lecture 1 Indication - Aesthetic -Fxn : Speech , mastication -Prosthesis -Prophylactic Benefits : -Better Apperence -Dental health Riskis -Decalsification

-Dental Caries -Root resorption -Gengival Recession -relapse -Medical history ---------------------Lecture 2 Growth is increase in size while Development is increase in Function

Growth site affected by STIMULUS control while Growth center affected by GENATIC control -Growth Concept * Pattern : Direction:Cephalo-Cuadal Tissue * Variability : Depend on Genatic , Enviroment , Fxn demands , Fxn respond * Timing : Growth spurts so we use "Developmental age . -Types of Growth : * interstential * surface apposition In bone : Intra-membranous :MT will hypertrophy & ,atrix calcified Endochondoral : Undifferential MT will become osteoblast the Matrix Calcified . Deposition done by (Osteoblast ) to maintain the Resorption done by ( Osteoclast) Crynacytosis : is a condition in which one or more of the fibrous sutures in an infant skull prematurely fuses by turning into bone -Ossifying center >> 3yrs fofetal to 1 yr after birth -First 5 yrs ( occipto-sphenoid ) and ( spheno-ethmoidal) synchondrosis take place

- Ciribriform plates closes at 2-3 yrs -spheno-occipital closes at (11-13) in female & (13-16). in male -spheno-ethmoidal closes at (6-7)yrs - at age of 3 (50%) of cranial base ( post natal growth ) is completed . -cranial vault achieves > 90% of adult size by age 5 Cranial valaut : Intramembranous ossification Cranial Base : Endochondoral Ossification Cranial base growth : Forward and upward Postnatal Maxilla & mandible growth : Forward and downward -Primary center of ossification of mandible in bifurcation of mandible nerve in mental branches -The main ossification center of maxilla is ABOVE DENTAL LAMINA that form primary canine -Growth in maxilla Width : Sutures deposition AP : Ant resorption , Post deposition Height : teeth eruption Lalate : resorption in nasal floor & deposition in mouth roof -Fibrous perichondrium forms 1-sphenomandibular ligment

2-Ant ligment of malleus ( middle ear ) 3- malleus and incus ( by dorsal end) -Secondary growth Cartilage of Mandible : Condylar , symphseal and coronoid ! Postnatal maxilla '& Mandible development : Both grow as intramembranous ossification WHILE postnatal growth of the mandible ;-Both endochondral and intramembranous growth. *endochodral growth occurs at the condylar cartilage *intra-membranous growth occurs at the rest of the mandible ------------------------------------lecture 3 -The lateral sulcus which is a landmark in canine area , used to identify the occlusion at birth (class II) -Upper arch ( horse-shoes) while the Lower arch is U-shaped -A B D C E --In decidous teeth :It is OVERBITE that reduced after (3-4) yrs

-Characteristics of anterior teeth 1. Spacing between the anterior teeth. 2. Primate spaces: there’s a space distal to the lower primary canine, and mesial to the upper primary canine. 3. Upper incisors are usually upright. 4. Flush terminal or mesial step molar relationship -What are the changes in deciduous dentition to prepare for the permanent dentition state? 1) Minimal changes in the dimension of the upper and lower arches. 2) Minimal change in the space condition. 3) Occlusion: forward migration of the lower teeth occupied by the primate space -Primate space ? To start changing the molar relationship from flush terminal to class I -The Preemergent Eruption requires two processes: a) Bone resorption. b) Tooth movement -Primary failure of eruption: delayed eruption, or uneruption are seen in some medical syndromes like the cliedocranial dysplasia ,Hypothyroidism also causes delayed eruption -Postemergent Eruption: a- Postemergent spurt : which is the period when the maximum eruption takes place. b- Juvenile occlusal equilibrium : the bone will grow, and so the ramus height will increase, taking the lower teeth with it,,in this stage will continue erupting, until they reach the equilibrium, where no further eruption will take place c- Adult occlusal equilibrium:In the adult state, if you extract a tooth, the opposing tooth will over-erupt

-When (E) has MESIAL STEP relationship , then the (6) will erupt in Class I. -what are the changes that will convert this relationship into normal ( class I)? 1. The initial growth of the mandible is faster than the maxilla . 2. Primate space, it’s distal to lower canines and mesial to upper canines, so the posterior teeth will not move forward. 3. Leeway space: it’s the difference in the mesiodistal width between the primary and permanent premolars and canines. {IMP} Leeway space in the lower arch is larger than Leeway space in the upper arch -So usually there’s mild crowding, and this is called Incisor liability. -So usually there’s mild crowding, and this is called Incisor liability -The permanent incisors are larger than the deciduous ones. The extra space required for their alignment comes from : 1. Already existing spaces. 2. Arch width increase 3. Labial eruption path of the permanent incisors. 4. Repositioning the lower permanent canines in the mandibular arch. (they will erupt distally and buccally). 5. And the incisors will start to procline, and this will give space -In Maxilla , "ugly duckling stage" will have Diestima that will be closed by lateral and by canines later on

-The overall size of the deciduous molar and canine is greater than that of the premolars and permanent canines. This space is known as “Leeway space -Usually NO orthodontic treatment required until the permanent canines erupt --(6 weeks to 2)yrs U/L increase by 14-16 mm with greater increase in the upper arch and in males. -Maxillary arch continue to increase till the age of 13 years by (2.4 mm )in females and (4 mm) in males -Mandibular arch continue to increase till the age of 8 years by 2mm - movement of the teeth forward may end up with something called ( late lower incisor crowding) -After that both arch lengths decrease by (4.6-5.7 )mm in the upper arch and (7.4-8.3 )mm in the lower arch with more reduction in females --------------------lecture 4 -(A)anterior-posterior dimension: *Class I incisors relationship: when the lower incisal edges occlude on the cingulum plateau of upper centrals *Class II incisor relationship: when the lower incisal edges bite (posterior) to the cingulum plateau of upper centrals.

**Class III incisor edge relationship: when the lower incisal edges bite (anterior) to the cingulum plateau of upper centrals -bimaxillary proclination ,when the upper incisor procline and lower incisors are also procline but the relationship between upper and lower is class I -Angle’s classification :classification is the mesio-buccal cusp of the upper permanent first molar . *class 1: if the cusp bites in the buccal groove of the lower first molar< this is normal>. *class 2: if the mesio-buccal cusp bites anterior to the buccal groove of the lower first molar . *class 3: if the mesio-buccal cusp bites posterior to the buccal groove of the lower first molar -For Canine : *Class I : when the long axis of the canine is biting in the embrasure between the lower canine and first premolar. * Class II :when the upper canine is biting anterior to the embrasure. *Class III : when the upper canine is biting posterior to the embrasure -Vertical Diminision : over bite which means the amount of vertical overlap between upper central incisor and lower central incisor -Transverse Relationship: the palatal cups of the upper molars and premolars occlude in the central fossa of the lower premolars and molars .. ( All about lower buccal cusp )

*buccal cusp of the lower posterior teeth occlude buccaly to the buccal cusps of the upper posterior (buccal croos-bite) *buccal cusps of the lower posterior teeth occlude lingually to the palatal cusps of the upper posteriors (scissor bite or lingual cross-bite) -In skeletal relationship (Maxilla and Mandible ) : ANB angle (A represents maxilla, B represents mandible, N represents nasion -the reference point (1) If this angle is (2 degree-4degree) then this is class I. (2) If it is more than 4 degree then this is class II. (3)And if it less than 2 degree then it's class III -MaxillaryMandibular-Planes-Angle ( MMPA) , which is the relation between maxillary plane and mandibular plane . - Normally around (27±5 degree), from 22 up to 32 this is normal. *High angle means the (more than 32) : the maxilla will carry teeth away with it as the mandible will do the same ,and it's called skeletal because the etiology of due to skeletal problem. *Low angle (less than 22) : will produce skeletal deep bite -vertical skeletal relationship , the lower facial hight ( from the subnasale to the menton: *The normal average is 55 % of the total . *If it is > 55% then it's increased. *And if it's less than 55 % then it's reduced -transverse skeletal relationship :

* Skeletal maxilla : . *If the Maxilla is (wide ) this will cause lingual cross bite. *if the maxilla is (narrow ) this will cause buccal cross bite. -Mandible . If the mandible is (wide ) this will cause buccal crossbite. if the mandible (narrow ) this will cause lingual crossbite -------------lecture 5 -Aetiology of malocclusion are: Skeletal factors, Soft tissue factors or Local (dental) factors -Specific causes -known causes *Disturbances in utero *Skeletal growth disturbances: Foetal moulding and birth injuries: -Intrauterine moulding ,,Trauma to mandible during birth Childhood fracture of the jaw *Acromegaly and hemimandibular hypertrophy Acromegaly: (anterior pituitary tumour) - Increase growth hormones, increase growth of mandible class III. Hemimandibular hypertrophy

-Genetic causes *Some malocclusion are inherited (same family). *Skeletal pattern is genetically determined *Disproportions between jaw sizes: Improper occlusion relationship (class II,III). *Disproportions between jaw size and teeth size: If the jaw is large and the teeth are normal spacing, whereas if the jaw is small while the teeth are normal crowding -Soft tissue factor *Lip line: -Lower lip should cover 1/3rd to ½ of the upper incisor *Lip competence: A potential competent lips are in contact but not at rest. -Incompetent lips can not control the anterio-posterior position of incisors class II div I or bimaxillary proclination -Lip trap: (rabbit teeth) lower lip trapped behind upper incisors these will increase the overjet Class II div 1 ---Tongue: tongue at rest are more important than at function -Muscle of mastication: These muscle can have an effect on dimension of the jaw and dental arch *Less use may lead to underdevelopment of arches and crowding

*Biting force have an influence on the vertical eruption of posterior teeth and so affecting lower facial height and OB * for muscle dysfunction : *Damage to motor nerve results in muscle atrophy. *Decrease in tonic muscle activity result in excessive jaw displacement: Increase vertical growth. Excessive eruption of posterior teeth. AOB -Soft tissue factors and habits: *Thumb sucking : Proclination of upper incisors.- Retroclination of lower incisors,, AOB ,,Crossbite and deep palate. *Mouth breathing : AOB because the mouth will be opening for breathing and this will lead to supra eruption of the posterior teeth. Crossbite and high palatal vault ,, Increase lower face height *Tongue thrust: adaptive tongue thrust ---------------lecture 6 -Supernumeray teeth more in Males

-consequences of supernumerary teeth on occlusion are ( crowding, spacing, impaction -Types of supernumerary : 1-supplemental :It's an erupted identical tooth, similar to the last tooth in series 2-conical (mesiodense) : usually it is located in the premaxilla between central incisors (midline) and usually its inverted 3-tuberculate :usually comes in pairs of teeth more than one - root formation in tuberculate is delayed compared to that of the permanent incisors 4-odontoms can be complex :doesn't look like normal teeth or compound:look like small teeth grouped together -Consequences of supernumerary :: -midline diastema caused by mesiodense -crowding. -delayed eruption of central incisors. -malposition of central incisors root resorption of central incisors, -Cystic formation, -Most common in hypodontia 1-mand. 2nd premolar 2-maxilla lateral incisor

3-maxilla 2nd premolar 4-mand. incisor -Consequences of missing the lat. Incisor: Spacing Unilateral missing of lateral incisor is more common than bilateral Affects the eruption of canine -Missing Max.Canine due to : 1-guidence theory 2-genatic theory -Consequences of missing man. Second premolar :: -retained deciduous 2nd molar (retained) -Gemination :2teeth - 1tooth bud Fusion : 1tooth- 2teeth buds -Cases of premature loss : *in the case of Ds and Es the most common cause of premature loss is caries . *In case of Cs is mostly as a result of root resorption by crowded lateral incisor -Most common is 1st permanent molar loss because it’s the first erupted permanent tooth -Impacted tooth

-Incisors : It is due to tuberculate Canine :Palatal impaction usually more than buccal impaction - Unilateral is more common than bilateral = 4:1 THE AETIOLOGIES : -disturbed path of eruption -as result of crowding, not enough space and in this case its impacted buccally -Hereditary (genetic theory ):points to genetic factors as a primary origin of palatally displaced canine . -long path of eruption because the canine has the longest path of eruption -SLOB tech to find canine when no bluge buccaly : you take two radiograph of same place if they are parallel to cone then LINGALLY IMPACTION but if it is in opposite direction then BUCCALY IMPACTION -For ectopic *the most common ectopic tooth is Max.1st molar For local soft tissue factor *High labial frenum will cause midline diastema , treatment would be frenectomy --------------------lec 9 -PROBER TREATMENT PLANE WILL DEPEND ON : 1- Correct Diagnosis , .

. 2- Defines your aims of treatment , . 3- How to establish/Achieve these aims --SEQUENCE OF PLANNING THE TREATMENT *1- Take the patient's actual chief complain 2-History and Clinical Examination. 3- Records 4- Analysis of the records to get diagnosis. 5- Problem list: what are the problems in this case (all of them). 6- Your aims; are you going to correct this problem? . 7- Means of Achieving the aims --How to achieve these goals (treatment modalities) 1) Removable appliance 2) Fixed appliance 3) Growth modifications: moderate to severe skeletal discrepancy and the patient is still growing 4) Orthognathic surgery: moderate to severe skeletal discrepancy but the patient is not growing anymore -Extraction or non extraction philosophy : * Crowding * Overjet (Increased / reversed ) -Removable Appliances : to achieve simple tooth movement which is the tipping movement (rotation around the fulcrum of the tooth), in

this movement the crown moves to one direction and the root moves towards the opposite direction *There is a difference between the crown and the root moves both, in bodily movement movementin the same direction and in the same amount -Functional appliances : ( Growing patient ) by stimulate the growth center -Fixed appliances 1-bodily movement; bring the crown and root back. 2. Severe rotation 3. Intrusion 4. Extrusion -Orthognathic surgery For (non grower patient ) where you do an ortho treatment to prepare patient’s teeth for surgery. In surgery you move the jaws to get a normal relationship *Indication Severe malocclusion – can nort be treat by ortho treatment only -Dental crowding -mild crowding 1-4 mm solved by : either you do expansion(proclination or interproximal expansion) -interproximal stripping Done with removable or fixed application -Moderate crowding Border line :5-8 mm solved by :Expansion -Distal movement of molars using head gear -interproximal stripping

-Severe crowding ≥ 9 mm Need extraction -Choice of teeth to be extracted *1- Site of crowding 2- Degree of crowding : *extracting fours will give you more space than extracting fives 3- Health of the Teeth 4- Amount of Overjet *overjet is increased, and then you need to extract upper Fours, if the amount of overjet is decreased then we will extract fives 5- Presence of midline shift . 6- Malpositioned Teeth . --Extraction vs. non extraction: Degree of crowding . Amount of overjet : *overjet is increased ..extract. *overjet is minimal you don’t need to extract. Overbite : the extraction increases the overbite.. Aesthetics and lip position : *If the patient has prominent lips and strong profile , then you can extract.

*dished profile / retrusive profile , then you should try to avoid extraction. . Width of the smile : *Wide / broad smile is against extraction: Stability --Lower incisors stability Very mild crowding where extraction cannot be justified (proclining up to 2mm). Class II div.2 : procline the upper incisors that will create space and still the lower lip will be touching the upper incisors, as a result all the space can be utilized for proclining the lower incisors. Class II div.1with thumb sucking if you remove the thumb then lower incisors can move back to their normal position (proclination by removing thumb sucking). In orthognathic cases: where you are changing the soft tissue environment –changing the neutral zone of the lower lip ---------------------first half of 8 -The machine itself, used to take lateral cephalogram is called cephalostat. it is used to measuring the head dimension

-Distance between xray source and the patient’s mid facial axis is around 6 ft -whereas the distance between midfacial axis and the film is 1 ft -Advantages (Indications) of lateral cephalogram 1. Assess dento-skeletal relationship. . 2. Evaluation of change due to growth & growth prediction 3. Evaluation of post treatment changes We take lateral cephalogram before and after treatment to assess change as a result of treatment 4. Research purposes and long term follow up studies -Cephalometric Landmarks *Sella (S) : midpoint of sella turcica *Nasion (N): most anterior point of the frontonasal suture (deepest point) *Anterior nasal spine (ANS) it is the tip of the nasal spine *Posterior nasal spine (PNS) : intersection between pterygomaxillary fissure and the maxillary plane *Point A: it is a reference point for maxilla. the deepest point on the profile of the maxilla between anterior nasal spine and alveolar crest *Point B: again, it is the most posterior or deepest point of the profile of mandible between the chin point and alveolar crest *Pogonion: most anterior point (most prominent point) of the bone chin.

*Gnathion: it is most anterior inferior point on mandibular symphysis in the midline. *Menton : it is the most inferior or lowest point on the mandibular symphysis in the midline (*note: ) gnathion is the point between menton and pogonion *Gonion: at the angle of the mandible *Orbitale : most anterior inferior point of orbital border *Porion: uppermost, outermost point of the external auditory meatus Porion is important to locate the Frankfort plane *Articulare: it is the intersection between posterior border of the neck of mandibular condyle and lower margin of the posterior cranial base *basion represents the posterior inferior of the cranial base * Condylion: means condyle. It is most posterior inferior point on the head of the mandibular condyle. Incision superius: the tip of the crown of the most prominent (upper incisor. ) * Incision inferius: the tip of the crown of the most prominent (lower incisor.) * Centroid: the midpoint on the ( root axis ) of the most prominent upper incisor -Cephalometric reference lines: *Frankfort plane: it is between porion and orbitale

*sella-nasion plane (SN plane): plane between sella point to nasion point de coaster’s line: it is the floor of the anterior cranial base. From ethmoid to sella turcica. Including anterior wall of sella turcica max line: between anterior nasal spine to posterior nasal spine. mand line: between menton and gonion *occlusal plane: cusp tip of first molars to incisor’s tip of lower central incisor( functional occlusal plane. It is cusp tip of lower 1st molar to cusp of lower 1st premolar) facial plane: between nasion and pogon. A-pogonion line: between point A and pogonion ----------------lecture 8 second part --Skeletal relationships *Anterior-Posterior Skeletal Relationship -SNA angle: it relates the maxilla only to the cranial base. The reference is the cranial base (83+3) -SNB angle : normally it is from 79 + 3. Again indicated anteriorposterior relationship of mandible -ANB : (3+1) to asses the skeletal relationship of maxilla nd mandible to each other

-A-B/FOP : A point to B point= A-B line, functional occlusal plane =FOP . A-B line to FOP angle must be 90 + 5 -Wits measurements : Indicates skeletal relationship between maxilla and mandible by ‘dropping’ the perpendicular line from A point to the functional occlusal plane. And from B point to functional occlusal plane. And measuring the difference between those 2 points -Vertical Skeletal Relationship MM angle : maxillary plane-mandibular plane angle. In normal angle=(27 + 5. ) (Large angle means skeletal open bite. )(Small angle means skeletal deep bite. ) Frankfort-mandibular plane angle : normally again=( 27 + 5.) Normally maxillary plane is parallel to the Frankfort plane. Again (large=skeletal open bite) and (small=skeletal deep bite. ) anterior face height : upper facial height from nasion to anterior nasal spine. Lower facial height(LFH) from menton to anterior nasal spine and LFH should be 50%-55%. So, total facial height is from nasion to menton. gonial angle : normally( 126 + 5.) It is between body of mandible and ascending ramus --Dentoskeletal relationship -UI/mx plane angle : we look at the inclination of upper incisor to the maxillary plane (108+5) -LI/mn plane angle : angle between lower incisor and mandibular plane. Again to assess the inclination of lower incisor. (Normal angle =92+5)

-interincisal angle : angle between long axis of upper incisor and long axis of lower incisor. It should be (133 + 10) To measure overbite ( increased / reduced) (NOTE) Its important feature of Bimaxillary Proclination. ( interincisal angle should be reduced) -LI/A-pog distance : distance between from edge of lower incisor to Apogon line {it's a line from A point to Pogonion}. Lower incisor edge to A-Pog is {0±2} --Soft tissue analysis *Harmony line (holdaway line): line tangent to the soft tissue Pogonion & the vermillion border of the upper lip -Aesthetic (Ricketts) line : it’s from the soft tissue Pogonion to the tip of the nose ; lower lip should be on the line or {0±2] The lower lip is more anterior than upper . --Cephalometric Superimposition involves the evaluation of : Changes in the overall face . Changes in the maxilla & it's dentition . Changes in the mandible & it's dentition . Amount & direction of condylar growth & mandible rotation -Superimposition on (cranial base structures) made by *De Coster's Line : Growth center closed after 7 yrs so it is a reference line . if not working then

*SN line: it's between the S point & the Nasion point since the S point in constant . -2. Superimposition on (Maxillary structures) -The anterior surface of the zygomatic process - The maxillary plane (contour of the palate at alveolar process base) maxillary plane used to assess the incisors inclination , & to record changes in Intermaxillary space( space b/w maxilla and Mandible) 3. Superimposition on Mandibular structures -The contour of the mandibular canal (ID canal). - The inner contour of the cortex of the mandibular symphysis - The tooth bud (crypt) of the 3rd permanent molar (from the time of commencement of mineralization until root formation begins) Done By : Ahmed Al Shammari 2010 .