an edge to edge
incisor contact can be achieved or not  Amount of dento-alveolar compensation present
Treatment modalities
 Growth modification
 Orthodontic camouflage
 Orthognathic surgery
Growth Modification  In young patients who are still in their growing phase orthopedic and
myo- functional appliances can be used in cases of skeletal class III malocclusion.  Either
there is deficient growth of maxilla or excess growth of mandible.
FRANKEL III FUNCTIONAL APPLIANCE  Used in mild skeletal problems  Causes downward
and backward rotation of the mandible
 Has little or no effect on maxilla
Reverse pull headgear (facemask)  Indicated in patients with retrusive maxilla  Obtains
anchorage from forehead and chin  Exerts force on maxilla via elastics that attach to
maxillary splints
 Effects include: 1. Forward and downward movement of maxilla 2. Downward and
backward rotation of mandible 3. Lingual tipping of lower incisors
 Treatment given at the mixed dentition is advocated by most researchers.  Requires great
patient cooperation.
Chin Cup Therapy  An effort to restrain mandibular growth  Redirects mandibular growth in
a more vertical direction  Ideal in patients with  mild skeletal problem  reduced lower
anterior facial height  normal or proclined lower incisors
 Most of the reported studies recommended an orthopedic force of 300 to 500 g per side 
Patients are instructed to wear the appliance 14 hours per day.
Vertical pull chin cup Occipital pull chin cup
Orthodontic Camouflage  Proclination of the upper labial segment
 Retroclination of the lower labial segment
 Combination of both
 Extraction pattern may vary from extraction of lower first bicuspids only to extraction of
upper second premolar and lower first premolar and sometimes even lower incisor
Proclination of upper labial segment  Correction of incisor relationship by proclination of the
upper incisors can only be considered with the following features:  a class I or mild class III
skeletal pattern
 The upper incisors are not already significantly proclined
 Adequate overbite will be present at the end of treatment to retain the corrected position
of the upper incisors
. Retroclination of lower labial segment  In cases with mild to moderate class III skeletal
pattern or in case of reduced over bite  Space is required in the lower arch for retroclination
of lower labial segment and extractions are required
Orthognathic Surgery  In some cases the severity of skeletal pattern and/or the presence of a
reduced overbite or an anterior open bite precludes orthodontics alone.  Orthognathic
surgery is almost always indicated if: Value of ANB is -4 Inclination of lower incisors to
mandibular plane is 83
Common Surgical Procedures  Lefort I maxillary advancement For retrognathic maxilla 
bilateral saggital split (BSSO) mandibular setback For prognathic mandible  Surgically assisted
RPE
SUMMARY: Treatment of Class III Malocclusion
 Non-growing patients 1. Acceptance 2. Orthodontic Camouflage 3. Orthognathic Surgery
 Growing patients 1. Acceptance 2. Functional orthopedic appliances 3. Orthodontic
Camouflage

50.preventıon and treatment of the open bite

Malocclusion in vertical plane. A deviation in the vertical relationship of the maxillary and
mandibular dental arches characterized by a definite lack of contact between opposing
segments of teeth
Treatment Deciduous dentition: The main cause of open bite in deciduous dentition is the
prolonged habit of thumb sucking.
Thus, the most important measure to fix it would be to break the bad habit, through
techniques of behavioral change. It was observed significant changes in the cephalometric
measurements, in the interincisal and angles, before and after the treatment with methods of
awareness and positive reinforcement, without any use of orthodontic braces.
The correction of open bite also depends on the restoration of nasal breathing
Mixed dentition: The cases of open bite in which the tongue causes or keeps the infra-
occlusion of the maxillary and mandibular incisors, the use of the functional braces of Balters
Bionator
The use of a functional applians to restore the muscle function of the anterior open bite.
The action on the tone of the buccinator, in the maxillary atresia and the lack of stability
during the swallowing, guides the closing.
When the anterior open bite is characterized by extrusion of the anterior teeth, the intrusion
of the upper molars is a form of treatment, may use “high-pull”, vertical elastics in anterior
region, the combination of two mechanical or bite-blocks.
The use of posterior bite-blocks in the early treatment of the skeletal open bite, produces
mandibular rotation forward and upward, by transmitting the masticatory forces to the
dentoalveolar regions, inhibiting the vertical.
Permanent dentition: In adult patients with severe open bite, the treatment aims to ensure
the containment and the stability over time, indicating orthognathic surgery.
The aditional bilateral sagittal split osteotomy does not affect the stability, while the
multisegmental Le Fort I osteotomy, stabilized by rigid internal fixation, provides a superior
transverse stability if it is compared to the intraosseous fixation with surgical thread, and
maxillomandibular fixation.
In the deciduous and mixed dentition, the early diagnosis of the anterior open bite decreases
the time of treatment and simplifies the aparatology that is used for correction. The treatment
of anterior open bite requires, mostly, multidisciplinary approach. Due to the high rate of
unstable results with relation to the period of treatment and post-treatment of anterior open
bite, more research is needed in this area.

51. Prevention and treatment of deep bite

The horizontal plane is used for the assessment of vertical discrepancies
Upper incisors cover more than 1/2 of the clinical crown of the lower ones
Deep overbite: when incised edge of mandibular incisors occlude apically to the cingulum of
maxillary incisors
Forms of deep bite:
dental form: overerrupton of incisors and/or undeerruption of molars and excessive curve of
Spee. Tooth size discrepancies can contribute to deep bite
Treatment: habit control, elimination of abnormal mental muscle function
Appliances: interceptive, habit breakers, myofunctional therapy
2. Treatment: during active growth phase-intrude anteriors - erupt posteriors and combination of
both Appliances: removable intraoral, after active growth phase: intrusion of anteriors with
fixed technique and/or orthognatic surgery
Prevention: oral habit control/elimination eg finger sucking, lower lip sucking, lateral swallow
avoid hard food, chewing gum
Treatment of primary dentition:
based on severity and localisation of malocclusion and dentition develpment stage
In primary dentition- skeletal deep bite is observed
Treatment: interceptive appliance, control of oral habits
Treatment of mixed dentition:
1. dentoalveoral deep bite:
Early mixed: interceptive appliances, habit breaking appliances, fixed bite opening appliances
Late mixed: fixed appliances(braackets, quad helix), Bite planes and functional appliances
2. skeletal deep bite
severity of malocclusion ( fixed technique and headgear)
Permanent dentition:
dentoalveoral deep bite:
Bite opening (fixed appliances, bite plane-brackets, quatrohelix,) extra oral appliances (cervical
pull headgear, molar extrusion, pull for incisor intrusion
2. skeletal deep bite
Orthodontic camouflage, fixed technique and mini screws, orthognatic surgery
Reversed curve of speed arch wire used for anterior intrusion
Extrusion of posterior teeth in infra position, decreasing the overbite of anterior teeth,
combination of both
Treatment phases:
Phase1: preparation of dental arches: expansion, proclamation of incisors if retroclined, incisor
protrusion opens the bite

52. Prevention and treatment of laterognathia

Laterognatism is diagnosed from assessment of Saggital Plane- transverse discrepancies
By centric occlusion, the midline of mandibular arch doesn't coincide with midline of maxillary
arch and is shifted left or right (midline shift present in both occlusions in rest position)
Prevention:
-elimination of bad oral habits
Dental midline shifts:
-correction of unilateral cross bite
-majjor shift over 2mm (assymetric extraction-midline shifts in the direction of the extraction-
assymetric distalization)
-minor shift: less than 2mm (assymetric elastics usually class2/class3 and diagonal elastics)
Skeletal midline shifts:
-orthognatic surgery
-distraction osteogenesis
-surgically assisted rapid palatal expansion
-vertical ramps osteotomy
removable: bimaxillary functional appliances, splints, frankel, activator, monobloc
fixed: unilateral bite jumping devices
brackets with rectangular Swirls and asymmetric crisscross elastics
Construction bite:
important to bring mandible forward to o match the midline and also open vertically more on
affected site
-wax soft on unaffected site
-wax hard on affected site
-frankel type buccal shield on affected site (creates transverse expansion)
-bite block (stabilises occlusion on the normal site and inhibit tooth eruption there)
-ligual shield on the site where there is vertical development (keeps tongue away from in
between the teeth on the affected site)
-lingual pad (posture the mandible forward)
Retention: -functional appliance of Rent (facial and skeletal growth) and fixed permanent
retainers on major central line shift: on the site to which central line is shifted , cuspid can be
retracted with light pressure using light intramaxillary elastics worn between molar hook and
tag of cuspit lovk pin Light pressure and free tilting of cuspid reduces the chances of anchorage
loss

56) Tissue changes during orthodontic treatment as a result of orthodontic appliance

therapy.
Periodontium: is a major factor influencing tooth movement during orthodontic treatment. It
includes: gingiva, alveolar bone, periodontal ligament, cementum.
Functions of Periodontal Ligament: formation, supportive, protective, nutritive, sensory.
Mechanism of orthodontic movement: Modeling and remodeling of the alveolar bone is
caused by: 1) osteoblastic activity ( bone formation) and 2) osteoclastic activity ( bone
resorptive). These 2 activities remove, or replace bone.
Orthodontic tooth movement causes : 1) pressure side ( cell production is decreased ), 2)
tension side ( cell replication is increased ).
Periodontal and other tissue reaction to tooth:
1) physiologic tooth pressure movement: resorptive bone wall , depository bone wall.
2) orthodontic tooth movement: dentoalveolar reaction, pressure side, tension side,
hyalinization.
Alveolar bone resorption occurs on the side in which the tooth is moving forward.
Alveolar bone deposition occurs on the side opposite direction to which the tooth is moving.
!!! So the tooth doesn’t simply move through bone, but supporting structures move with it.
Resorption may occur 12 h. AFTER THE FORCE APPLICATION IN YOUNG INDIVIDUALS.
Light continuous forces to PL cause: osteoclastic formation  removal of the lamina dura
tooth movement. ( this process is called Frontal resorption.)
Heavy forces to PL cause: blood supply to PDL / aseptic necrosis / PDL becomes hyalinized. 
Undermining resorption.