Contents

Chapter Topic Page

1 Diagnostic Procedures In Orthodontic …………1

2 Tissue Changes In Orthodontic…………………. 27

3 Preventive Orthodontics……………………..…… 39
4 Interceptive Orthodontics…………………….…... 43
5 Treatment of Malocclusion……………………….. 49
6 Orthodontic Treatment For Adolescents……….. 59
7 Orthodontic Appliance Design………………….... 66
8 Extraction In Orthodontics……………………….…89
9 Orthodontic Retention and Relapse………………96
 Introduction

Providing excellent orthodontic service requires in a part a

scrupulous orientation of dental graduates for understanding of
orthodontic concepts. Knowing skills of orthodontic diagnosis is
highly recommended. Tooth movement principles, planning for
detailed treatment, and selection of appropriate orthodontic
appliances should all be carefully well-informed. Detailed perception
of Preventive and interceptive measures are essentials. An overall
view of orthodontic corrective phases is necessary.
An emphasis on principles of orthodontic retention and causes of
relapse is also part of the fundamental knowledge.
Laboratory and clinical skills of impression taking, production of
professional orthodontic models and Cephalometric concept are
included in the course. Planning for and fabrication of simple
removable and habit breaking orthodontic appliances will be
considered as well during the course.
It should be pointed out that, a crucial objective of the course is to
prepare the dental practitioner to be a versatile member within the
realm of the orthodontic profession.

Prof Dr. Amr Labib

 Chapter 1
Diagnostic Procedures in Orthodontic
The prefix "dia" means through. The suffix "gnosis" means knowledge. Thus,
diagnosis means through knowledge. Medically speaking, diagnosis is the art and act of
identifying a disease from its signs and symptoms. Orthodontically speaking, diagnosis
is a concise scientific of the malocclusion and related abnormalities of facial structures
through an analysis of the cause of nature of these conditions.

The following diagnostic procedures should be considered:

· Essential diagnostic procedures:
- Medico-dental history.
- Clinical orthodontic examination.
- Orthodontic study casts.
- Facial and intra-oral photograph.
- Lateral cephalometric radiographs in centric occlusion.
- Full-mouth periapical or panoramic radiographs.

· Supplemental diagnostic procedures:

- Hand-wrist radiographs.

- Lateral cephalometric radiographs in postural resting position.

- 45° lateral cephalometric radiographs, right and left.

- Posteroanterior cephalometric radiographs.

- Functional cephalometric radiographs.

- Three dimensional (3-D) cephalogram

- Bite-wing and occlusal radiographs.

- Diagnostic setup.

- Occlusograms.

- Magnetic Resonance Imaging (MRI).

- Psychological tests.
- Electromyographic records.
- Endocrine tests.
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 A. Essential Diagnostic Procedures
1. Medico–dental History

More than two thousands and five hundreds years ago, the ancient Chinese
philosopher "Confucius" stated: "Study the past, if you divine the future". In orthodontics,
we study the medico- dental history in order to divine (i.e., apprehend, perceive,
foresee, foreknow, etc.) the nature of the orthodontic problem.

The medico-dental history form is a questionnaire which may be completed

either online or in the office. For the online history forms, the orthodontist must warn the
patients if no encryption is present. The in-office history forms should be completed by
the patient (or one of her/ his parents) through the help of the orthodontist or one of her/
his dental assistants. The history form ought to include a section on each of the
following items: personal information, medical history, dental history, genetic history,
and nutritional history. It the patient is younger than 18 years old, a section on
maturational status is to be added.

The personal information section must include questions about the patient's
name, sex, date of birth, email address, home address, telephone, etc.

The medical history section should contain questions about the general health
status, hospitalization, medications, abnormal birth, removal of tonsils and adenoids,
mouth-breathing, respiratory problems, allergies, anemia, bleeding tendencies,
diabetes, epilepsy, heart diseases, other systemic diseases, etc.

The dental history section ought to comprise questions about the chief
complaints (specific esthetic and functional problems), general oral health status,
frequency of dental visits, bad dental experiences, fear of dentists, poor oral habits,
previous facial trauma, soreness of jaw muscles, temporomandibular joint clicking, and/
or pain, etc.

The genetic history section should consist of questions about the similarity of
the dental condition and/ or facial appearance of the patient with any member of her/ his
family abnormal growth problems among relatives, early or late pubertal changes in the
family circle, etc.

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 The nutritional history section must enclose questions about the nutritional
health program, numerous sweet foods, numerous snacks, weight problems, multiple
vitamins, etc.

The maturational status section is added only to patients younger than 18 years
old. This section should include questions about height, weight sings of sexual
development (e.g., voice changes and facial hair growth for males), menarche date (i.e.,
the date of the first menstrual period for females), etc.

2. Clinical Orthodontic Examination

The clinical orthodontic examination is an investigation process based on

knowledge and observation for the purpose of providing adequate database necessary
for a tentative diagnosis.

In order to perform a thorough clinical orthodontic examination, the following six-

step routine is suggested:

A. General examination of the patient.

B. Static examination of the face.

C. Functional examination of the face.

D. Static examination of the occlusion.

E. Functional examination of the occlusion and the TMJ.

F. Open- mouth examination of the oral cavity.

A. General Examination of the Patient

In reality, the clinical orthodontic examination starts the moment the patient is
first seen. The general health, general appearance, general body growth and
development (i.e., signs of secondary sex as body curvatures for females, and facial
hair growth for males), speech mannerisms, and psychological attitudes are observed.
The height and weight of the patient are measured for possible future references.

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B. Static Examination of the Face

For a static examination of the face, the patient should not be reclined in the
dental chair. Rather, the patient should be either standing relaxed or seated straight in
the dental chair (or any other chair). Ask the patient to look straight at any specific
distant object. In this manner, the visual axis will be leveled, and the natural head
position will be obtained.

The natural head position is determined physiologically and not anatomically. It is

the way the head is normally oriented, and is individualistic in nature. For most subjects,
the natural head position coincides with Fränkfort-horizontal plane. The Fränkfort-
horizontal plane is anatomically determined. It joins orbitale (i.e., the lowest point on the
bony orbital margin) to porion (i.e., the upper margin of the external auditory meatus or
the notch above the tragus of the ear).

The static examination of the face should be done from the following three
aspects: frontal, profile, and three-quarters aspects.

Fig. 1. Facial types and related dental arch forms.

1. Frontal static examination of the face

a. Facial type
Examine the facial type (Fig.1) of the patient. Brachycephalic individuals have
very broad and relatively short faces, and tend to have square u-shaped dental arches.
Dolichocephalic persons possess long narrow faces, and are inclined to have taper
v-shaped dental arches. Mesocephalic. People enjoy average size faces, and have a
tendency for ovoid u-shaped dental arches.

Cephalo=head…..Brachy=short….Dolicho=long….Meso=intermediate

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b. Facial symmetry

Inspect the right-left symmetry of the face. Record noticeable deviations. Ask the
patient to smile to observe the relationships of the maxillary and mandibular dental
midlines to each other and to the facial midline.

Fig. 2. Normal facial proportions.

c. Facial proportions

Examine the facial proportions (Fig. 2) of the patient. In normal facial proportions,
thirds of the face are roughly equal in vertical dimensions (Fig. 2). Specifically, the
following three facial heights are nearly equivalents in vertical dimensions: the upper
anterior facial height (UAFH from trichion or hairline to glabella), the middle anterior
facial height (MAFH from: glabella to subnasale), and the lower anterior facial height
(LAFH from subnasale to menton) as evident from Fig. 2. In few words, UAFH = MAFH
= LAFH (Fig. 2).

Further the upper lip height (subnasale to stomion) equals one third of the lower
anterior facial height (LAFH) as obvious from Fig. 2. The alar-nasal base width is almost
equivalent to the inter-inner-canthal distance (Fig. 2), and the width of the relaxed
mouth equals the interlimbus width . 20 D).

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 Fig. 3. Straight, convex and concave facial profiles.

2. Profile static examination of the face

a. Facial profile

The facial profile may be straight (orthognathic), concave, or convex (Figs. 3) and
4). If the mandible is positioned posterior to the soft tissue nasion (the deepest
concavity above the bridge of the nose corresponding to the hard tissue nasion which
is the intersection of the internasal suture with the frontonasal suture), the face is
"posteriorly divergent" (Fig. 4).

Fig. 4. Convexity /concavity of the lips, and anterior/posterior divergence of the facial profile.
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 If the mandible is located anterior to the soft tissue nasion, the face is "anteriorly
divergent" (Fig. 4). An individual, having a concave facial profile, may also have a
posterior divergence, no divergence, or an anterior divergence (Fig. 4). The same holds
true for an individual having a convex facial profile (Fig. 4). However, an individual,
having an orthognathic (i.e., straight) facial profile, has no divergence whatsoever (Fig.
4).

b. Lips, gummy smile, anterior teeth, and mentalis

Assess lip competence at rest. Normally, the interlabial distance measures 0 -

3.5 mm at rest. Note the presence or absence of an everted lower lip. An everted lower
lip may be caused by the underlying dentoalveolar complex, or by true hypertrophy of
the lip itself.

Notice the presence or absence of a gummy smile, or a prominent mentalis

muscle. A prominent mentalis muscle may be part of the physiologic adaptation to the
malocclusion, or an etiologic factor. Observe the protrusion or retrusion of the anterior
teeth (anterior teeth in labioversion or linguoversion).

c. Mandibular plane angle

Clinically, the mandibular plane can be visualized by placing the dorsum of your
hand along the lower border of the patient's mandible. The mandibular plane angle
could be normal (directed slightly downward and forward), too steep (mainly downward),
or too flat (mainly forward).

d. Facial proportions

Re-examine the facial proportions from the profile aspect.

3. Three-quarters static examination of the smiling face

Contemplate the patient's smiling face from the three-quarters aspect.

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C. FUNCTIONAL EXAMINATION OF THE FACE

You may functionally examine the face during any muscular facial activity such
as: mastication, swallowing, respiration, speech, etc. You may examine the masticatory
aspect if you go to any place where people eat. The swallowing (or deglutition),
respiratory (or breathing), and speech aspects are noticed during the functional
examination of the face.

Fig. 5. Abnormal swallowing.

The swallowing aspect is examined as follows. Note whether or not the lips
contract as the patient unconsciously swallows her/his saliva. Subsequently, place your
index finger (or a mouth mirror), to retract the lower lip, and ask the patient to swallow.
Normal swallowing is completed while abnormal swallowing is inhibited. The reason is
that the contraction of both the lower lip and the mentalis muscle is inhibited.

By looking at Fig. 5, you may notice that, during abnormal swallowing, both the
lower lip and the mentalis muscle contract, the teeth are apart, and the tongue thrusts
forward. For a further confirmation of the swallowing behavior, palpate the temporal
muscle (Fig. 6). Normal swallowers contract this muscle to elevate the mandible to hold
the teeth in occlusion while swallowing. Abnormal swallowers do not contract it because
their teeth are apart during swallowing.

The respiratory aspect is examined by asking the patient to close the lips, and to
take a deep breath through the nose. The nasal, breathers dilate the external nares
because they have a good reflex control of the alar muscles. Most full-time habitual
mouth-breathers do not change the shape or size of the external nares.

The speech aspect is examined by asking the patient any question to stimulate
her/his speech. Notice if the patient lisps (i.e., has a defect of pronouncing the sibilants
"s" and “z” imperfectly). Further, note if the patient stutters (i.e., has a defect of speaking
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with involuntary disruption by spasmodic repetition or by prolongation of vocal sounds).

Fig. 6. Palpation of the temporal muscle for checking the swallowing behavior.

D. STATIC EXAMINATION OF THE OCCLUSION

Examine the occlusion status in centric occlusion. Categorize the occlusion as
either normal occlusion or malocclusion. Classify the malocclusion according to the
Angle's classification. Further, depict the vertical and transverse variations for the
malposition of groups of teeth.

After that, through an open-mouth examination of the dentition, express the

malposition of any individual tooth by using the Lischer's terminology. Detect the
relationships of the maxillary and mandibular dental midlines to each other and to the
facial midline.

E. FUNCTIONAL EXAMINATION OF THE OCCLUSION AND THE TMJ

Examine the occlusion functionally by following the Ronald's Roth concepts.

Observe any deviation in the distribution of the occlusal stops by using an articulating
paper. Notice any absence of harmony in protrusive and lateral movements.

Palpate the muscles of mastication. Place your index fingers in the patient's ears
to detect any condylar dislocation. Further use your own ear or even a stethoscope to
carefully listen to any temporomandibular joint crepitus or clicking sounds. Furthermore,
note any limitation of mandibular movements.

F. OPEN-MOUTH EXAMINATION OF THE ORAL CAVITY

Identify the teeth present, the teeth extracted, and the teeth missing. Notice
developmental disturbances in size, shape, or number of teeth. Observe the oral
hygiene status, the gingival appearance, the upper and lower labial frenum, the palate,
the tonsils, and the tongue.

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 3. ORTHODONTIC STUDY CASTS

Fig. 7. Orthodontic study casts.

A dental cast is a plaster replica of the teeth and surrounding tissues, typically
made directly from an alginate impression. The dental casts may be used for study and
diagnosis, or for fabrication of appliances. The orthodontic study casts (Fig. 7) differ
from other dental casts in three aspects:

• The impressions are extended maximally to include the teeth and as much as
possible of the alveolar process and soft tissues.

• Centric occlusion could be obtained (without the use of a wax bite or an articulator)
when the posterior surfaces of the maxillary and mandibular casts are placed
together on any flat surface.

• Each cast is trimmed with a symmetrical base to facilitate visualization of

asymmetries in tooth positions and arch forms.

The pretreatment orthodontic study casts are essential for many reasons such
as:

a. ORTHODONTIC DIAGNOSIS

Through the following four aspects:

1. Three-dimensional record and assessment of the following:

· Dental anatomy of each erupted tooth.

· Curves of occlusion.

· Occlusion itself. (Remember that the lingual view of the occlusion can be
assessed only with the casts.)

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 · Dental arch from.

· Anatomy of the palate.

2. Total space analysis of the dental arches and the dental arches and the
erupted teeth.

3. Duplicates of the original casts could be used for the construction of a diagnostic
setup on which the proposed treatment plan could be simulated.

4. Radiographs of the original casts could be employed for the supplemental orthodontic
diagnostic procedure entitled “occlusograms"

b. CASE PRTESENTATION

To explain the treatment plan to the patient and/or parents.

c. EVALUATION OF TREATMENT PROGRESS.

d. A PART OF THE TRANSFER RECORDS in order to assist another orthodontist to

whom the patient may be transferred to in the future.

e. RESEARCH STUDIES.

4. FACIAL AND INTRA-ORAL PHOTOGRAPHS

These photographs may be digital pictures, print pictures, or slides. A minimum

of three facial photographs (frontal, profile, and three-quarters) should be taken in the
natural head position by asking the patient to look straight forward at a distant object.
For the frontal and profile photographs, the teeth must be in maximum intercuspation,
and the lips have to be lightly touched. For the three-quarters photograph, the patient
should be relaxed and smiling. Further, the facial photographs may be black and white,
or colored.

The digital facial photographs may be an analyzed through faciometrics. In 1996,

in the International Journal of Adult Orthodontics and Orthognathic Surgery, EI-
Mangoury, Mostafa, Rasmy, and Salah introduced this analysis through a research
article entitled: "Faciometrics: A new syntax for facial feature analysis". Actually,
faciometrics is a new computerized nonradiographic cephalometric soft tissue analysis.
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They stated: 'The faciometric system is proposed as a complement to, rather than a
replacement for, available soft tissue cephalometric analysis A minimum of three
colored intraoral photographs (frontal, right side, and left side) should be taken in centric
occlusion. Because these intraoral photographs are colored, enamel discoloration may
be noted and documented.

5. LATERAL CEPHALOMETRIC RADIOGRAPHS

IN CENTRIC OCCLUSION

The following topics will be discussed:

a. Introduction to cephalometry

b. Tracing of cephalograms.

c. Lateral cephalograms in centric occlusion with the lips lightly touched.

a. Introduction to cephalometry

Fig. 8. Cephalometric arrangement diagram.

By definition, cephalometrics means craniometries or measurements of the

head or skull. In 1931, radiographic cephalometry was independently introduced by
Broadbent (in the U.S.), and by Hofrath (in Germany). The original purpose of
cephalometrics was research on craniofacial growth and development. Actually, our
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current concepts of normal craniofacial growth were largely derived from cephalometric
research. Nowadays, cephalometrics is an essential diagnostic tool for malocclusions,
and underlying skeletal discrepancies.

The cephalometer is composed of an x-ray source and a cephalostat. The

cephalostat serves to hold both the head of the patient and the radiographic cassette in
a firm stable reproducible position. For cephalometric radiography, two important
distances exist. First, the standard distance of "the x-ray source to the midsaggital plane
of the head" is 60 inches (152.4 cm) or 5 feet (Fig. 8). Second, the usual distance from
the midsaggital plane of the head to the cephalometric cassette (containing the
radiographic film) is 15 inches, but may be varied in different machines according to the
patient's size. This last distance must be recorded for each exposure in order to be
constant for the same individual patient.

The cephalometric radiograph is an 8" x 10" standardized radiographic image

of the human skull, taken laterally, posteroanteriorly, or obliquely through the use of a
cephaiometer. It shows in detail the angular and linear relations of the craniofacial
components. A lateral cephalometric radiograph in centric occlusion with the lips lightly
touched (Fig. 9) is an essential orthodontic diagnostic procedure.

Fig. 9. Lateral cephalometric radiograph.

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b. TRACING OF CEPHALOGRAMS

The following materials are needed for cephalometric tracings:

• A clear cephalograph.

• A view box.

• Frosted acetate tracing papers 0.003" in thickness

• Masking tape

• Thick black papers

• 0.5 millimeter lead pencils

• Artgum eraser

• Millimeteric ruler

• Precise transparent protractor

The cephalometric tracing is done as follows. With the frosted side up, the tracing
paper is taped to the top of the cephalograph. This permits lifting of the tracing, from
time to time, for better inspection. In a darkened room, tracings should be done very
slowly. With the exception of that part being traced, all of the view box will be covered
with thick black papers.

c. LATERAL CEPHALOGRAMS IN CENTRIC OCCLUSION WITH THE LIPS

LIGHTLY TOUCHED

The following topics will be discussed: cephalometric landmards, cephalometric

reference planes, and cephalometric analysis.

1. CEPHALOMETRIC LANDMARKS

Several Important anatomical landmarks are Identifiable on lateral cephalograms

(Fig. 10). A tracing (Figs. 10 and 11) of selected anatomical structures is made on
translucent acetate paper from a cephalometric radiograph for purposes of
measurements, superimpositions, and evaluations.

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 Fig. 10. Cephalometric landmarks

The following is a glossary of the standard cephalometirc landmarks (identified in

Fig. 10):

• Nasion (N): the intersection point of the internasal suture with the frontonasal suture
in the midsagittal plane.
• Anterior Nasal Spine (ANS): the tip of the anterior nasal spine.
• Subspinale or point A (A): the deepest point on the midline curvature of the maxilla
between the anterior nasal spine and prosthion.
• Supramentale or point B (B): the deepest point on the midline curvature of the
mandible between infradentale and pogonion.
• Pogonion (Pg): the most anterior point on the mandibular symphysis.
• Gnathion (Gn): the most outward and everted point on the profile curvature of the
mandibular symphysis located midway between pogonion and menton.
• Menton (Me): the lowest point on the mandibular symphysis.
• Point D (D): the center of the mass of the cross-section of the body of the
symphysis.
• Gonion (Go): the most outward and everted point on the left angle of the mandible.
• Articulare (AR): the intersection point of the mandibular ramus with the inferior
surface of the occipital bone.
• Porion (Pr): the most superior point on the external auditory meatus
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• Y point (Y): the point on the SN plane established from a perpendicular erected from
gonion to the SN plane
• Sella (S): the center of sella turcica.
• Point X (X): the point on the SN plane established from a prerpendicular erected
from point A to the SN plane.
• Orbitale (Or): the lowest point on the external border of the left orbital cavity.
• Posteior nasal spine (PNS): the tip of the posterior nasal spine.
• Upper incisor (U1): the outline of the most labial maxillary permanent central incisor.
• Lower incisor (L1): the outline of the most Labial mandibular permanent central
incisor.
• Upper molar (U6): the outline of the maxillary permanent left first molar.
• Lower molar (L6): the outline of the mandibular permanent left first molar.

Fig. 11. Cephalometric reference planes

2. CEPHALOMETRIC REFERENCE PLANES

The following is a lexicon of the frequently used cephalometric reference planes (Fig.
11):

· Sella nasion line or plane (SN): the cranial plane connecting sella to nasion.

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· Fränkfurt horizontal plane (FH): the craniofacial plane connecting porion to
orbitale.

· Palatal plane (PP): the palne connecting the posterior nasal spine to the anterior
nasal spine.

· Functional occlusal plane (OP): the plane drawn through the region of maximum
cuspal interdigitation by connecting the mesiobuccal cusp of the maxillary left first
molar to the midinterocclusal point between the maxillary and mandibular left first
premolars. In cases, in which the maxillary and mandibular first premolars were
absent, the maxillary and/or the mandibular second premolars could be used.

· Gonion gnathion plane (Go-Gn): the plane connecting goning to gnathion.

· Mandibular plane (MP): the plane connecting menton to the most posteroinferior
border of the mandibular body.

3. CEPHALOMETRIC ANALYSIS

The cephalometric measurements could be either angular or linear in nature.

Using a protractor, angular measurements should be recorded to the nearest 0.25
degree. Using a millimetric ruler, linear measurements should be taken to the nearest
0.25 millimeter.

The following four topics will be discussed: cephalometric angular measruments,

cephalometric linear measurements, a “petite” piece of the diagnostic mosaic, and
computerized cephalometrics.

* CEPHALOMETRIC ANGLULAR MEASUREMENTS

The following is a list of classic cephalometric angular measurements:

· SNA: the posteroinferior angle formed between the SN plane and point A. It
represents the relative anteroposteior position of the maxillary apical base to the
cranial plane SN.

· SNB: the posteroinferior angle formed between the SN plane and point B. It
represents the relative anteroposterior position of the mandibular apical base to the
cranial plane SN.
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· ANB: the angle formed by connecting point A, nasion, and point B. it represents the
relative anteroposterior position of the maxillary and the mandibular apical bases to
nasion.

· NAPg: the posteroinferiror angle formed by the intersection of a line joining nasion
to point A to pogonion. When pogonion is positioned posterior to point A, the angle is
positive,and vice versa. It represents the skeletal facial convexity.

· Y axis: the anteroinferior angle formed by the intersection of the FH plane with the
SGn line. It represents the direction of the mandibular growth relative to the FH
plane.

· Gonial angle: the anterosuperior angle formed by the intersection of the mandibular
plane with a tangent erected from articulare to the posterior surface of the
mandibular ramus.

· U1- L1: the posterior angle formed by the intersection of the long axis of U1 with the
SN plane. It represents the interincisal angle.

· U1-SN: the anteroinferior angle formed by the intersection of the long axis of U1 with
the SN plane. It represents the axial inclination of the maxillary central incisor
relative to the SN plane.

· L1-GoGn: the anteroinferior angle formed by the intersection of the long axis L1 with
the GoGn plane. It represents the axial inclination of the mandibular central incisor
relative to the occlusal plane.

* CEPHALOMETRIC LINEAR MEASUREMENTS

The following is a list of classic cephalometric linear measurements:

· Wits: the horizontal difference between from points A and B onto the occlusal plane.
When point A is positioned anterior to point B, the measurements is positive, and
vice versa. It represents the relative anteroposterior position of the maxillary and the
mandibular apical bases to the occlusal plane.

· UAFH: the linear distance along the Z line from nasion to ANS. It represents the
upper anterior facial height.
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· LAFH: the linear distance along the Z line from ANS to mention. It represents the
lower anterior facial height.

· TAFH: the linear distance along the Z line from nasion to mention. It represents the
total anterior facial height.

· PFH: the linear distance between point Y2, 3 and gonion. It represent the posterior
facial height.

· UAFH/ LAFH: the ratio between the upper and lower anterior facial heights.

· TAFH/ PFH: the ratio between the total anterior facial height and the posterior facial
height.

· U1-APg: the linear distance from the incisal edge of U1 to a line connecting point A
and pogonion. If the incisal edge is anterior to the line APg, the measurements is
positive, and versa.

· L1- APg: the linear distance from the incisal edge of L1 to a line connecting point A
and pogonion. It the incisal edge is anterior to the line APg, the measurements is
positive, and vice versa.

* A “PETITE” PIECE OF THE DIAGNOSTIC MOSAÏC

Actually, cephalometrics is a “petite” piece of the diagnostic mosaïc. The lateral

cephalometric radiograph in centric occlusion is essential for many reasons such as:
orthodontic diagnosis, case presentation, treatment progress, transfer records, and
research studies. (Notice that these same five reasons were stated for the
pretreatment orthodontic study casts in the diagnostic procedures).

The lateral cephalometric radiograph in centric occlusion is an essential

diagnostic procedure through the various cephalometric analyses which enable the
orthodontist to:

· Determine the relationship of the cranium, maxilla, mandible, and teeth as well as
their contributions to the malocclusion and dentofacial deformity.

· Analyze the facial profile and dentofacial esthetics

· Predict craniofacial growth.

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· Perform functional analyses for mandibular movements, palatal functions during
speech, etc.

* COMPUTERIZED CEPHALOMETRICS

Computerized cephalometrics has been used for more than three decades.
However, it required manual tracing or digitization of landmarks. In 1990, in a clinical
research study, Mostafa, El-Mangoury, Salah, and Rasmy explored a new approach
“that fully exploits the power of computers through image-processing algorithms that
elimination manual landmark identification. “At the end of this article, these researchers
predicated that: “With further research and development, the orthodontist of the 21st
century may be able to attach a digital image processor directly to the automatic film
processor and reduce manual intervention even more.”

6- FULL- MOUTH PERIAPICAL OR PANORAMIC RADIOGRAPHS

Fig.12. A panoramic radiograph. Note that you can survey in this one radiograph the
dentition, the jaws, and the temporomandibular joint.
A series of full-mouth periapical radiographs or a panoramic radiograph should
be taken to complete the essential diagnostic procedures. A panoramic radiograph is
presented in Fig. 12.

These radiographs are essential because they help the orthodontist in detecting
congenital absence of teeth, supernumerary teeth, pathologic conditions, unfavorable
eruptive patterns, etc.
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 B. SUPPLEMENTAL DIAGNOSTIC PROCEDURES

1. HAND- WRIST RADIOGRAPHS

A hand-wrist radiograph may be needed in order to determine the skeletal age of
the patient and to predict the possible onset of pubertal growth spurt.

2. LATERAL CEPHALOMETRIC RADIOGRAPHS IN POSTURAL RESTING

POSITION

The lateral cephalometric radiograph in postural resting position may be

desirable for purposes of functional analyses of mandibular movements or palatal
functions during speech.

3. FORTY- FIVE DEGREE LATERAL CEPHALOMETRIC RADIOGRAPHS, RIGHT

The right and left 45 degree lateral cephalograms (a cephalogram is a synonym

for cephalometric radiograph) may be wanted to determine the developmental status
and relative eruptive position of the individual teeth in seial individual teeth in serial
extraction cases as well as in cases requiring the evaluation of third molar status.

4. POSTEROANTERIOR CEPHALOMETRIC RADIOGRAPHS

The posteroanterior (PA) cephalograms may be considered necessary to

evaluate symmetry. These PA cephalograms are recommended in case of gross facial
symmetry as well as cases of transverse skeletal problems.

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Fig. 13. Posteroanterior cephalometric landmarks. ZF, Zygomatico-frontal suture:
intersection of the medial margin of the zygomatico-frontal suture with the orbit.Z,
Zygomatic arch: center of the root of the zygomatic arch. N, Nasal cavity: point located
at the widest area of the outline of the nasal cavity. J, Jugular process: intersection of
the tuberosity and zygomatic buttress on the jugular process. AIMS, Anterior nasal
spine: tip of the anterior nasal spine above the hard palate and just below the nasal
cavity. U6, Upper first molar: point on the occlusal plane perpendicular to the buccal
surface of the crown of the maxillary permanent first molar. L6, Lower first molar: similar
to th-2 upper first molar. U3, Upper canine: tip of the maxillary permanent canine. 13,
Lower canine: similar to the upper canine. A, Point A: interdental papilla of the maxillary
permanent central incisor at the dentogingival junction. B, Point B: similar to point A. Ag,
Antegonial protuberance: point at the inferior lateral margin of the antegonial
protuberance. M, Menton: the most inferior point on the mandibular symphysis.
The classic posteroanterior cephalometric landmarks are identified in Fig. 13. EI-
Mangoury, Shaheen, and Mostafa pointed out that: "By definition, philosophy is a good
think (with a "k" rather than a "g" at the end-not a typographic error). It is not the
philosophy of the present researchers to tell their fellow orthodontists what to use and
what not to use. Rather, the philosophy is to make us (the orthodontists) aware of the
magnitude and direction of variation for a particular posteroanterior cephalometric
landmark. Taking this into consideration will enable us (the orthodontic clinicians and
researchers) to look upon our cephalometric numbers with a mental awareness of the
possible variations".

22
 5. FUNCTIONAL CEPHLOMETRIC RADIOGRAPHS
The functional cephalograms may be needed to analyze mandibular function
through a series of different positions (e.g., wide open- mouth, narrow open-mouth,
postural resting position, and centric occlusion). Further, functional cephalograms may
be needed to analyze palatal function during speech though the use of phonation
cephalograms. (The phonation cephalograms are lateral cephalometric radiographs
taken during the pronunciation of certain alphabetic letters or certain sounds).

6.Three dimensional (3-D) cephalogram

The 3-D scene allows combination of 3-D hard and soft tissue representations with
lateral and frontal cephalograms (fig. 14.).

This allows the set-up of a reliable 3-D cephalometric reference system. Moreover, 3-D
cephalometric hard and soft tissue landmarks can be precisely defined and accurately
positioned.

Each landmark is visualized on the surface representations together with its projection
points on both cephalograms.

7. BITE- WING AND OCCLUSAL RADIOGRAPHS

Bite-wing radiographs may be looked for to detect interproximal caries. Occlusal
radiographs may be required to accurately locate the position of an impacted maxillary
canine, or the position of a mesiodens.

8. DIAGNOSTIC SETUP
The diagnostic setup may be necessary to simulate the proposed treatment plan
in three – dimensions in the diagnostic set-up, teeth are cut from the dental casts, and
reset in more desirable positions through the use of wax.

23
Fig. 14. A virtual cephalogram is computed from CT image volume. A virtual parallel
x-ray beam is sent through the patient. Extra radition dose is avoided, and the
geometrical relationship is known

24
 10. MAGNETIC RESONANCE IMAGING (MRI)
In some temoromandibular disorders, magnetic resonance imaging (MRI) of the
temporomandibular joint (TMJ) may be needed. Fig. 14 represents a simplified diagram
of the MRI-TMJ measurements.

25
Fig. 14. Diagram of MRI-TMJ measurements. The landmarks C, A, and P points represent
condylion (C point), anterior discal band (A point), and posterior discal band (P point). The
reference planes x-axis and y-axis are respectively the horizontal and vertical Cartesian
coordinates. Notice the following measurements: disc length (A'-PO, condylion to anterior band
H space (C-AO, condylion to posterior band H space (C-PO, condylion to anterior band V space
(C-A"), and condylion to posterior band V space (C-P").

11. PSYCHOLOGICAL TESTS

Psycho-orthodontic tests may be taken to psychologically predict the cooperation

of the orthodontic patients.

12. ELECTROMYOGRAPHIC RECORDS

Electromyographic records may be wanted in abnormal muscle function cases.

13. ENDOCRINE TESTS

Endocrine tests may be needed when the orthodontist suspects the presence of
endocrine problems.

26
 Chapter 2
TISSUE CHANGES IN ORTHODONTIC
TOOTH MOVEMENT

I) Orthodontic Force

1. Manner of force application.

2. Amount of force application.

3. Duration of force application.

4. Direction of force application.

5. Optimal orthodontic force.

II) Tissue Reaction

1. Normal Anatomy and function of periodontal ligament.

2. Theories of tooth movement.

3. Mechanism of tooth movement.

4. Effects of force magnitude

5. General reaction.

6. Special reaction.

27
 TISSUE CHANGES IN ORTHODONTIC
TOOTH MOVEMENT

1. Learning Objectives: By the end of the lecture every student should be

able to:
a. Understand the normal anatomy and function of the periodontal
ligament.
b. Understand the theories of tooth movement.
c. Understand the mechanism of tooth movement
d. Acknowledge the effect of using light versus heavy forces in
orthodontic tooth movement.

2. Detailed Outline: enclosed

3. Learning Material:
a. Department Book
b. Contemporary Orthodontics by Proffit & Ackerman. Chapter 9
"The Biological Basis of Orthodontic Therapy" p.296-304. 3rd
edition, Mosby, Inc., 2000.

4. Teaching Methodology:
a. Lecture using Powerpoint Presentation
b. Clinical Sessions
5-Suggested Method of Assessment:
c. Written Exam; short essay
d. MCQ
Normal Anatomy and function of the periodontal ligament.( Pdl)
28
 The periodontal ligament (pdl) is a heavy collagenous structure
that attaches the cementum on the root surface to the dense bony
plate around it “lamina dura”. It is about 0.5 mm in width.
Histologically, the pdl is composed of :
¨ Fibres:
These run at an angle attaching more apically on the
tooth than the bone in order to resist tooth displacement during
normal function.
¨ Cells:
1. Undifferentiated mesenchymal cells which can
differentiate into fibroblasts and osteoblasts.
2. Blood cells.
3. Nerve cells for pain & proprioception.
¨ Tissue Fluids:
Pdl is a fluid filled chamber with porous walls; thus can act
as a shock absorber.

Teeth can be moved by means of orthodontic appliances because of certain

fundamental properties of bone tissue. Bone is resorbed wherever there is pressure and
new bone is deposited where there is stretching force acting upon the bone surface.
The reaction of the bone to pressure is the same regardless of weather the pressure
upon the bone is caused by any erupting tooth, by a slowly growing cyst, tumor or by
gently orthodontic force. All these factors cause a compression of the periosteum
overlying the bone with the resulting appearance of osteoclasts and the elimination of
bone which eventually tends to relieve the compressed soft tissues and to restore the
distributed tissue equilibrium.
Performance of satisfactory tooth movements depends on the understanding of:
I. Orthodontic force. II. Tissue reaction to orthodontic force.

29
I) Orthodontic force:
1- Manner of force application:

A- Continuous forces:
Maintain approximately the same force magnitude over a period of time, for
example, a coil spring

B- Dissipating forces:
Are continuous but decreasing within a short period, for example, a banded tooth
ligated to an arch wire. Many tooth movements effected by modern orthodontic
appliances result from the dissipating type of force application.

C- Intermittent forces:
The force is active when the appliance is in the mouth and it is not existent when it is
removed. Maxillary plates with auxiliary springs (removable appliance) and extra-oral
traction appliances are examples of appliances using intermittent forces.

2- Magnitude of force:
The magnitude of force determines to some extent the duration of hyalinization (seen
later). When excessively strong forces are applied, a longer initial hyalinization period
will result. Interruption of the heavy forces will moderate the rate of hyalinization. The
amount of force that is optimal varies with the type of tooth movement.
a) Gentle (mild) force:
Gentle force will cause hyperemia, which will lead to differentiation of osteoclasts
and osteoblasts. Direct bone resorption will occur on the pressure side while
deposition of osteoid tissue will be on the tension side.
b) Strong force:
Strong forces will lead to ischemia and decrease of cellular element, hyalinization
will result. Undermining bone resorption will occur in the pressure side to remove
the hyalinized tissue.
c) Severe force:
Severe forces will lead to necrosis of periodontal tissues, massive undermining
bone resorption will occur that may lead to root resorption and healing by
ankylosis.
30
3- Duration of force application:
It is claimed that the periodontal ligament needs to have recovery periods to replenish
the blood supply.

4- Direction of force application:

Direction of force depends on the type of tooth movement required.
A- Tipping movement:
Crown and root are moved in opposite directions around a center of rotation
within the root. Diagonally opposite areas of compression and tension are
produced within the periodontal ligament. During tipping the crown of the tooth
moves much more than does the root.

B- Translation movement (Bodily movement):

Crown and root are moved in the same direction at the same time.
C- Rotation movement:
Movement of the tooth around its long axis
D- Intrusion movement:
Movement of the tooth in an apical direction.
E- Extrusion movement:
Movement of the tooth to an occlusal direction.
F- Torque movement:
Movement of the root with minimal movement of the crown.

5- Optimal orthodontic force:

It is the force that moves the tooth most rapidly in the desired direction and with the
least tissue damage and the least amount of pain.

31
II) Tissue reaction to orthodontic forces:

1- Normal Anatomy and function of the periodontal ligament

The periodontal ligament (pdl) is a heavy collagenous structure that attaches the
cementum on the root surface to the dense bony plate around it “lamina dura”. It is
about 0.5 mm in width. Histologically, the pdl is composed of:
A- Fibres:
These run at an angle attaching more apically on the tooth than the bone in order
to resist tooth displacement during normal function.

B-Cells:
1- Undifferentiated mesenchymal cells which can differentiate into fibroblasts and
osteoblasts.
2- Blood cells.
3- Nerve cells for pain & proprioception.

C- Tissue Fluids:
Pdl is a fluid filled chamber with porous walls; thus can act as a shock absorber.

Lamina Dura
Cementum

Collagen Fibres

Figure 1: Normal anatomy of PDL

32
 There is continuous remodeling of pdl collagen during normal function. The
fibroblast-clast cell produces new collagen and removes old collagen. Similarly,
but to a smaller scale, bone and cementum are removed by specialized
multinucleated giant cells; osteclasts and cementoclasts, respectively. At the
same time, new bone and cementum are formed by osteoblasts and
cementoblasts.
Occlusal forces are in the range of 1-2 kg during chewing soft food, but may
reach up to 50 kg during chewing hard substances. If pressure is maintained on
a tooth less than 1 sec, a piezoelectric signal is produced. If pressure is
maintained 1-2 seconds, some fluid is expressed from the pdl which is thus
compressed allowing a slight displacement of the tooth. Maintaining pressure 3-
5 seconds, results in squeezing out of all pdl fluid and pain.

2- Theories of Tooth Movement:

A- Pressure-Tension Theory:
If pressure is sustained against a tooth, it will shift within the pdl compressing it in
areas and stretching it in others. Blood flow is reduced in pressure areas,
resulting in a reduction of oxygen levels and increases in areas of tension with a
resultant increase in oxygen level. These chemical changes stimulate the
release of cellular messengers which stimulate cellular differentiation and activity.
Cellular messengers include prostaglandins, interleukin-1 beta, nitrous oxide and
cyclic AMP.

B- Bioelectric Theory:
If pressure is applied to bone crystals electric signals are emitted due to
displacement of electrons from 1 part of the crystal to another. This phenomenon
is known as “Piezoelectricity”. Piezoelectric signals are characterized by a
quick decay rate and the production of an equivalent signal opposite in direction
when the force is released (as the electrons jump back into their previous
position). Ions in the fluids that bathe living bone interact with the complex
electric field generated by bone bending resulting in temperature changes as well
as electric signals, convection and conduction currents. The small voltages
33
 observed are known as “streaming potentials”. Such electric signals are
essential to maintain bone mineral, otherwise atrophy occurs. However,
sustained forces of this kind, as in orthodontic tooth movement do not produce
prominent signals.
On the other hand, areas of active bone growth produce electronegative charges
“bioelectric potential”, whereas inactive areas are nearly electrically neutral.
Application of external electric signals (low voltage direct current) and pulsed
electromagnetic fields results in faster tooth movement by changing the
membrane potential.

3- Mechanism of Tooth Movement:

48 hours after force application, chemical messengers are released. They trigger
the differentiation of undifferentiated mesenchymal cells in the pdl resulting in
formation of osteoblasts on the tension side and bone formation. Osteoclasts
differentiate on the pressure side and start resorbing bone. Theses osteoclasts
arrive in 2 waves implying that the cells in first wave may be derived from a local cell
population while the others arrive in a larger second wave from distant areas via
blood flow. These osteclasts attack the adjacent lamina dura removing bone by
“frontal resorption” and the tooth begins to move.

Root
Bone
Proliferation Zone;
Osteoblasts +
Fibroblasts
Osteoi
d

Figure 2: Frontal Bone Resorption

34
4- Effects of Force Magnitude
Light prolonged forces produce tooth movement in the manner described above i.e.
by frontal resorption. Higher prolonged forces lead to a greater reduction of blood
flow in pdl until to the point where the vessels are completely occluded. Sterile
necrosis occurs in the compressed areas and the cells disappear. This is called
hyalinization of the pdl. Resorption of bone next to the hyalinized area is
accomplished by osteoclasts which appear in adjacent bone marrow spaces and
attack the underside of bone adjacent to the necrotic pdl. This process is therefore
called “undermining resorption”, since the attack is from the underside of the lamina
dura. Under Heavy Orthodontic force, tooth movement will be delayed than when
using a light force for 2 reasons;
a. More time is needed until the stimulus reaches the undifferentiated mesenchymal
cells in adjacent marrow spaces.
b. A greater thickness of bone needs to be removed from the underside before
tooth movement can take place.

Bone

PDL

Cementum
Osteoclasts
in Howship's
Lacunae

Figure 3a: Undermining Bone Resorption

35
 Figure 3b: Delayed Tooth Movement with Undermining Bone
Resorption
5- General reaction:
In response to orthodontic forces tissues react in 3 stages:

A- Periodontal vessels are compressed few minutes after force application, in this
stage a rapid limited movement occurs.
B- Compression of periodontal ligament against the wall of the alveolus. The area of
the compressed periodontal ligament becomes cell free (it is called hyalinized
tissue). Movement of the tooth stops until the hyalinized tissue has been
removed. The duration of hyalinization in human may vary from few days to few
weeks. Undermining bone resorption occurs during this period.
C- Periodontal space is widened. In pressure area direct bone resorption occurs
(osteoclastic activity). On the tension side osteobalstic activity is present.

6- Special tissue reaction:

A- The alveolar bone:

As the diagram (showing tipping movement), as the crown is tipped lingually, with
resorption at the lingual crest area and deposition in the labial crest area, there is
internal reorganization in the vicinity of the moving tooth. Resorption takes
place on the external surface of the labial plate, with individual trabeculae
mirroring this reaction (resorption on the side among from the labial surface of
the tooth, deposition on the lingual aspect of the trabeculae). This helps to
36
 maintain a constant thickness of the labial alveolar bone covering. On the lingual
aspect, modeling resorption and deposition of bone also take place, as individual
trabeculae resorbs on the side nearest the tooth and deposition of bone occurs
on the side farther away.

Force on the tooth (F) causes tilting about a point near

the center of the root, and resultant resorption and deposition
of bone from the periodontal ligament side of the socket wall.

B- Periodontal membrane (PDM):

Using the same hypothetical example of maxillary central incisor with lingual
pressure applied to the crown, compression of the PDM at the lingual alveolar
crest, the lingual apical third shows an increase in thickness and the elongation
of the PDM fibers, as this area is subjected to tensional force. On the labial
surface, the same tensional force in the incisal third shows and the same
compression at the apical third occurs.
37
C- Cementum:
The surface of the root normally has an acellular organic layer of cementoid over
the cementum, when orthodontic pressure is applied this protective cementoid
layer may be perforated. After treatment cementoblasts usually fill in.

D- Dentin:
With severe pressure a break through the cementoid layer and cementum
resorption are followed by actual dentin resorption in some cases. Such areas
are not repaired by dentin but are filled in by the action of cementoblasts with
resulting instosis.

E- Pulp:
There is a reduce sensitivity to electric pulp testing methods during orthodontic
treatment. The pulp reaction returns to normal after completion of orthodontic
therapy.

F- Enamel:
No tissue changes are observed in the enamel as a result of tooth movement.
Decalcification around bands may be seen, it is a result of debris that is not
removed.

G- Root resorption:
The factors that may influence root resorption are:
1- Magnitude of the force.
2- Duration of force application.
3- Direction of movement.
4- Age of the patient.

38
 Chapter 3
Preventive Orthodontics

It is essential that a proper rapport be established between the dentist and his parents
at the first visit. The child should be seen by his dentist as early as two and a half
years of age. Clinical examination, diagnostic records (especially dental panoramic x-
rays examination, study models, occasional photographs may help) should be obtained.
The timing and mode of preventive treatment procedures should usually be made by in
orthodontist. Thus refer the patient for an orthodontic consultation whenever there is
any question of developing malocclusion.

Orthodontics has three phases:

1- Preventive orthodontics.
2- Interceptive orthodontics.
3- Corrective orthodontics.

Preventive Orthodontics
It is the principle used to maintain an occlusion which is normal and will continue to
be normal unless some unnatural outside influences disturb it.

All principles of preventive dentistry are principles of preventive orthodontics.

Preventive orthodontics:

-Care of the general health.

-Care of deciduous dentition.
-Care of permanent dentition.
-Prevention of habits and abnormal soft tissue function.

39
A. Care of general health:
1- Breast-feeding of the infant is recommended for proper development of jaws and
teeth.
2- Soft diet, malnutrition, illness have indirect effect on occlusion by their bad effect
on teeth quality and caries incidence.
3- Nasal passages for breathing should be free for any problems with tonsils and
adenoids. Patients should be referred to E.N.T specialist.
4- Early management of craniofacial disorders e.g. cleft lip and palate.

B. Care of deciduous dentition:

1- Good oral hygiene: the mother should be aware of the importance of tooth
brushing from infancy. By the time the incisor eruption, the child should be
acquainted with the toothbrush. By 2 years of age, the child should be able to
brush his teeth after each meal.

2- Prevention of caries:
- Fluoride application: public water fluoridation, topical
application of 2% sodium fluoride tables, fluoridated chewing
gum.
- Diet: ratio of carbohydrate in diet should be as low as possible, sticky
carbohydrates and sweets should be minimal, no eating between meals.
- Prophylactic operative dentistry, e.g. filling of deep fissures.

3- Space maintainers:
- Deciduous tooth is the best space maintainer for the coming
permanent tooth.
- The dentist should be aware of importance of deciduous teeth, and
perfectly know how to keep them and detect any abnormality, deal with it
till the proper time of exfoliation.

40
 - Where extraction is unavoidable, steps should be taken to maintain the
space for permanent successors.
Space maintainer therapy will be affected by:
- Time of deciduous tooth loss.
- Type of occlusion.
- Patient co-operation.

4- Over-retained deciduous teeth should be removed after radiographic

verification of presence of permanent successors.

5- Cuspal interference: failure of normal attrition of deciduous teeth may cause

some cuspal interference; the latter could be removed by grinding offending
cusps.

6-Abnormal resorption pattern: are associated most frequently with space

deficiency problems. Abnormal resorption of any deciduous tooth may be a factor in the
deflection of the permanent successor into an abnormal path of eruption. The deciduous
canines and the second deciduous molars are the teeth mostly affected. In an ideal
sequence, right and left deciduous teeth should be lost at about the same time.

C.Care of permanent dentition:

1- Proper oral hygiene and great attention to the gum is of great importance to
permanent teeth.
2- Early and unbalanced loss of permanent teeth will lead to malocclusion,
traumatic occlusion and periodontal lesions.
3- In cases of maxillary and mandibular deformities, congenital missing, impacted
and supernumerary teeth. Consultation with an orthodontist is essential.
4- Ectopic eruption: malposition of a permanent tooth bud leads to eruption in a
wrong place. This condition is called ectopic eruption.

41
 Order of occurrence:

a.Maxillary 1st molar: which may erupt far mesially hitting distal roots
of 2nd deciduous molars damaging the deciduous molar and causing
severe arch crowding.
b.Mandibular lateral incisor: which may lead to a transposition with
the mandibular canine.
c.Maxillary canine: may be due to:
-Lack of space in the arch.
-Tooth bud is poorly positioned and tooth erupts ectopically
even when the space is adequate.
4- Mandibular 2nd premolar.

5-Eruption cycle of the permanent teeth: Each patient has his own "norm"
for the eruption of the deciduous and permanent teeth, and it is up to the dentist through
careful study to determine and maintain the eruption cycle of each patient.

Dentist must lookout for anything that might stand in the way of eruption of a
tooth e.g retained deciduous root fragments, supemumary teeth, ankylosis of the
deciduous tooth, soft tissue barrier, overhanging restoration in a deciduous tooth.

D.Prevention of habits:
Bad habits should all be stopped, as a preventive orthodontic measure, otherwise
partial or complete destruction of permanent occlusion will be the inevitable result.

Examples for oral habits:

- Thumb sucking. –Lip biting -nail biting.

- Wrong postures (like supporting a jaw by the fist may cause cross bite).
- Mouth breathing.
All bad habits could be prevented by habit breaking appliance, e.g. tongue guard,
oral screen.

42
 Chapter 4
Interceptive Orthodontics

Definition: it is the principle that is taken to maintain occlusion which is normal but

an external factor started to influence the normal development. The difference between
preventive and interceptive orthodontics lies in the timing of the services rendered. In
interceptive, the dentist is dealing with malocclusion of a minor degree. If he renders the
proper service and adjustment he will restore normal occlusion, and if he waits he must
resort to the corrective orthodontic procedures.

Equilibration of occlusal disharmonies:

To check an occlusal harmony or lack of harmony the patient should be observed

carefully as he closes from wide open mouth to postural resting position and from
postural resting position to full occlusion. Postural resting position is a balanced
unstrained relationship of mandibular condyle, articular disk, articular eminence,
articular capsular structures and ligaments, and of die controlling musculature. This
balanced relation should not be disturbed as the mandible moves into full occlusal
contact i.e habitual occlusal position should be the same as centric occlusal position.

- Anterior mandibular displacement:

One form of tooth guidance in the deciduous and mixed dentition is the anterior
mandibular displacement. At initial contact there is an edge to edge incisal relationship
usually due to lingual malposition of the maxillary incisors or incipient mandibular
prognathism, the condyles slide forward on the articular eminence and the posterior
teeth make occlusal contact. The dentist must be quite sure that he is not dealing with a
true class IIl malocclusion.

43
-Cross bite conditions:

Tooth guidance can also deflect the mandible laterally or posteriorly as well as
anteriorly from the initial contact to full occlusion range. Narrowing is usually bilateral.
Unless these crossbite are eliminated not only it will lead to asymmetry of the dental
arches but an actual facial asymmetry may result in the adult.

In the primary dentition the tooth guidance usually requires less spot grinding
than later on to establish normal relationship. Inclined planes are not so deep and in
conjunction with growth and development, the adjustment to a new position is
comparatively easy. In the mixed dentition greater care must be exercised to avoid
removing too much tooth material from the permanent teeth.

Developing anterior crossbite:

It is quite normal for the maxillary lateral incisors to erupt slightly to the lingual
side of the line of the central incisors and to come forward as the clinical crown is
exposed and as the tongue function makes itself evident. Occasionally, even with
adequate arch length, the lateral incisors may erupt too far lingually. Maxillary incisors
may be trapped on the lingual side by the occlusion, leading to a developing anterior
cross bite, which should be intercepted before full malocclusion occur.

Therapeutic techniques:

Before the correction of an anterior cross bite, determine whether the cross bite
is a symptom of a more generalized malocclusion or purely a localized irregularity.
Assuming that there is adequate space for the tooth in cross bite to be moved into its
correct position, several approaches are possible:

- The use of an acrylic inclined plane that is cemented to the mandibular incisors
opposing the tooth in cross bite.

- The use of a palatal removable appliance, with a lingual finger spring.

44
- The use of a simple labial arch wire and two maxillary first molar bands the lingually
malposed incisor is ligated to the arch wire.

It is easier to intercept a developing anterior cross-bite than to correct it after it is

established. Frequent observation by the dentist at this critical time and the use of a
tongue blade for one or two hours a day over a three-week produced the result seen in
the three top rows. The mechanics of tongue blade action is illustrated in the bottom row
of photographs and in the diagram.

-Control of abnormal habits

First a trident of habit factors must be recognized and evaluated i.e duration,
frequency and intensity of the habit.

Thumb sucking:

Control of abnormal habits usually begins in phase II.

- It begins with a discussion of the problem with the child alone.

- Prescribing finger size plastic bandages (or bands aids) to be placed on the thumb
each night by the child (NOT the parent) to remind the thumb to stay out of the
mouth.

- Insertion of a habit breaking appliance. The best appliance is a palatal archwire with
short spurs soldered at strategic locations to remind the tnumb to keep out. An oral
shield can be used in the correction of the habit but it requires an unusual amount of
patient cooperation.

Tongue thrusting:

- Patient should be instructed to practice correct swallowing at least 40 times daily.

- When the new swallowing pattern has been learned on the conscious I level, it is
necessary to reinforce it subconsciously. A flat sugarless drops can be used to
reinforce the unconscious swallow.

45
- A well adapted soldered palatal arch wire having short strategically located spurs
can be inserted.

Lip biting and sucking:-Abnormal lip activity almost associated with Class II
div. l malocclusions. The treatment of malocclusion usually restores normal muscle
function.

- If the habit is primarily a neuromuscular tic or "nervous habit", the lip habit appliance
can be effective e.g a modified oral shield.

Orthopedic control of class III malocclusions. Force magnitude of 2 to 3 pounds for 12 to

16 hours per day ix required to effect the desired changes. Dentofacial orthopedics is
successful only in the growing child. Longrange guidance by the specialist is desirable
in there problems, starting in the dentition. Usually 2 to 3 short periods of orthopedic
guidance are necessary before the end of puberty.

Developing mandibular prognathism

Patients with mandibular prognathism must have the excessive mandibular

growth restrained and /or redirected through an extraoral force (chincap). Cases of
skeletal Class III with midface deficiency require midface orthopedic traction to promote
maxillary growth.

46
 Serial extraction

Definition: it is a planned extraction of some of the deciduous teeth followed by

extraction of some of the permanent teeth to relieve tooth size arch length
discrepancy.

Timing: it is decided that at age of 8-9 years and when upper laterals are
erupting, it is diagnosed that arches are crowded and that reduction of dental units
will be necessary, serial extraction may be advisable.

Procedure:
1- X-ray to assure the presence of all teeth and check the shape, size and
development. It is desirable that the 1st premolars are developmentally ahead of
canines (nearer in eruption).
2- Occlusion should be Angle’s class I with no increase in overjet and overbite.
3- All deciduous canines are extracted, lateral incisors are expected to adjust into
place by utilizing a part or all of the space, which would later, needed for
permanent canine.
4- Nearly one year later, when half of roots of the 1stdeciduous molars have been
resorbed, deciduous 1st molars are extracted.
5- 1st premolars are then extracted when they erupt.
6- Because lower canines are always ahead of lower 1st premolars in eruption, it
may be advisable to extract lower 1st deciduous molars before lower deciduous
canines to hasten eruption of lower 1st premolars.
7- The second deciduous molars are extracted and the residual space will be taken
by the second premolar and the canines for better alignment.
8- Limited orthodontic treatment phase is always needed to achieve final settlement
of the occlusion.
9- The procedure of serial extraction provides space for permanent canines at its
eruption when there is insufficient bone supporting area for the tooth, and also
shorten the period required for active orthodontic correction.

47
Indications for serial extraction:
The following is a list of possible clinical clues for serial extraction, occurring
singly or in combination:

1- Premature loses of the deciduous lateral incisors or canines during eruption of the
permanent incisors.

2- Arch length deficiency and tooth size discrepancies (large teeth and small jaws).

3- Lingual eruption of lateral incisors with lack of their spaces.

4- Unilateral deciduous canine loss and shift to the same side.

5- Mesial drift of buccal segments.

6- Abnormal eruption direction and eruption sequence.

7- Flaring or fanning of the incisors.

8- Ectopic eruption.

Abnormal resorption.

Contraindications:

1- Uncooperative subjects.
2- Class II and III Angle malocclusion.
3- Deep bite and open bite cases.
4- Congenital absent teeth.
5- Impacted canines or improperly inclined teeth.

48
 Chapter 5
TREATMENT OF MALOCCLUSION
According to the demand and need, orthodontic treatment can be carried out for
children, adolescent and adults. There is no best time for all patients at all time;
however, malocclusion should be treated as soon as possible when postponement of
treatment would lead to severe functional or esthetic problems.
In this chapter, treatment of malocclusion in children, adolescent and adults will be
briefly reviewed.
ORTHODONTIC TREATMENT FOR PREADOLESCENT CHILDREN
1 Sometimes called early, mixed dentition or phase I orthodontic treatment.
2 It is treatment provided to a patient during mixed dentition and occasionally late
primary dentition (about 6-12 years age).
3 “Preventive and interceptive orthodontics” are terms used in the past for
description of orthodontic treatment in children.
4 Prevention of malocclusion is possible only in few special circumstances
(e.g. space maintenance). Interceptive treatment can be very helpful in reducing the
severity of problems (e.g. serial extraction – discussed later).
5 A second phase of treatment (phase II) is always necessary after eruption of
succedanous teeth.
6 General dental practitioner may treat mild orthodontic problems in children
where as, complex problems should be managed by orthodontic specialist.
Benefits Of Early Treatment In Children:
1 Influence jaw growth in positive manner.
2 Harmonize width of the dental arches.
3 Improve eruption patterns.
4 Lower risk of trauma to protruded upper incisors.
5 Correct harmful oral habits.
6 Improve esthetics and self-esteem.
7 Shorten and simplify treatment for later corrective orthodontics.
8 Reduce likelihood of impacted permanent teeth.
9 Improve speech problems.
49
10 Preserve or gain space for erupting permanent teeth.
Clinical Problems And Treatment Procedures:
Dentoalveolar problems
- Space problems.
- Eruption problems.
- Occlusal relationship problems.

Skeletal problems
- Skeletal Class II, III.
- Skeletal posterior crossbite.
- Skeletal openbite.

Dentoalveolar Problems
І. Space Problems (space maintenance, space deficiency, excess space).

1. Space maintenance:
2. Space Deficiency (Crowding)
- Crowding is the term given to malaligned (irregular) teeth due to difference in size
of teeth (needed space) and space available for them within the alveolar arch
perimeter.
- The main two causes of crowding are:
A) Space deficiency.
B) Space loss.

A. Management of crowding due to space deficiency:

- Space analysis (mixed dentition analysis) is necessary to evaluate the degree and
severity of crowding and hence the method of treatment.
1. Minimal crowding (< 2mm): No treatment is indicated
2. Mild crowding (2-4 mm): Interproximal reduction of primary lateral incisor and
canines to allow alignment of permanent central incisors and lateral incisors.
3. Moderate crowding (3-5 mm): It is managed by arch expansion using removable
or fixed appliance (Figs. 1, 2)

50
 Fig. 1 Fig. 2

4. Severe crowding > (5mm):

- Need careful management. It is a complex problem and must be managed by
specialist.
- Generally this problem can be treated by expansion or extraction of some
teeth.
- The decision depends upon so many factors. Consultation with an
orthodontist is required.

Serial extraction: is an interceptive measure that means planned sequence of tooth

removal to reduce crowding during the transition from the primary
to permanent dentition.

B. Management of crowding due to space loss (space regaining):

- Space is lost for two reasons:
● After premature loss of a primary tooth, space may be lost from drift of other
teeth before dentist is consulted.
● Ectopic eruption.

Localized space loss (3mm or less)

- Space regaining followed by fixed space maintenance.
- Maxillary space regainers:
● Removable Appliance (Fig. 3).
● Head Gear (extra-oral force).

51
 Fig. 3

- Mandibular space regainers:

● removable lingual arch (Fig.4) ● lip bumper (Fig. 5)

Fig. 4 Fig. 5
Space loss greater than 3 mm
- Extraction is evaluated against space regaining. Consultation with orthodontist is
necessary.

3. Dental Spacing
A. Localized anterior spacing (maxillary midline diastema), no treatment is
indicated during mixed dentition.
B. Generalized Anterior spacing
1. Generalized spacing without protrusion
- Excess space is not a frequent finding in mixed dentition in the absence of
incisor protrusion.
- It can result from either small tooth in normal sized arches or normal teeth
in large arches.
- No treatment is indicated in transitional dentition. It is recommended to
52
 allow the eruption of the remaining permanent tooth before closing the
space with fixed appliance.
2. Generalized maxillary spacing with protrusion
- It is often a sequella to prolonged thumb sucking.
- Habit breaking (reminder) appliance is usually used in early mixed
dentition to stop the habit.

II. Eruption problems

1. Over –retention of primary teeth:
- A primary tooth is considered over–retained if 1/3 of the root of its successor is
formed and the primary tooth is not exfoliated.
- Over- retained primary tooth causes:
1) Delayed eruption, or
2) Deflect the eruption path of their successors. Thus causing malocclusion
(anterior or posterior crossbite).
3) Over-retained deciduous tooth must be removed to allow the permanent
successor to erupt in good occlusion.

2. Ankylosed primary teeth:

1) When the cementum of the root and alveolar bone is united, the tooth is
considered ankylosed.
2) Ankylosed primary tooth is unable to continue its development and reach the
occlusal line, when adjacent teeth continue to do (submerged tooth).
3) If an ankylosed tooth is not exfoliated in suitable time (usually does), extraction
must be done.
4) When the ankylosed primary tooth has no successor, seeking the advice of an
orthodontist is required. Treatment of such case may be:
· Maintaining the space of the ankylosed tooth for future prosthesis, or
· Closing the space by moving the adjacent teeth.

3. Ectopic eruption of permanent teeth:

1) Is the eruption out of normal position ( ectopia= abnormal position ).
2) The most common ectopically erupted teeth are:
53
 ·Maxillary first molar
·Permanent lateral incisors.
·Maxillary canine.
- causes of ectopic eruption may be:
* Small arch size.
* Abnormal eruption path.
* Long path of eruption (maxillary canine).
* Abnormally located tooth bud

Lateral incisors (maxillary and mandibular):

1) Usually cause resorption of roots and early loss of adjacent primary canine.
2) It is considered a sign of severe arch size deficiency.
3) When unilateral loss of primary canine occurs, extraction of the contra lateral
one is necessary to prevent dental midline shift.
4) A lingual arch space maintainer is required to prevent lingual tipping of
incisors and further decrease of arch size.

Maxillary first molar and maxillary canine:

- Space management and the advice of a specialist are recommended in such
cases. Careful diagnosis and treatment planning are necessary.

4. Delayed eruption of permanent teeth:

1) Caused mainly by:
· Presence of supernumerary teeth in the eruption path.
· Space deficiency following early loss of primary predecessor.
2) Delayed eruption of a permanent tooth, mainly upper incisors or canine, must
be managed by Orthodontist, as it is a complex problem.

5. Congenitally missing permanent teeth (those teeth whose germ did not
develop):
1) The most commonly missing permanent teeth are the mandibular second
premolars and maxillary lateral incisors.
2) This clinical problem is more common than supernumerary teeth. It is a
54
 complex problem and its management needs the experience of an orthodontist.

a. Mandibular second bicuspid:

- Treatment options are:
1. Maintaining its space for bridge.
2. Space closure, by moving first molar mesially and first premolar distally (in
case of anterior crowding).
3. Retaining of primary second molar in place (if occlusion is acceptable).
Mesiodistal crown reduction is often necessary to allow proper interdigitation
of teeth.
b. Maxillary lateral incisor:
1. Primary lateral incisor is not usually retained (poor esthetic, easily
resorption).
2. Treatment options are:
3. Extraction of primary lateral incisor allows the eruption of maxillary cuspid in
its place. Reshaping (recontouring) the cuspid and composite build up to
simulate lateral incisor is done.
4. Opening space for prosthesis (bridge or implant).

6. Supernumerary teeth:
- The most common site of supernumerary teeth (extra teeth) is the anterior
maxillary region (premaxilla).
- Supernumerary teeth may cause:
1. Crowding if erupt in line of occlusion (e.g.supplemental lateral incisor).
2. Ectopic eruption of permanent teeth.
3. Delayed eruption or impaction.
4. Diastema (mesiodense).
- A supernumerary tooth must be removed when it is diagnosed to prevent
occurrence of malocclusion.
-
III. Occlusal relationship problems
1. Antero-posterior relationship:
Anterior dentoalveolar crossbite:
55
- Skeletal maxillomandibular relationship is normal anteroposteriorly.
- Usually one or two incisors are in crossbite.
- It is caused by:
· Over retention of upper primary incisor.
· Lack of space.
· Lingual development of permanent incisor tooth buds.
- It must be treated as soon as it is diagnosed.

Fig. 6

- When space is enough, a removable appliance (Fig. 6) with finger spring. Palatal
spring can be used to correct the crossbite.
- If space is inadequate, space analysis is necessary. Space regaining before
correction of crossbite is required (consult a specialist).

2. Transverse relationship:
Posterior dentoalveolar crossbite: (Fig. 7)

Fig. 7
Causes:
· Narrow maxillary dentoalveolar arch.
· Palatally erupted posterior permanent teeth.

56
May be also caused by:
· Cheek sucking habit.
· Mouth breathing habit.
Must be treated as soon as it is diagnosed (even in primary dentition)
Treatment can be done by:
· Removable appliance (Fig. 8), an acrylic plate with screw used to
widen maxillary dental arch.

Fig. 8
· Fixed appliance (Fig. 9), W-arch. It is a type of lingual arch used to
correct posterior dentoalveolar crossbite in primary and mixed
dentition. Orthodontic bands may be used for primary 2nd molar or
permanent first molar. This appliance is effective for expanding the
maxillary dental arch and posterior crossbite correction.

Fig. 9

57
3.Vertical relationship
1. Anterior dentoalveolar open bite:
- It is failure of anterior teeth to overlap.
- It is mainly caused by finger sucking habit and persistence of infantile
swallowing.

- Self – correction usually occurs if child stops the habit.

- Treatment is started in early mixed dentition if the habit persists.
- Fixed habit breaking (reminder) appliance is effective.
- A removable reminder is usually ineffective for this habit.

2. Deep dentoalveolar deep bite:

- Early treatment could be considered.

SKELETAL PROBLEMS
A. Skeletal class II, III. (Anteroposterior dysplasia).
B. Skeletal posterior crossbite (Transverse dysplasia).
C. Skeletal open bite or deep bite (Vertical dysplasia).
· These are complex problems.
· Must be treated by a specialist.
· Orthopedic treatment through growth modification to accelerate, inhibit
or change the directions of jaw growth to treat skeletal problems is best
done during the pubertal growth spurt (late mixed and early permanent
dentition).
· Skeletal problems must be carefully diagnosed and differentiated
from dentoalveolar problem to select the proper treatment plan for each.

58
 Chapter 6
ORTHODONTIC TREATMENT FOR ADOLESCENTS

(Comprehensive Orthodontic treatment in early permanent dentition)

- Comprehensive orthodontic treatment is the procedure of making the patient
occlusion as ideal as possible, which necessitates repositioning of all or nearly
all the teeth in the process.
- A second phase (phase II) of comprehensive treatment is usually needed for
children having a first phase (phase I) of treatment in the mixed dentition.
- The ideal time for comprehensive treatment is during adolescence when the
succedanous teeth have just erupted for 3 reasons:
· Patient is self- motivated, hence good cooperation is expected.
· Usually some growth remains to change anteroposterior and vertical jaw
relationship.
· Treatment time is quite reasonable (18-24 months).
- Three major stages of treatment are usually performed:
* The first stage of comprehensive treatment is leveling and alignment.
* The second stage is correction of molar relationship and space closure.
* The third stage is finishing and retention.
Orthopedic treatment
- Skeletal problems are best treated during early adolescence.
- Comprehensive treatment and growth modification require complex fixed
appliance and the experience of well- trained orthodontist.

ORTHODONTIC TREATMENT FOR ADULTS

Adjunctive treatment for adults:
- Adjunctive orthodontic treatment is defined as tooth movement carried out to
facilitate other dental procedures necessary to control disease and restore
function.
- Older adults (typically in their 40’s or 50’s) who have other dental problems need
orthodontic treatment as part of large treatment plan (multidisciplinary treatment).
59
 - Typically, appliances are required in only a portion of dental arch and only for short
time.
Objectives of adjunctive treatment:
· Facilitate restorative treatment (conservative, prosthetic and implants).
· Improve periodontal health.
· Establish favorable crown to root ratio and position of teeth so that
occlusal forces are transmitted along the long axis of the teeth.
·
Procedures for adjunctive treatment:
1. Uprighting of posterior teeth. 2. Alignment of anterior teeth.
3. Forced eruption. 4. Crossbite correction.

1. Uprighting of posterior teeth

Loss of first permanent molar is a frequent problem in adults. The adjacent teeth usually
tip, drift and rotate. Also, the adjacent gingival tissue becomes distorted and impossible
for patient to clean (Fig. 1).

Fig. 1
- The benefits of molar uprighting are to:
* Improve the periodontal health,
* Facilitate or may eliminate the need for restorative procedure (bridge or
implant).

- Uprighting a tipped molar by distal crown movement leads to increased pontic space
and facilitate the path of bridge insertion (Fig.2).
60
 Fig. 2

- Uprighting the molar by mesial root movement reduces pontic space and eliminates
the need for prosthesis (Fig.3).

Fig. 3

2. Alignment of anterior teeth

Rotation, crowding, spacing, tipped teeth and cross bites all pose problems for
restorative and periodontal problems.
A. Alignment of crowded, rotated and displaced teeth:
- Anterior teeth that require alignment should be brought into their proper position
before definitive restoration procedures.
- Moving teeth lingually and correction rotation of anterior teeth requires
additional space within the arch.
- Arch expansion, interproximal reduction and extraction are the methods for
gaining additional space for alignment of teeth.
- Careful space analysis is required by experienced orthodontist.

B. Gaining space for single tooth implant:

- Single tooth implant now provides a preferred method of restoration for many

61
 patients with missing teeth, either congenitally absent or lost due to trauma.
- For placement of an implant, there must be adequate room not only between
the crowns of adjacent teeth, but also between the roots.
- A fixed appliance is required to obtain the necessary space at the crest of the
ridge and between the roots of the adjacent teeth. Thus, the surgeon is able to
place the implant without damaging the roots or apical tissues.

C. Anterior diastema closure and space redistribution:

- Closure of anterior spacing is usually relatively simple orthodontic procedure,
but often requires permanent retention with:
* Bonded lingual retainer.
* Fused crowns, or
* Fixed prosthesis.
- For best esthetics, partial closure of maxillary incisor spacing and redistribution
of the space of central diastema, followed by composite build-up often is the
treatment of choice.

3. Forced eruption
- Defects of the tooth structure near the alveolar bone, such as subgingival
tooth fracture, cervical caries, endodontic perforation and internal root
resorption are difficult to restore.
- The frequent treatment procedures are:
* Extraction of the fractured tooth.
* Endodontic treatment followed by periodontal surgery for crown
lengthening and restorative treatment.
* Endodontic treatment, orthodontic extrusion of the root and restorative
treatment.
- Orthodontic forced eruption has the following advantages:
· Prevent extraction of otherwise non- restorative tooth.
· Provide an adequate crown/root ratio.
· Replace the periodontal surgical procedure to lengthen the root
that can lead to unwanted esthetic result (uneven gingival

62
 margins).
- Forced eruption (Fig. 4) as a controlled extrusion procedure is usually limited to
one, two or three maxillary anterior teeth or premolars, with as much as 5 mm of
extrusion possible. It is contraindicated in multirotated, dilacerated and
periodontally compromised teeth.
-

Fig. 4

4. Crossbite correction
- It is indicated if successful restorative or periodontal treatment cannot
be done with one or two teeth in crossbite position (dental crossbite).
- If a group of teeth are involved (skeletal crossbite), limited orthodontic
treatment is contra-indicated.
- Crossbite often causes functional problems such as occlusal
interferences, occlusal trauma and improper occlusal loading.
Anterior cross bites are esthetic problem as well.
- Removable or fixed appliance (Fig. 5) can be used to solve this
problem.

Fig. 5

63
Comprehensive Treatment for Adults
- Adult patients, typically under 35, often in their 20’s who desired but did not receive
orthodontic treatment as youth, seek it as they become financially dependant. The
goal is to improve the quality of life.
- Comprehensive treatment for young adults tends to be difficult and technically
demanding.
- The absence of growth in adults means that growth modification to treat jaw
discrepancies is not possible. The other two treatment possibilities are:
* Tooth movement for camouflage and
* Surgical modification through orthognathic surgery.
- Comprehensive treatment for young adults requires understanding of orthodontic
diagnosis and should be managed only by qualified orthodontist.

Special consideration in orthodontic treatment for adults:

- The response to orthodontic force may be slower in an adult than in a child or
adolescent, but tooth movement occurs in similar way at all ages.
- About 10% of adult patients have comprehensive orthodontic treatment primarily
because of periodontal problems, but periodontal considerations are important for all
adults who undergo orthodontic treatment.
- Due to lack of growth, adult patient whose orthodontic problems are so severe,
orthognatic surgery (surgical realignment of the jaw or repositioning of dentoalveolar
segments) is the only possible treatment. Surgery is not a substitute for orthodontics in
these patients. Instead, it must be considered with orthodontics and other dental
treatment to achieve good overall results.

Combined Surgical and Orthodontic Treatment

- Indicated in moderate and severe jaw discrepancies (skeletal problems).
- Successful management of combined surgical and orthodontic treatment requires
integration of pre- surgical orthodontic, surgical and post- surgical orthodontic phases
of treatment.

Pre- surgical orthodontic phase:

- The objective of pre-surgical treatment is to prepare patient for surgery, through
64
 placing the teeth relative to their own supporting bone without concern for dental
occlusion at that stage. The pre- surgical phase should almost never require more
than 12 months or so.
- The essential steps in pre-surgical orthodontics are to align the arches or segments
and to make them compatible, and to establish the antero-posterior and vertical
position of the incisors. Both are necessary so that the teeth will not interfere with
placing the jaws in the desired position.

Surgical phase:
- At the end of the pre-surgical phase, impression for model surgery and splint are
taken.
- An inter – occlusal wafer splint is made from pre-surgical model surgery casts since
this splint will define the post-surgical result, the orthodontist and surgeon will review
the model surgery together.
- Orthodontic appliance can be used for inter – maxillary fixation.

Post- surgical orthodontics:

- Final detailing of occlusion and retention is established in this phase.

65
 Chapter 7
ORTHODONTIC APPLIANCE DESIGN

I) Definition.

II) Basic Requirements for an Orthodontic Appliance.

III) Classification:
1 Removable appliances:
a) Classification:
· Mechanical removable appliances
· Functional removable appliances
· Passive removable appliances
b) Advantages.
c) Disadvantages.
2 Fixed Appliances:
a) Definition.
b) Components:
· Attachments.
· Archwires.
· Auxiliaries
c) Advantages
d) Disadvantages
3 Fixed removable appliances

IV) Appliance design:

1) Framework.
2) Retention.
□ Adams Crib
□ Jackson Crib
□ Continuous arrow head clasp
□ Clasps for anterior teeth
66
 3) Active components
□ Springs.
□ Elastics.
□ Wedging appliances.
□ Displacement appliances.
□ Bite planes.
◙ Anterior biting surface
◙ Oral screen
√ Definition
√ Uses
√ Construction
◙ Monoblock or Andreasen appliance
□ Definition
□ History
□ Class II division I malocclusion
√ Mode of action
√ Selection of patient
√ Practical treatment
□ Class I division 2 malocclusion
□ Class III malocclusion
◙ Other Functional appliances

V) Principle of design of appliances:

1) Anchorage.
2) Means of retention.
3) Activation mechanism.

67
 ORTHODONTIC APPLIANCE DESIGN

I) Definition:
Orthodontic appliances have been defined as appliances by means of which mild
pressure may applied to a tooth or group of teeth and their supporting tissues in a
predetermined direction to bring about the necessary reaction processes within the
bone which will allow tooth movement.

II) Basic Requirements for an orthodontic appliance:

1 Must not interfere with normal development of function.
2 Must be simple, comfortable, strong, and easy to keep clean.
3 Must have good retention.
4 The appliance should exert slight pressure that is completely under the operative
control.
5 It should offer sufficient anchorage.
6 Must not cause any damage to the teeth, bone, or produce undesirable tooth
movement i.e. movement of teeth already correctly aligned.
7 Must not be damaged by the oral secretion.

When designing an orthodontic appliance, all the basic requirements must be taken into
consideration.

The choice as to whether to use fixed or a removable appliance must depend on the
following requirements:

a) Cooperation and intelligence of patient and parents.

b) Type of tooth movement required.
c) Individual preference of the operator.
d) The amount of adequate supervision possible.
e) The general condition of the mouth and teeth.

68
III) Classification:
Orthodontic appliance can be divided into three main groups:
1. Removable appliances.
2. Fixed appliances.
3. Fixed removable appliances.

1- Removable Appliances:
These can be taken out of the mouth and cleaned by the patient, may be classified into:
a) Mechanical removable appliances:
These contain springs, elastics, screw …etc, as the active force.
b) Functional removable appliances:
Which harness natural muscular forces and transmit them to the teeth and
alveolar bone in a predetermined direction, e.g. oral screen and Andreasen
appliance (monoblock).
c) Passive removable appliances:
E.g. space maintainers, tongue guards, retention appliances and passive
monoblock.

Advantages:
1 May be removed by the patient if anything wrong happens to the appliance or the
patient.
2 Easy to clean and to attain good oral hygiene.
3 Low cost, may be made entirely by the technician and so economize chair side time.
4 Special equipment is not necessary.
5 They are easily replaced when lost or broken.
6 They are advantage in simple orthodontic cases as movement of single tooth.

Disadvantages:
1 Cooperation and intelligence of patient and parents is necessary.
2 Tooth movement is limited to tilting.

69
2- Fixed Appliances:
Definition:
A fixed appliance is an orthodontic device where attachments are fixed to the teeth and
forces applied by arch wires or auxiliaries through these attachments. This allows
precise control over the nature and direction of the force applied.
Fixed appliances are powerful and complex mechanism and their unskilled use may
lead to extensive and rapid unwanted tooth movements. The dental practitioner without
special training should not attempt to use fixed appliances. However he or she may
need to refer patient requiring fixed appliance treatment to an orthodontic specialist.
Thus he or she should have some knowledge of their scope and action.

Components of fixed appliances:

a) Attachments:
The attachment (brackets, tube etc.) is peculiar to each fixed appliance technique.
Their function is to allow a controlled force to be applied to the tooth.
Traditionally, stainless steel attachments are welded to preformed or custom- made
stainless steel bands, which are cemented to the teeth. With the development of
new adhesives, plastic metal brackets may be bonded directly to the enamels.
These are less conspicuous than bands but they may become detached more
readily and so they are used mainly on anterior teeth for aesthetic reasons.
b) Archwires:
Archwires depending on the technique round or rectangular archwires may be used
and are fixed to the brackets by soft wire ligatures, plastic rings or pins. The
archwire may be active or passive. Active archwires often have loops bent into them
to increase their flexibility at sites of irregularity or where spaces have to be opened
or closed.
c) Auxiliaries:
Auxiliary springs or elastics may apply forces to the teeth. Elastics are used for
transmitting forces between the arches (intermaxillary traction) as well as within the
one arch (intramaxillary traction).

70
Advantages:
1 Fixation is more secure and force may be applied with a high degree of gentleness
and precision (accuracy).
2 Cooperation of the child is assured, as he cannot remove it
3 All types of tooth movement can be accomplished i.e., bodily, tilting, rotation, etc.
4 There is relatively little bulk with little interference with normal function.
5 In experience hands, suitable fixed appliances can produce excellent results very
quickly.

Disadvantages:
1 Because the patient cannot remove the appliance, the incorrect adjustment may be
followed by marked tissue damage.
2 Increased caries index, as oral hygiene is difficult.
3 High cost, due to increased clinical time (chair-side time).

3- Removable – Fixed Appliances:

These can partly be removed by the patient but have molar bands which are cemented
on the teeth.

IV) Appliance Design:

1- Framework.
2- Retention.
3- Active components.

1- The Framework:
- It consists of a base plate in the removable appliance, and the labial and/or
lingual arch wires in the fixed appliances.
- It is a passive part of the appliance used to attach the retention means and
active components as well as to help the anchorage.

2- Retention:
Consists of clasps, cribs, or acrylic covering the teeth in removable appliance, and
bands cemented on teeth in fixed appliance.

71
 a) Adam's crib or universal clasp: It is the most commonly used and is most
efficient, depend on engagement of the mesiobuccal and the distobuccal
undercut by the loops which are placed into the crevice between the crown of the
tooth and interdental papillae. The crib is suited for buccal teeth (posterior teeth),
but less efficient on anterior teeth. Some modifications of the crib make it
suitable to do another factors, hooks or buccal tubes soldered to its bridge or
one loop modified to act as hook for elastic traction. It is constructed in St. St.
wire of 0.7 mm for posterior teeth and of 0.6 mm for premolars and deciduous
teeth.
b) Jackson crib: Less efficient than Adam's crib, the tooth should be completely
erupted for engagement of their height of contour by the crib.
c) The continuous Arrowhead or Toschler clasp: used on a group of teeth, less
efficient and prone to distortion. It is difficult to engage as the arrowhead must
pass horizontally into the interdental spaces and compress the papillae.
d) Clasps for Anterior Teeth: Has little stability, but can assist when most of the
retention is provided elsewhere. Simple labial bow of 0.7 mm wire can assist in
stabilizing the appliance. Adam's can be adapted and used on anterior teeth
when necessary.

3- The active component with the Activation Mechanism:

a) Spring: Depends on the elastic return of a spring wire towards its unpreformed
state.
b) Elastics: Depend on the elastic return of rubber to its unstretched state.
c) Wedging appliances: Using expansion screw.
d) Displacement appliances: Depend on the occlusal forces, addition of quick curing
acrylic.
e) Bite planes: Which depend upon occlusal forces and appliance, which harness the
activity of the orofacial muscle, i.e. the functional appliances.

72
a) Springs:
Designed to exert gentle pressure over a greater range. It is constructed of fine gauge
wire, generally 0.4-0.5 mm. St. St. wire for protected type and 0.7 mm. St. wire for the
unprotected type.

The range of action increase by:

1- Increase its length, either by the addition of other limb or coil.
2- Decrease the cross section of the wire.
The free arm should lie near the soft tissue than the acrylic to facilitate adjustment.
The force is applied at right angle to the long axis of the tooth.

b) Elastics:
The range of action is not readily controlled as the spring. Elastic used between
stabilized upper and lower appliance as intermaxillary traction, either to produce
change in arch relationship or to reinforce anchorage while the anterior teeth are
retracted.

c) Wedging appliances:
The term described appliances which are changing their shape and size from time to
time and when inserted produce or exert pressure on tooth or group of teeth, to move
them in a desired direction e.g. expansion screw.

d) Displacement appliances:
Those appliances which are modified so that occlusal forces are necessary to bite them
into position, and in so doing induce a particular tooth movement e.g. moving incisor
labially by addition of quick curing acrylic to the plate in position which presses on the
palatal surface of the incisor. Rubber hung or threaded rod can be inserted to the plate
and extended from time to time. The appliance although so simple tends to be
uncomfortable and rather traumatic.

e) Bite planes:
Bite planes are appliances which harness the activity of the orofacial muscle i.e.
functional appliances.

73
e.g.
a) Anterior biting surface.
b) Oral screen.
c) Monoblock or Andreasen appliance.

a. Anterior biting surface:

The anterior part of the appliance may be thickened for four reasons:-
1. Stage of treatment of deep over bite: By allowing the unopposed posterior
teeth to over erupt.
2. Gagging the bite: Temporary during particular tooth movement e.g. lingual
occlusion of upper incisors. Occasionally acrylic is carried over occlusal
surfaces of posterior teeth (it is called here posterior bite plane).
3. Anchorage reinforcement: The plane is inclined in order that there may be a
slight bite distal "kick" to the upper appliance, whenever the lower incisors
strike this will reinforce anchorage in the upper arch to some extent.
4. Retention appliance: In conjunction with low labial bow to retain incisors
relationships e.g. class II Angle's after treatment.

b. Oral Screen:

Definition: Thin plate of acrylic placed inside the lips and outside the teeth.
Oral screens are either:
1- Passive.
2- Active.
Uses:
1. Retraction of proclined upper incisor (Active)
2. Improvement of lip position and function (passive)
3. Habit abolishing (e.g. Mouth breathing, finger sucking)
4. Retention appliance after retraction of incisor. In the active oral screen,
for retruding of protruded incisor no contact between the palatal
surface of upper incisors and the labial or incisal edge of lower incisors
to avoid traumatization of periodontal membrane from both direction.

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Construction:
1- Upper and lower models correctly oriented.
2- Sheet of base plate wax applied to the labial and buccal aspect of the teeth and
extended well to the mesial aspect of first permanent molar and about 2 mm. away
from the buccal and labial fold.
3-The muscle attachment should be relieved. This sheet acts as a relief for the labial
and buccal surface of teeth and the canine eminence.
4- A duplicating sheet of wax over the first one after application of separating medium.
5- In active oral screen exposure of the proclined central incisors on the first sheet of
wax are made. So the second layer touches only the proclined incisors and is
relieved from other teeth. Successive activation is made by adding quick curing
acrylic on the indentation of the proclined incisors. The second sheet of wax flasked
and replaced in clear transparent acrylic. Patient wears the oral screen at night only
and one hour before bedtime.

c. Monoblock or Andreasen appliance:

Definition:
It is a combined upper and lower plate used as a loose interdental splint. It consists
of a plate with flanges covering most of the hard palate, the lingual aspects of the
maxillary and mandibular teeth and alveolar process.
History:
Viggo Andreasen evolved it in the period immediately following the First World War.
It was adapted from another appliance called the monoblock, designed by Robin
just before the first war. However, Robin's monoblock was intended as a retention
appliance whereas Andreasen appliances were intended for active treatment.
Andreasen himself used the appliance to treat all types of malocclusion including
many for which it was quite unsuitable and it therefore fell into disrepute in some
circles. Its use is much better confined to a few carefully selected cases.

Class II Division 1 Malocclusion:

Mode of Action:
In treating class II division 1 malocclusion, the appliance consists from upper and
lower acrylic splints fused together into a single block. A labial bow is fitted on
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the labial side of the upper incisors. The appliance is so constructed that when
worn the lower jaw has to be protruded in order that the teeth will fit into the
splint. With the mandible in this protruded position, the muscles of mastication
are stretched and tend to return to their resting length taking the mandible back
with them. Retrusion of the mandible is prevented by the acrylic of the appliance.
The acrylic appliance relation to the upper teeth is producing a posterior force on
these teeth and thus tending to move the buccal teeth distally and the anterior
teeth (from pressure transmits the pressure from the retruding mandible by the
labial bow) lingually. At the same time the reciprocal force from the appliance on
the lower incisors is undesirable, it is usual to carry the acrylic over the tips of
these incisors so that they may not be tilted labially and this increases the
anchorage provided by the lower arch. Early workers with the appliance claimed
that it caused the mandible to be repositioned in a more anterior position, either
by increasing the growth of the lower jaw or by repositioning the temporo
mandibular joint further anteriorly. That is, they claimed that the appliance
changed the skeletal pattern. They have been several investigations using lateral
skull radiographs to attempt to prove or disprove this belief and the findings are
conflicting. From a careful study of these investigations, it would seem that there
is no evidence that the skeletal pattern can be changed to any clinically worth
while extend. For practical purposes, it can safely be assumed that the appliance
works, like all orthodontic appliances, by moving the teeth through the alveolar
bone and not by changing the skeletal pattern.
It has been suggested earlier that the appliance consists essentially from upper
and lower acrylic splints joined together. The teeth fit into immersions in the
acrylic precisely and accurately. This would tend to prevent their moving since
they could only move along a very narrow path, and with bodily movement, the
splint preventing any tilting movement. The appliance is therefore trimmed away
leaving only a spur of acrylic on the mesial side of each posterior tooth in the
upper jaw and on the distal side in the lower jaw, allowing teeth to take the line of
least resistance. Where it is desired to reduce the overbite, the acrylic is trimmed
away between the occlusal surface of the posterior teeth so that they may erupt.
The important feature of trimming away the acrylic is to trim generously so that
the teeth are quite free to move.
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The Andreasen Appliance

77
Two views of monoblock to show trimming and buffer points of the plate

Selection of patient:

Andreasen appliance works best in the following patients:

1. In cooperative patient, while it is not indicated when patient and parental

cooperation and understanding are low.

2. In actively growing individuals.

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3. In class II division 1 which is characterized by:

· No element of crowding the teeth.

· Minor to moderate antero–posterior skeletal discrepancy with proclination
of the upper incisors.
· Deep overbite, while not indicated in cases of excessive lower face height
or open bite tendency.
· Retroclined lower incisors and little spacing in the lower arch may be an
advantage.

Practical treatment:

1. Impressions of the upper and lower dental arches are taken in an alginate
impression material, care being taken that the lingual flanges in the lower
impression are fully extended.

2. The bite is then taken using a wafer of pink wax, which is rather thicker than
that normally used when taken the bite for study impression. We should look
at the bite in three deferent planes:
Antro–posteriorly:
In the normal case the main forward movement of the mandible average
about 10 mm. The optimal movement of the mandible for the
construction bite is usually half of the individual maximum range
because of the following reasons:
a) If the bite is more it will be uncomfortable for the patient he is less
likely to keep the appliance in his mouth.
b) The distance of 5 mm. is approximately the same as that
between the point of the buccal cusps of the first molar. This is
the amount of distance necessary to change a class II
malocclusion into class I occlusion.
c) It was found that the best position for obtaining the desired
biologic transformation of the T.M.J. from class II to class I
occlusion is approximately half the distance that the condyle can
move forward along the anterior wall of the fossa to the articular
tubercle.
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 Vertically:
The opening of the construction bite by 2 mm. in excess of individual's
postural resting position is optimal. The normal free way space is 2- 3
mm. in molar area and 4-5 mm. in incisors area i.e. an opening of
construction bite should be 4-5 mm. in the molar area and 6-7 mm. in
incisors area.

Transversely:
Care should be taken that the centerlines remain coincident during bite
construction. Models are cast from the impressions and are amounted
on a straight – line articulator using the squash bite. It is customary to
mount the models with the articulator at the front of the models that is
back to front .The appliance is constructed in wax with a 0.8 mm. labial
bow and is then processed in acrylic. It is not practicable to have the
two halves of the appliance in opposite halves of the flask, since if this is
done.
It is very likely that the bite will be opened during processing. In other
words both halves of the appliance should be in the same half of the
flask, packing of the acrylic being from the posterior side.

3. After processing the appliance is trimmed, polished and tried in the patient
mouth for fine adjustment.

4. This appliance is worn principally during the night and for at least an hour
before bed time. Patients should be warned that frequently it will come out
during the night at first but they should get use to it .

5. The patient is seen at about six weekly intervals and at each visit the
occlusion should be checked for improvement. The Andreasen appliance
does not works by any miraculous jumping of the bite and there should be a
progressive improvement in the occlusion of the posterior teeth. If the
treatment is not progressing after six months this appliance should be
discarded and another form of treatment considered. When the occlusion is
normal, the appliance may be worn for a period as a retainer, and some

80
 operators at this time reduce wear to three nights per week for perhaps two
or three months before the appliance is finally discarded.

Class II Division 2 Malocclusion:

The Andreasen appliance may also be used in the treatment class II Division 2
malocclusion. The traditional technique 1/1 involves proclining so as to convert
the case into a class II Division I malocclusion. However, this does not always
work well and it is probably protruded better to leave the incisors alone and to
take the bite with the mandible the small amount possible and also with the
mandible displaced downwards. Two or three subsequent appliances are often
necessary in this case. As with class II Division I malocclusion it is only
indicated where the dental bases are long and crowding absent. Since such a
condition is very rare in class II Division 2 the appliance itself is rarely applicable
in this type of malocclusion.

Class III Malocclusion:

The Andreasen appliance may be used in class IIII malocclusion and in this case
the mandible would be retruded when the bite is taken so that the incisors are
brought into an edge to edge relationship. The labial bow would be fitted in the
lower arch instead of the upper. This form of the appliance has not been very
satisfactory and is seldom if ever used nowadays.

d. Other Functional Appliances:

A number of other appliances have been derived from the Andreasen appliance
using the same principles of harnessing the patient's own muscles to provide a form
of intermaxillary traction. Indeed the oral screen has been used as a functional
appliance by constructing it with the model mounted in a protruded bite but the
results have been not sufficiently encouraging to warrant further development of this
appliance.
The Frankel Appliance:
Dr.Frankel in East Germany designed this unlike the three preceding
appliances, which are products of West Germany. It is again constructed of
wires and acrylic and is exceptionally difficult to construct. There are three
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 types of functional regulators known as F.R.I., F.R.II and F.R. III. They are
designed for treatment respectively of class II division 1 malocclusion, class II
division 2 malocclusion, and class Ш malocclusion. The first two involve the
taking of the protruded bite and the third of a retruded bite and they incorporate
rather heavy springs to produce minor tooth movements. There is a screen or
"bumper" in front of the labial segment in the lower jaw in the case of F.R.I and
F.R.II to encourage proclination of the lower incisor teeth, and similarly there is
a screen on the buccal side of the posterior teeth to encourage arch
expansion. It is claimed with this and with many functional appliances that arch
expansion is produced although there is little permanent evidence of the world.

Frankel Appliance

v) Principle of Design of Appliance:

In designing appliance the following should be considered :

1- Anchorage.
2- Means of retention.
3- The activation mechanism.

1- Anchorage:
Anchorage consists in the selection of adequate and properly distributed resistance
units for the control and direction of force. In orthodontics the applied forces excerted
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by the appliance on the teeth that are in malocclusion, in tur must be strong enough to
withstand the applied force.
There are two sources of anchorage:

1) Intraoral anchorage utilizes teeth, alveolar bone, basal bone and musculature
surrounding them.

2) Extraoral anchorage utilizes the head and neck.

The resistance of a tooth to a given force is proportional to the following factors:

a) The surface area of the alveolar bone to which it transmits the force
(i.e. to the surface area of its roots).
b) The direction of forces relative to the axes of the roots. e.g., the molars
to a force exerted upon them in a distal direction offer greater
resistance . This is due to:
· The fact that the general direction of growth is outward. occlusally
and forward.
· To the distal inclination of the roots.
c) Greater resistance is offered to a force, which is disposed equally over
the whole length of the root of a tooth (i.e., a force which causes bodily
movement of the tooth), than one which permits the tooth to tilt.

Intraoral anchorage may be either:

a) Intrarmaxillary i.e., within the same jaw.
b) Intermaxillary i.e., between the two jaws.

Each one of them could be divided into the following types:

1- Reciprocal Anchorage:
The anchorage is said to be reciprocal in those cases when it is designed that two
groups of teeth shall move to an equal extent in opposite direction. It is necessary
that each group should offer equal resistance otherwise the movement will be
unequal.

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2) Simple Anchorage:
Simple anchorage is obtained by engaging, with the appliances. A greater number
of teeth than are to be moved with the same dental arch. The ratio of surface area
of the roots of the anchor teeth to that of the teeth to be moved is sufficiently high to
ensure adequate stability of the anchorage, bearing in mind the direction of force.
The ratio of surface area of the roots should usually be at least two to one. Simple
anchorage is either:
Single simple anchorage
Mean a tooth with a larger surface root area (e.g. first molar) is used to move
another tooth with a smaller surface root area in the same dental arch (e.g. first
premolar).
The use first permanent molar in either side of arch as an anchorage with molar
bands cemented on them with round tubes soldered on buccal surface and a round
archwire fitted into the tubes is another example of simple anchorage.
No other teeth are employed to overcome the force nor is the appliance so
constructed as mechanically to aid the anchor tooth. There is reasonably freedom of
movement of the arch wire in the tube and the anchorage resistance comes
therefore entirely from the support and the strength of the tooth or teeth used as the
point of anchorage.
If the resistance offered by the anchor tooth or teeth is insufficient, it may become
necessary to reinforce the simple anchorage by the inclusion of one or more teeth in
as reinforced or compound simple intramaxillary anchorage.
With the use of simple anchorage, there is danger of tipping or moving the anchor
tooth if too much force is brought to bear upon the anchor tooth.

3) Stationary Anchorage:
In stationary anchorage the appliance is so attached to the anchor tooth that this
tipping movement of simple anchorage is possible. All parts of the appliance must
be so constructed as to increase the natural resistance forces of the teeth selected
for anchorage. When it becomes necessary to obtain added strength from the
mechanical design and construction of the appliance so that there will be
combination of resistance of tooth and of mechanical principles the result is
stationary anchorage.
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 This is a rigid form of anchorage. There is no freedom of movement. A rectangular
wire entering a rectangular tube illustrated the principles.

In order to have stationary anchorage there are two things that must be secured:
1- Rigidity.
2- Stability of the appliance.
As with simple anchorage, stationary anchorage may need to be reinforced by the
addition of one or more teeth.

4) Reinforced Anchorage:
It happens frequently that the stability of simple anchorage is insufficient to
withstand the reaction of the movable part. This is particularly shown when the
upper molars are to be moved distally.
The anchorage may then be augmented or stabilized in one of several ways:
a Extraoral anchorage (cervical or occipital).
b Intermaxillary traction.
c An anterior incline plane. The lower incisors tend to bite the plate distally. Also
extending bite plane over the incisal edges, this is called saved type plate.
d A labial bow + thickening of the plate anteriorly. This has the effect of splinting
the incisors.
e The anchorage may be reinforced in the case of fixed appliance by designing the
appliance so that only bodily movement (i.e., movement of the crown and root to
an equal extent) of the anchor teeth can occur, and tilting is prevented. (e.g.,
edgewise arch, a rectangular wire entering a rectangular tube soldered on bands
attached to adjacent teeth).

INTERMAXILLARY ANCHORAGE
Has been defined as that form in which the resistance necessary to overcome
the malposed tooth or teeth is derived from a tooth or teeth in the opposing arch.
Intermaxillary anchorage may be simple, stationary and is frequently reciprocal.
The use of intermaxillary elastic stretched between a hook on the maxillary labial
arch and a hook on the mandibular first molar is as much a form of force as a
form of anchorage. The teeth and appliance are the resistance unit.
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a) Simple Intermaxillary Anchorage:
Is that form in which the force necessary to move a malposed tooth or teeth in one
arch is derived from a tooth or teeth in the opposite arch.
b) Stationary Intermaxillary Anchorage:
Is that form in which the attachment is made to the anchor teeth in one arch in such
a manner that if they move at all they must dragged bodily through the process.
The anchor teeth and the moving teeth of course, being in different arches, this form
of anchorage is obtained by constructing and applying the appliances in such a
manner as to make use of additional mechanical support.
c) Reciprocal Intermaxillary Anchorage:
Is that form in which the force necessary to move malposed tooth or teeth in one
arch is derived from a malposed tooth or teeth in the opposite arch,
counterbalancing in such a manner as to cause both to assume a proper position on
the line of occlusion.
Extra oral Anchorage:
This has the advantage of affecting the tooth or teeth to be moved and leaving
others, which are in satisfactory position free for normal growth adjustments.
Extra oral anchorage is either:
a Cervical.
b Occipital.
c Facial.
This form of anchorage is made effecting by the use of elastics, though it had for its
basic support cervical resistance or head caps.
However, there is also intraoral base of attachment for molar teeth are banded and
a labial arch is inserted in tubes attached to the cemented bands in conjunction with
the face bow and the cervical strap or head cap and elastics.

86
 Intermaxillary anchorage

Intramaxillary anchorage

87
 Reciprocal anchorage

Extra-oral head gear

High Pull Cervical Pull Straight Pull

88
 Chapter 8
Extraction in Orthodontics

“To extract or not to extract???” sounds like Shakespeare’s quotation from Hamlet
“To be or not to be!!!” and that is the question.

It has been the key question in planning orthodontic treatment for more than 100 years.

Why we do extraction in orthodontic treatment?

There are 2 main reasons to extract:

- To provide space for correction of severe crowding.
- To allow teeth to be moved:
*Canine to be retracted.
**Incisors to be corrected.

So protrusion could be reduced, crowding could be relieved and skeletal class II and III
could be camouflaged.

Alternatives to extraction?
- Arch expansion to correct crowded teeth
- Growth modification: e.g. functional appliances to advance the mandible
in mandibular deficiency cases (class II)
- Ortognathic surgery for skeletal cases

All things being equal, it is better not to extract. In some cases extraction provides the
best treatment.

The great extraction controversy:

Around 1900, Edward Angle (father of modern orthodontics) struggled for both
facial esthetics and stability though idealized normal occlusion. He believed that proper
function of dentition would be the key to maintaining teeth to their correct position. He
stated that:”when teeth could have been saved by dental treatment, extraction for
orthodontic purposes seemed inappropriate”.

89
 It became a law for Angle and his followers that every person had the potential for
an ideal relationship of all 32 natural teeth, and therefore extraction for orthodontic
purposes was never needed. Angle presented to clinical orthodontics the edgewise
appliance, the first appliance capable of fully controlling root position and he claimed
that “merely tipping the teeth to a new position might be inadequate and bodily
movement of teeth is necessary for stability.”

In summary, according to Angle: proper orthodontic treatment for every patient

involved expansion of dental arches and rubber bands as needed to bring teeth into
occlusion and extraction was contraindicated.

On the other hand, Calvin Case told that though arches could be expanded and teeth
could have been corrected neither esthetics, nor stability would be satisfactory in the
long term. Angle followers won that game and extraction of teeth for orthodontic
treatment disappeared from the American Orthodontic Society between World War I
and II.

After Angle’s death by 1930, relapse after non-extraction treatment was

markedly observed. One of Angle’s students (Charles Tweed) decided to re-
teat by extraction plans. The four first premolars were removed and teeth were
aligned and retracted. Tweed observed that occlusion was more stable.

The trend for extraction increased by that time. By the end of 1960, more than
50%of American patients had extracted some teeth for their orthodontic
treatment.

After that time, there was a continuing decline in extraction rate.

Experience has shown that premolar extraction did not guarantee stability of
teeth correction. Besides, orthodontists realized that general public often
preferred fuller and prominent lips. The change from fully banded to largely

90
bonded appliance made it easier to expand arches, also recent claims were
made that temproromandibular dysfunction (TMD) problems could be attributed
to extraction of the first premolars.

Summary of extraction guidelines:

1) Less than 4 mm. arch length

No extraction

2) 5-10 mm.
Possible extraction
Possible non – extraction

3) More than 10 mm.

Extraction

Therapeutic Extraction

It is the extraction of permanent teeth for orthodontic treatment purposes.

Indications:
1- Severe crowding.
2- Protrusion in one or both arches.
3- Camouflaging for skeletal cases.
4- Balancing extraction.

A previously extracted tooth from one side of a dental arch may cause a
loss of symmetry in dental mid-line due to disturbance in the anterior
component of force. So extraction from the other side may be indicated to
adjust the occlusion and the mid-line symmetry.
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Anterior component of force:

Teeth in the upper and lower dental arch articulate together during function to
produce occlusion. Being tilted and not vertically oriented, the posterior teeth will
elaborate tilted forces that will be analyzed to vertical and horizontal forces. Vertical
forces will fade each other. On the other side, horizontal forces will aggregate and form
anterior component of force pressure caused by eruption and growth will of course
influence the anterior component of force. If a tooth is extracted from only one side of
the dental arch, the forward movement of the tooth mesial to the space is impaired, and
therefore, pressure from that side is deficient. Pressure from the other is normal. The
inequality of pressure may cause incisors to be deviated towards the side from which
the tooth was removed, especially when the tooth is the lost at an early age.

Another example:

Unerupted right maxillary canine for example may cause the entire left maxillary
segment to go to the right side and you can see the space for the unerupted canine is
totally lost and a dental contact between the upper right lateral incisor with the upper
right first premolar is established.

The solution:

The solution may be the extraction of a tooth; most probably a premolar from the

left side to rebalance the dentition and adjust the mid-line, canine inclination will
be a factor in planning for other extractions.

5- Supernumerary teeth.
6- Teeth unfavorable for orthodontic treatment.
7- Teeth with abnormal shape and size.
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 Choice of teeth for extraction

- Orthodontic treatment may include the extraction of any tooth in the arch,

but in general, all the anterior teeth should not extracted

whenever possible.
- Pathological conditions and defects in the teeth structure may determine
the choice.
- Choice of teeth to be extracted usually lies between the premolars and
molars.
- The possible extraction of a permanent incisor or canine tooth for
orthodontic treatment is to be avoided unless there is severe displacement
of the root apex.

An overview for permanent teeth extraction

1-Third molar:

- Should be removed if impacted or severely displaced.

- Should be removed after treatment of severely crowded cases to minimize
relapse tendency.
- Impacted third molars are not a direct cause for anterior teeth crowding,
but they may be a result of tooth size and arch length discrepancy.
- Generally, it is advised to extract third molars after treatment of cases with
sever crowding to minimize relapse tendency which may be aggravated by
back pressures from third molars.

93
2- Second molars:

- Sometimes they are extracted to give space for the first molar
distalization, provided that 3rd molars are normally developed and
erupting.

3-First permanent molars:

- Considered an important key of good occlusion.

- Should not be extracted whenever possible.
- Being the 1st permanent tooth to erupt, it is susceptible to caries and early
loss.
- Hypoplasia and pathological disorders are not uncommon as well.
- Extraction of 1st permanent molars should be delayed until 1st premolars
are erupted sufficiently to maintain the vertical dimension.

4- Premolars:

- They are the teeth most commonly extracted for orthodontic treatment.
Because:

-They are close to crowded sites.

- They are two in number in each mouth quadrant.

- They are not front teeth (esthetics).

- They are not masticatory molars (function).

Choice of 1st or 2nd premolar for extraction may be affected

by:

- Degree of crowding.
- Degree of protrusion.
- Form, shape, pathology and defects of the tooth.
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N.B
Before extracting a 1st premolar it is very important to establish the presence and
normal development of 2nd premolar by X-ray.

If a decision to extract 1stpremolar is taken, it is advisable to do it before eruption of

canines to assure better eruption of the canine in the extraction space to minimize
treatment time.

5- Canines:

-As a general rule, extraction of canines for orthodontic purposes is avoided.

- When the canine apex as well as the crown is displaced, so that the tooth is
completely out of the symmetrical arch, it is indicated to extract the canine.
- Canine is the key stone of a dental arch.

6- Incisors:

A-Upper incisors:
- Unless severely periodontally affected, any of the upper incisors should
not be extracted.
- A cross-bited lateral incisor may be removed provided that its space is
totally closed and the midline symmetry is preserved, the adjacent canine
may be rounded and reshaped to simulate the lateral incisor.

B- LOWER incisors:
- As a general rule, the removal of a lower incisor from a crowded arch is
to be avoided because it leads to lower arch collapse and narrowing of
inter-canine measurement.
- If a lower incisor is totally labially or lingually excluded from the dental
arch, its extraction could save extraction of two lower premolars.
- Severely peridontally affected lower incisors should be extracted.

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 Chapter 9
ORTHODONTIC RETENTION AND RELAPSE

Orthodontic retention:

1) The period of retention

· No retention.
· Standard retention.
· Prolonged retention.
· Permanent retention.

2) The means of retention

· Mechanical retention.
· Retention by achieving balanced occlusion.
· Retention by carrying the teeth into soft tissue and muscular balance.

Orthodontic relapse:

1) Problem of relapse.

2) Causes of relapse.

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 ORTHODONTIC RELAPSE
Definition:
It is the fall back into the former state of malocclusion, or the loss of correction achieved
by orthodontic treatment after the removal of the retaining device.
Problems of relapse:
1) Increase of reduced overbite and overjet.
2) Re- opening of closed spaces.
3) Re- crowding of de- crowded teeth.
4) Re- collapse of expanded arches.
5) Re- rotation of de-rotated teeth.

Causes of relapse:
1) Periodontal ligament:
The principal fibers undergo re-organization while the gingival fibers distort with
force application then undergo recoiling, causing relapse of de-rotated teeth
after removal of retainers.

2) Persistence of the cause:

Persistence of the habit of mouth breathing, tongue thrusting or thumb
sucking will cause relapse after oral correction and therefore the offending
habit should be broken first.

3) Failure to carry teeth into balanced occlusion and soft tissue balance.

4) Undesirable type of growth:

For example, horizontal type of growth accompanying skeletal class III and
vertical type of growth accompanying skeletal class II division 1 cases.

5) Change in arch form, particularly increasing the inter-canine width by

expansion.

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 6) Failure to adapt the muscles to the new rest position in corrected deep bite
cases
7) Failure to retain the teeth until end of bone remodeling.

ORTHODONTIC RETENTION

Definition:

It is a passive phase of orthodontic treatment.

It is the procedure of maintaining the improved relationship of the teeth
achieved by orthodontic treatment, until the periodontal ligament and the
supporting bone have remodeled both in function and structure to meet the new
demand.

[I] the period of retention:

A- No retention:
1) Some serial extraction cases.
2) Cross bite cases:
· anterior cross bite with adequate bite.
· posterior cross bite with adequate cusp height and good bucco
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 lingual axial inclination.

B- Standard period of retention:

When teeth are carried into positions of balanced occlusion and soft tissue, for
example:
1) Class I non- extraction cases with increased overjet where the upper
anterior teeth are retroclined until controlled by the lower lip.
2) Class I and II extraction cases, finished with good occlusion.

C- Prolonged period of retention:

This is needed in cases of rotations, which tend to relapse by the elastic supra-
gingival fibers. The retention can be shortened by:
· Pericision.( surgical cutting of supra gingival fibers)
· Over correction.

D- Permanent retention:
1) Some cases of skeletal dysplasia treated in the young age, where
retention should continue until growth ceases, as in class III mandibular
excess and late teen crowding, which are retained until the mid-
twenties.
2) Other cases need permanent retention as generalized diastemas with
enlarged tongue.

[II] The means of retention:

A- Mechanical retention:
Orthodontic retainers can be classified into:
1) Removable retainers:
* Last removable appliance after its passivation.
* Functional appliance after correction.
* Hawley retainer and its modifications, e.g. with anterior bite plane in
cases of deep bite correction.
2) Fixed intra-oral retainers:
* Last fixed appliance after its passivation.
* Cemented lingual arch between canines or molars.
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 * Bonded lingual arch between canines.
3) Orthopedic retainers:
* Chin cup and high pull headgear until the mid-twenties
* Chin cup and vertical pull head gear for skeletal open bite until the
late teens.
* Face bow with extraoral pull (high, straight or cervical according to
the anterior bite depth) in skeletal class II excess maxilla.
* Functional activator in skeletal class II retrognathic mandible.

B- Retention by achieving balanced occlusion:

1) Adequate anterior bite to retain corrected anterior cross bite.
2) Proper interincisal angle to retain corrected anterior deep bite.
3) Adequate cusp height and normal bucco-Lingual axial inclination to
retain corrected posterior cross bite.
4) Proper anteroposterior intercuspation between upper and lower canines,
premolars and molars to retain corrected dental arch relationships.

C- Retention by carrying the teeth into soft tissue and muscular balance:
1) Retroclination of upper proclined incisors in class I or class II div. 1
cases until controlled by the lower lip.
2) Re- education of the mandible to the new resting position in cases of
corrected deep bite.
3) Lip exercise, to improve tonicity of hypotonic lips to retain retroclination
of proclined maxillary anterior teeth.

RETENTION
Retention indicates the biologic and mechanical preservation of the post
treatment tooth position .Thus orthodontic treatment in reality consists of two phases, an
active tooth moving phase and a retaining phase, in many instances teeth which
have been moved by orthodontic means have a tendency to return (or recover) to their

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original position, a circumstance appropriately termed relapse. For example, most
incisor teeth which were depressed by orthodontic means .erupted again after treatment
and almost 80% of the maxillary incisors which were retracted move forward again after
treatment to a certain extent.

Common relapse problems include:

a) Reappearance of crowding and rotation.

b) Reappearance of spaces after full space closure particularly in extraction

sites.

c) A tendency for the return of Class II molar relationship with consequent over-jet
reappearance after reduction of ClassII div.l malocclusions.

Etiology

1- Undesirable oral habits:

A habit which persists after orthodontic treatment of the teeth can easily
jeopardize the dental stability which quite often ends up into relapse. The most common
abnormal habits which result into relapse after orthodontic treatment include:

a) Thumb sucking.

b) Abnormal swallowing.

c) Abnormal perioral muscular habits, particularly involving the mentalis muscle.

All these habits exert abnormal forces to the teeth which could move them to
undesirable positions. In general .orthodontic treatment might not be started before
the elimination of the habit or treatment might be postponed until there is evidence that t
habit will not persist.

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2- Tooth position:

Tooth position is an important aspect of the retention-relapse problem because

tooth contact can generate forces. For dental stability these forces along with other oral
forces must not produce resultant force vectors in any direction.

In order to obtain stability of dental arches and occlusion, the teeth after
orthodontic treatment should be well aligned, in proximal contact and in correct axial
position. The inter-arch relationship should conform to a Class I pattern, with resultant
maximum intercuspation in centric relation. There should be no overjet and the overbite
relationship indicates that the maxillary incisors should not overlap more than one third
of die lower incisor.

3- Soft tissue :
There are three soft tissue entities that may influence the stability of the tooth in
its new position:

A) The supra-alveolar (gingival group of fibers)

. B) The periodontal ligament

C) The muscles. The exact mechanism by which the first two soft tissue entities may
influence relapse is not clear. The supraalveolar (gingival group of fibers) and the
penodontal ligament are essentially composed of inelastic non contractile tissue, how
does this tissue apply a force that is responsible for relapse? The answer is not well
known.

The muscle is an important factor in retention and relapse. Unless tooth position
is in harmony with its environments stability is in jeopardy. The instability of space
closure associated with a retained tongue thrust is an example regarding the role of the
muscle in retention relapse problem.

4-Bone:

The alveolar bone surrounding a repositioned tooth is a functional tissue which

generally responds to force. There is no evidence to suggest that bone will produce
forces which may reposition teeth. Accordingly alveolar bone is probably not a causative
factor in relapse.

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5-Growth:

Growth can be an important factor in retention -relapse because the active phase
of treatment of many patient is completed while facial growth is still in progress. If a
patient is in the retention phase of treatment during the last stages of facial growth,
some changes in skeleton-dental relationship may occur.

Finishing and retention

Treatment criteria:

Teeth with appliances are considered to be placed as favorably as possible when

one look with satisfaction upon the following:

1- Proper axial inclination with artistic positioning of the incisors.

2- Good buccal intercuspation.

3- Good arch alignment.

4- Good overbite and overjet, accompanied by a good cephalometric interincisal angle.

5- Good root paralleling, especially at extraction sites.

6- Good arch form.

7- Reasonably flat occlusal plane.

8- Corrections of rotations.

9- Continuity of tooth contacts.

10- Unhindered functional movements.

Retention appliances:

After completion of the tooth movement the bone trabeculae are reoriented again
in the direction of the axis of the root of the tooth. This takes about six months to
complete. The bone is found to be more responsive to the influence of pressure where
the occlusion will not hold the tooth in position, therefore, it is necessary that after active
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orthodontic tooth movement, the tooth should be retained in position by means of a
retention appliance to prevent its relapse.

Retention appliances should be made as simple as possible as the young patient

is usually anxious by this time, to abandon orthodontic appliances. As a measure for
retention, muscle exercises may be used either alone or in conjunction with appliance. It
should be abandoned gradually and under supervision by having the patient
progressively reduce, the number of hours it is worn every day.

Retention appliances may be either removable or fixed. Occasionally, it is

possible to use as a retainer the appliance which has actively corrected the
malocclusion by rendering the appliance passive (as in cases of screws) so that it
exerts no further pressure, or by substituting an appliance of simpler design which will
hold the teeth in their correct position. A retaining appliance should be simple .efficient
and should not interfere with the proper cleansing of the teeth and care of the soft tissue
of the mouth by the patient.

Removable retention appliance:

a) Upper retention appliance:

An upper appliance is often used which consists of a plastic base (acrylic) with
molar cribs, a labial arch and a suitably shaped inclined incisor bite plane, if it is
required. It is of particular use after the distal movement of canines .premolars or
molars. It is also useful after the lingual movement of upper incisors. The acrylic base
prevents the lingual movement of teeth and the cribs prevent movement of the molars.

b) Lower retention appliances:

As in the upper, this consists of a plastic base with molar cribs and a short labial
arch. Such a retainer can hold the teeth in the lower arch and prevent the lingual
movement of the lower incisors or migration of the lower molars.

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c) The activator:

It can be used to maintain the relationship of the dental arches in any plane i.e
anteroposteriorly, vertically and transversely. It can also provide strong
intermaxillary anchorage to prevent unfavorable movement of the teeth, relapse of the
skeletal condition, and aids the re-establishment of normal muscle behaviour.

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Retention by fixed appliances:

l) Mechanism used to maintain tooth position:

l- For retention of a tooth which has been moved from torsiversion e.g a lateral incisor
.Two spurs are added to the band on the teeth to engage each of die neighbouring
teeth one labially and the other lingually.

2- For retention of a tooth or a group of teeth moved from labio or linguoversion

attachment band with spurs or bands with connecting bars of wire.

2) Mechanism used to maintain arch form:

Molar bands and a rigid lingual or labial bow are often sufficient. Occasionally
both labial and lingual bows are used together. To maintain lower intercanine width after
extraction treatment is done.

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3) Mechanism to maintain arch relationship:

In case of corrected posterior molar relationship of the lower arch a lingual arch
wire may be used for the support of lower teeth with hooks soldered to the buccal
surface of the lower molar bands. A plain labial arch wire may be used on the upper
teeth .either alone or in combination with a lingual arch wire and hooks soldered to the
labial arch, in this region of the upper canines. Light intermaxillary elastics are then
worn continuously for a varying period (i to 6 months and then at night only for a similar
period.)

In the retention of cases which previously were in prenormal occlusion, an upper

palatal arch wire soldered to molar band that have hooks attached to their buccal
surface is used for the upper arch. A plain labial arch wire is used for the lower arch with
hooks at the canine region. Light elastics are worn as before but the direction is
reversed.

In the mandibular arch satisfaction can generally be found with the conventional
canine to canine fixed lingual arch. Some clinicians prefer to use a second premolar
to second premolar lingual arch in extraction cases to prevent mesial tipping of these
teeth or opening of the extraction sites. In extraction cases, if care is taken to parallel
the roots of the teeth adjacent to the extraction sites this sure would be better. Hygienic
designs are now considered for better periodontal care as these retention forms may
last for indefinite times.

Retention by muscle exercises:

Once the malocclusion has been corrected, it is possible to institute muscle

exercises, by exerting correct forces upon the dental arches, exercises help
maintenance of normal occlusion by training the muscles to a normal behavior.
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The duration of retention:

The period varies greatly in different cases. varying from few weeks to one year
or longer, when we feel that the recently moved teeth or modified arches have been
harmonized in function with all the forces to which they are subjected, the appliance
may be removed and the case should be kept under close observation. In adult
orthodontic cases, retention might be carried on for indefinite time.

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List of References:

- Contemporary Orthodontics, W. Proffit

4th edition 2007.

- Three-dimensional Cephalometry - A Colored Atlas

and Manual, Gwen R.J. Swennen.

- Illustrated orthodontic series, N, H, Elmangoury and

Y, A, Mostafa.

- Orthodontic notes for dental students,

by Orthodontic Department, Cairo University, 2007.

- Orthodontics for undergraduate students,

by orthodontic department Alexandria University, 2007.

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