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The Art and Science

S.I. Bhalajhi
The Art and Science
The Art and Science

Dr. Bhalajhi Ssmdaresa lyyer

Orthodontist Ministry of Health, State of Kuwait Formerly Assistant Professor,
Department of Orthodontics College of Dental Surgery, Kasturba Medical College,
Mangalore (A unit of Manipal Academy of Higher Education}

Third Edition
(With over 1250 illustrations)

4805/24, Bharat Ram Road, Darya Ganj, New Delhi 110 002
Orthodontics - The Art and Science
1st Edition : June 1997
2nd Edition : June 1999
3rd Edition : October 2003
Reprint : February 2004
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may be reproduced or transmitted in any form or by any means, electronic,
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No cast-iron guarantee is given that this book is totally free from errors of any kind. If
there are errors, they are inspite of our best efforts. The author or the publisher will not
be responsible for these unintended errors.

ISBN 81-86809-16-3

Published by:
Mr. Sudhir Kumar Arya
for Arya (MEDI) Publishing House,
4805/24, Bharat Ram Road,
Darya Ganj, New Delhi - 110 002.

Dr. Bhalajhi Sundaresa Ivyer

Orthodontist, Ministry of Health,
State of Kuwait
Assistant Professor
Department of Orthodontics
College of Dental Surgery, Mangalore
(A unit of Manipal Academy of Higher Education)

Dr. Seenia Iyyer Bhalajhi

Orthodontist, Ministry of Health,
State of Kuwait
Assistant Professor
Department of Orthodontics
College of Dental Surgery, Mangalore
(A unit of Manipal Academy of Higher Education)
Dr. V. Surendra Shelty i.u.s KOS. Dean, Dr. Shaheer Malik 2.D.S >.OS
Professor and Head Department of Olhcdcntisl
Cr.hodontes College of Dental Surgery Dental Speciality Center
Mangalore Ministry1 of Health,
State of Kuwait
Dr. Ashima Valiathan a.o.s. o.o.s., vs Dr. Soben Peter BOS., M.D.S.
IUSA> P'ofesscr and Hoad Depar.menl of
Orthcdo-tics College of Dental Surgery Department of Community
Dentistry College of Dental
Dr. Mohan Bal iga B.;-S., M.D.S Associate Surgery Mangalore
Dean, Professo' and Head Department of
OralSurcery College of Dental Su-ge-y Dr. Rajiv Ahluwalia 3D S MAS. Ass
Mangalore slant Professor. Maulana Azad
Medical College Dental Wing, New
Dr. Akhter Hussain s.c.s m.o.5. Professor Delhi
of Ort-oiontics Yenopoya Dental Co'ece
Dr. Gurkeorat Singh 8.D.S.. MDS.
Consultant Orthccontist N ew
Dr.Anil.S.Malik3.D.S,. MOS. Professor of Delhi
Orthodontics Yenopoya Dental College
Dr. Menaka Chona BOS.. V.D.S
Consultant Ortrodontist
Dr. H.S.Divakar j.n.s >.os.. v.orw&Rcs New Delhi
Assistant Professes Department of
Orthodontics Univo'sity of Trinidad Dr. Elbe Peter &c S M.D& Forrrerly
Assistant Professor Department of
Dr. Rohan Mascarenhas BDS.. M.D.S. Orthodontics College of De-tal
Assistant Professor of Olhcdcntics Surgery Mangalore
Yenopoya Denta Colfege Manga ore

Dr. Binnoy Kurian a.D.s.. MDS. Associate

Professor Department of Cr.hodontics it Work
KA'.G.Dentel Co.e-go Sullia Raul Aguirre Brizuela

Lab Work
Henry Sudario Sumagpao
Orthodontic Technician,
Ministry of Health, Slate of
Dental Technicsn, Dr. Anand K.S. tc<s Dental
Ministry of Health. Surgeon
State of Kuwait

Dr Namilha Kama ^ns Dental Surgeo*

The eagerness on /he part of rhe graduating den/isJs /o .know more aboi/J Orthodontics and
the lack of an a i/ encompassing book vvos /he driving force /ha/ /ed me to author the first
edition of this text book of Orthodontics. Six years, two editions and numerous reprints,
.have encouraged me to come up v/tffo fb/s third edition.

Orthodontics is a dynamic field with changes occurring at a rapid pace.

Or/bodon/tos Js much more rhan o cosmetic field of Den/is fry. tfecen/ i'n/eres/ in /he
bio-cbemica/ and cellular aspects of tooth movement have proved beyond doubt that
Orthodontics is a specialization thai applies the principles of biology as well as
engineering. Orthodontics is also keen to adopt new technology to aid in imaging,
diagnosis ond treatment delivery. The new Technologies and a broader understanding of
the biological and mechanical aspects of tooth movement hove removed many of the
limitations of orthodontic treatment. The rapid improvements and advances place a
tremendous pressure on /he oufhors 'o frequently update and review the book, it has been
my endeavor to bn'ng to you some of fhese advances.

The third edition of this book adopts a friendly two color format followed
internationally by most publishers. An effort has been mode to improve /be overall quality
of the illustrations which have been pains/aki'ngJy redrawn and enhanced using the latest
available software. We hove aJso added a number of clinical photographs to enable easy
understanding of the subject.

I remain ever grateful to my /eocher Dr. VSurendra Shetty for his valuable
guidance over the years. I would a/so like to /bonk Mr Suc/biY Kumar Arya, /be pub/isber of/his
book for his whole hearted support in this endeavor. I hope this book is accepted ond
appreciated by the dental community.


j i <\\y \ jiywl
jU^-nV' w^a

Section 1 Introduction

1 Introduction to Orthodontics 1 Section 2

Growth and development

s Growth and Development - - General

Principles and Concepts '

8 Growth and Development of Cranial 55NjSs

and Facial Structures 21
BUI Development of Dentition and 37
SSs-t SS is? •sv'.-^;^ -y -y-•*-y-y-y -v -.yy-y-y
^-yy-y -y

Functional Development

Section 3 Occlusion & Malocclusion

6 Occlusion - Basic Concepts 55

W Classification of Malocclusion 63

s 81
Si.-^,; Etiology of Malocclusion Habits txsvsss
9 97

10 Epidemiology of Malocclusion 109

Section 4 Diagnosis ^V..•/-•.•".•.•;.-..-'i-.".-'.-'/.-

ll. Orthodontic Diagnosis 115

12 Gephalometrics 143

13 Skeletal Maturity Indicators 161

SfeSSSS S S S i ^ ^ ^ i i S ^ S S S :
,«,IAI -,

14 Model Analysis 175

Section 5 Biomechanics

15 Biology of Tooth Movement 13 •)

The Mechanics of Tooth Movement 195 W
Anchorage 203
Is Age Factor in Orthodontic^^^fe^l 1

Section 6 Preventive & Interceptlve Orthodontics

Section 7 Space Gaining

21 Methods of Gaining Space J||8l§i239

22 Arch Expansion

23 Extractions

Section 8 Orthodontic Appliances

Orthodontic Appliances |f|§ |jjjj271

llll General Principles ||§||||

;i ' 25 : Removable Appliances

26 Fixed Appliances

mm Myofunctional Appliances (|||S29

28 Orthopaedic Appliances 365
Section 9 Corrective Orthodontics

29 Treatment Planning 377

30 Management of Some Common 385

31 Management of Class II . 397
32 Management of Class III 407
33 Management of Open Bite 415

34 Management of Crossbite 423

35 Management of Deep Bite 433

36 Cleft Lip and Palate 439

Section 10 Surgical Orthodontics & Retention and relapse

Lab Procedures

Genetics in Orthodontics

41 Computers in Orthodontics

42 Adult Orthodontics

Section 11 Miscellaneous
rthodontics is t not branch of dentistry Malocclusion is capable of adversely affecting the
concerned with prevention, interception facial appcarance of an individual.
and correction of malocclusion and other
Risk of caries
abnormalities ol the dento-facial region. The word
orthodontics is derived from the Greek words o/ihos
meaning correct and odonios meaning teeth. The term
Orthodontics was first coined by le Felon.
In 1922, the British Society for the Study of
Orthodontics has defined the speciality as,
Orthodontics includes the study ol the growth end
development of the jaws and face particularly, and the
body generally as influencing the postion of the teeth;
the study of action and reaction of internal and external
influences on the development and the prevention and
correction of arrested and perverled development.'
Man has recognised the presence of dentofaciol
deformities and the need for its Treatment centuries
back. Crude appliances that were seemingly designed
to regulate the teeth have been excavated by
archeologistsfrom round the world including Egypt,
Greece and Mexico.
Normal alignment of teeth not only contributes to
the oral health but also goes a long way in the overall
well being and personality of an individual. Correct
tooth position is an important factor for esthetics,
function and for overall preservation or restoration ol
dental health. While most malocclusions may not
adversely affect the health of an individual, they
nevertheless are ccipoblc of producing undesirable
functional and esthetic imbalances. The following are
some of the unfavourable sequelae of malocclusion.

Poor facial appearance

Malalignment of teeth makes oral hygiene c. Esthetic harmony
maintenance a difficult task, thereby increasing the risk The orthodontist should strive to acheive these
of caries (fig 1). three main objedis'es of treatment.

Fig 1 I regu lor -eet-i aid crowding m eke ore I hygene maintenance f-ig 2 Tech that are severely proc hed are at a high risk of irjjry
difficult ond predispose to caries besides bfiing esthetically unpleasant.

Predisposition to periodontal diseases Functional efficiency

Malocclusion associated with poo-'oral hygiene is a Many malocclusions affect normal functioning of the
frequent cause of periodontal diseoses. Ir addition, stomatognathic system. The orthodontic treatment
teeth that are placed in abnormal positions can be a should thus aim at improving the functioning of the
cause for traumatic occlusion with resultant periodontal oro-facial apporatus.
t:ssuc damage.
Structural balance
Psychological disturbances
The oro-facial region consists of the dento-alveolar
Malocclusion that adversely affects the appearance of system, the skeletal tissue and the soft tissue
person leads to psychological disturbances. Unsightly
appearonce of teeth makes a person highly
self-conscious and turns him into an introvert. Thus
treatment of malocclusion in such patients helps in
improving the mental well being and confidence.

Risk of trauma
Teeth that arc severely proclined are at a high risk of
injury especially during play or by an accidental fall (fig

Abnormalities of function
Many malocclusions cause abnormality in the
functioning of the stomotognathic system such as
improper deglutition, defects in speech, improper
respiration, etc.,.
Temperomandlbular Joint problems
Malocclusion associated with occlusal prematurities
and deep bite are believed to be a cause of TMJ
problems such as pain and dysfunction.


The aims and objectives of orthodontic therapy have

been summarised by Jackson as the Jackson's triad.
The three main objectives of orthodontic treatment are:
a. Functional efficiency
b. Structure! bal o nee
rig 3 Aims ore objectives of orhodonlic trectmonl ortnedontist can bring about changes in all the three
planes of spoce i.e. sagittal, transverse and vertical.
including musculature. Stable orthodontic treatment is
best achieved by maintaining a balance between these
Alteration intosoft
Orthodontics 3
tissue pattern
The soft tissues that envelop the dentition are greatiy
influenced by the placement of the dentition. It is
possible to bring about favourable changes in the soft
tissue pattern by ortnodontic treatment.

Functional efficiency SERVICES OFFERED BY THE

three tissue systems. ORTHODONTIST

Esthetic harmony The sen/ices offered by an orthodontist can be broadly

classified as :
a. Preventive orthodontics
b. Interceptive orthodontics
Structural balance
c. Corrective orthodontics
d. Surgical orthodontics
Esthetic harmony
Preventive orthodontics
By far the most common reason for seeking
"Prevention"', they say, "is better than cure."
orthodontic care is to improve the appearance ot the
Preventive orthodontics includes procedures
teeth and face. Many malocclusions are associated
undertaken prior to the onset of a malocclusion in
with unsightly appearance of teeth and can thus offect
anticipation of a developing malocclusion. Preventive
the individual's self image, well being and success in
orthodontics can be defined as,
society. Thus tne orthodontic •reatment should aim at
improving the esthetics ci the individual.



Orthodontic treatment involves the three main tissue

systems concerned in dentofacial development,
namely the dentition, the skeleton and the facial and
jaw musculature. Orthodontic treatment can bring
about changes in the dentition, the skeletal system and
the enveloping soft tissue.

Alteration in tooth position

Orthodontic treatment is made possible by the fad that
teeth can be moved through the bone to ideal locations
by applying appropriate force on them. Most
malocclusions involving the dental system can be
effectively treated by moving teeth so as to normolise
tnc occlusion.

Alteration in skeletal pattern

Malocclusion may be associated with skeletal
disharmony involving the jaw bones (i.e. maxilla and
mandible). Deviation* from the normal can arise in
size, position and relationship between these skeletal

components. It is within the scopc of an orthodontist to
apply appropriate orthopaedic forces that are capable
of restraining, promoting or redirecting skeletal growth
so as to normalise the skeletal system. The
'Actions taken to preserve the integrity of what appears philosopher who gave medical science the first system
normal for that age.' of comparative anatomy. Aristotfe was the first writer
who studied human teerh and compared them with
Interceptlve Orthodontics
those of various other species.
Interceptive orthodontics includes procedures that are The first recorded suggestion for active treatment
undertaken at an early stage of a malocclusion to of malocclusion was by Aulius Cornelius Celsus (25
eliminate or reduce the severity of the same. By B.C.-A.D. 50) who advocated the use of finger
undertaking appropriate interceptive procedures, it is pressure to align irregu'artee'h.
oossible to prevent establishment of a full fledged Pierre Faucnard o French dentist is considered
malocclusion 'hat may require long term orthodontic the founder of modern dentistry. As early as I 723, he
treatment at a later age. developed whet is probably the first orthodontic
appliance co'led c Bandelette, that was designed to
Corrective Orthodontics expand the dental arch.
Orthodontic procedures undertaken to correct c fully Norman Kingsley an American dentist, was the
established malocclusion. first to use extra-orai force to correct protruding Aeeth.
He is considered os the oioneer in cleft palate
Surgical Orthodontics treatment.
They are surgical procedures that are undertaken in Emerson C. Angeil (1823 - 1903) first advocated
conjunction with or as an adjunct to orthodontic the open'ng of mid-polatal suture, a procedure
treatment.The surgical orthodontic procedures are which later came to be known as rapid maxillary
usually carried our to remove on etiologic factor or to expansion.
treat very severe dento-facial deformities that cannot
be treated by orthodontic therapy alone.


Orthodontics is considered the oldest speciality of

dentistry. Evidences suggest that attempts were made
to treat malocclusion as early as 1000 B.C. Primitive
applionces to move teeth have been found in Greek
and Etruscan excavations.
The Greek physician Hippocrates (460 - 377
B.C.) is believed to be the pioneer in medical science.
He was the first person to establish medicol tradition
based or facts rather than religion or fancy. A number
of references on teeth and jaws are found in his
Aristotle (384 - 322 B.C.) was a Greek

Fig 4 Edward -o-tlov Angle - ^o'lier of 'v'iooorr CMbodon* cs

F g 5 Calvin C c so Fig 6 Martin Dewey

Williom E. Mag ill (1823 - 1896) was the "irst In 1931, Holly Broadbent and Hoforoth
person lo band teeth for active toorh movement. independently developed cephalometric radiography
Henn^ A. Baker in 1 893 introduced what is cclled which standardised the positioning of the head in
Baker's anchorage or the use of intermaxillary e asl'cs relation to the film and X ray source. These
lo trect malocclusion. radiographs made it possible to visualise tne cranial
Edward H. Angle [1855 -1930} is considered :ne and facial skeleton. This can be considered a major
Father of Modern Ortnodontics' for his numerous advancement in orthodontic diagnosis and treatment
contributions to this speciality {fig 4). Through his planning.
leadership, orthodontics was separated from other Buonocore in 1955 introduced tneocid etch
branches of dentistry to establish itself as e speciality. technique. This enabled direct bonding of orthodontic
Ang.e's contributions include a classification of attachments to tne enamel which greatly enhanced
malocclusion and orthodontic appliances such as Pin esthetics.
and tube and the Edgewise appliance. Angle also Raymond Begg of Australia introduced a light
started a School of Orthodontics at 5?. Louis, New
London, Connecticut in which many c? the pioneer
American orthodontists were -'cined. Angle believed
tnatthe whole complement ct teeth could be retained
and yeT good occlusion could be ach'eved. He thus
advocated arch expansion for most patients.
Calvin Case (1847 - 1923} believed that ■racial
improvement was a guide to orthodontic treatment.
Case (fig 5) oiso claims to be the first orthodontist to
use intermaxillary elastics. Calvin Case was a critic of
Angle and opposed Angle's philosopny of arch
expansion to treat most cases. He advocated the
removal of certain teeth to achieve stable treatment
results and to improve facial esthetics.
Martin Dewey (1881 - 1933} was an ardent
champion of no n-extraction. Dewey (fig 6}also

modified Angle's classification of malocclusion.
wire fixed appliance technique that was based on the
concept of d ifferentia I force. He also advocated the
need for extraction of some teeth to achieve stable
While the American orthodontists were showing
keen interest in improving fixed orthodontic
appliances, their European counterparts continued to
develop removable and functional appliances for
guidance of growth. Pierre Robin in 1902 introduced a
Monobloc which protruded the mandible forward in
patients with glossoptosis. Viggo Anderson in 1910
developed the activator which made use of the facial
musculature to guide the growth of the jaws. Rolf
Frankel in 1969 - 1973 proposed the Function
Regulator to treat a variety of skeletal malocclusions.
Lawrence Andrews introduced the Straight Wire
Appliance in the early seventies. This was a
preadjusted appliance in which the brackets were
pre-programmed to accomplish the desired tooth
movements in all the three planes of space. This is
considered a major advancement in improving
orthodontic treatment results with minimal possible
wire bending.
This discussion on the history and evolution of
orthodontics is by no means complete. There have
been numerous people whose contributions have
gone a long way in the improvement of this speciality.
For a more complete review the readers are adviced to
refer other relevant literature.


1. Asbcll : A brief history of orthodontics. Am J Orlhod 1990;

2. Moorees, Bu'slone, Chrsticinsen, H'txonaid Wei ostein :
Research relaled to malocclusion. Arr J Orthod 1971 ;1-1B
3. Sa zrron JA : Prac'icc of Orthodontics, JB lippincotf corn
pony, 1966
A. Graber TV. : Ortnodontics : Principles end Practice.
WB Sounder,! 988

Growth and Development - General

Principles and Concepts
The practice of orthodontics has two basic
requirements. The first and foremost is to possess an
intimate knowledge of the anatomy and growth of the
head. The second is to master the techniques for
regulating tooth position. In the past, the interaction
between these two sets of information was considered
to be only minimal. It is now established that a sound
knowledge of growth and development is essential for
successful orthodontic treatment. There are a number
of treatment modalities that can regulate the growing
dentition and the jaw bones. Understanding the growth
of the oro-facial region is vitally important when
planning such treatment procedures.
This chapter will present a comprehensive
review of the basic concepts of growth and
development as understood today. It would be our
endeavor to stimulate the young student's mind so that
he at a later date can contribute to solve the
complexities of cranio-facial development.



There is no universally accepted definition of growth.

Various clinicians have defined growth in different
"The self multiplication of living substance." (J.S.
"Increase in size, change in proportion and progressive
complexity." (Krogman) "An increase in size." (Todd)
"Entire series of sequential anatomic ond physiologic
changes taking place from the beginning of prenatal life
to senility." (Meridith) "Quantitative ospect of biologic
development per unit of time." (Moyers)
"Change in any morphological parameter which is
measurable." (Moss)
Though growth is generally associated with environmental fcctors, there seems to be some
an increase in size, yet some conditions involving evidence that race does play a role i r growth process.
regression are also considered to take place during For example in American blacks, calcification and
growth. For example, the atrophy of the thymus gland. eruption of teeth occurs almost a year ecrlier than their
white counterparts.
"Development," according to Todd," is progress Socio- economic factors
towards maturity". According to iVioyers, develoo- ment Children brought up in affluent and favorable
refers to all the naturally occurring unidirectional socio-economic conditions snow earlier onset of
changes in the life of an individual from its existence as growth events. They also grow to a larger size than
a single cell to its elaboration as a multifunctional unit children living in unfavorable socioeconomic
terminating in death. Thus it encompasses the normal environment.
sequential events between fertilization and death.
Family size and birth order
Studies have shown thef *he first born babies tend to
Differentiation is the change from a generalized cell or weigh less at birth ard have smaller stature but higher
tissue to one that is more specialized. Thus I.Q. The smaller the family size, the better would be the
differ-entiation is a change in quality or kind. nutrition ond other favorable conditions.


Changes in size and maturation in a lorge population

A number of factors affect the rate, timing and can be shown to occur with time. For example, fifteen

character of growth. They include : year old boys are approximately 5 inches taller than the
same age group 50 years back. Although there is no
Heredity satisfactory explanation offered regarding this finding,

There seems to be a considerable genetic influence on it could possibly be due to changes in socio- economic

the size of parts, rate of growth and the onset of growth. conditions and food habits.

The genes hence play a major role in the overall growth

of a person.

Malnutrition may affect size of parts, body proportions,
quality and texture of tissues, and onset of groteh
events. The effects of malnutrition are reversible to a
certain extent as children have fine recuperative
powers. If the adverse effects are not too severe, the
growth process occelerates when proper nutrition is
provided. This is called catch-up growth.
The usual minor childhood illness ordinarily cannot be
shown to have much effect on ohys'cal growth.
Prolonged and debilitating illness however can hove a
marked effect on all aspects of growth.

Although the differences in growl1*! among different
roces con be attributed to other nutritional and

which is completed in girls

Growth and Development - General Principles and Concepts \ S
Climatic and seasonal effects between tne fourteenth and sixteenth year, but
Seasonal variation have been shown to affect adipose extends in boys tnrough the sixteenth or eighteenth
tissue content and the weight of new born babies. year. Following this, a final period of slow growrh is
Climatic changes seem to have little direct effect on seen which ends between the eighteenth and twentieth
rale of growth. years in females but goes on in boys until about the
twenty fifth year.
Psychological disturbances
It is seen that children experiencing stressfull
Growth spurts

conditions display an inhio'tion of growtn hormone Growth does not take place uniformly at all times.
secretion. Psycnological disturbances of prolonged There seems to be periods when a sudden
duration can hence markedly retard growth. acceleration of growth occurs. This sudden increose in
growth is termed growth spurt1.
Exercise The physiological alteration in hormonal
Although exercises may be essential fora healthy secretion is believed to be the cause for such
body, strenuous and regular exercises nave not seen accentuated growth. The timing of the growth spurts
associated with more favorable growth. Certain differ in boys and girls.
aspects of growth such as developmenr of some mo'or Tne following are the timings of growth
skills and increase in muscle mass is found to be spurts.
influenced by exercise. a. Just before birth
b. One year after birth
SOME CONCEPTS OF GROWTH c. Mixed dentition growth spurt
Boys : 8-1 1 years
Concept of normality Girls : 7-9 years

Normal re-'ers to thai which is usually expected, is d. Pre- p u be rta I g rowlh s pu rl

ordinarily seen or is typical. The concept of normality Boys : 14-16 years

must not oe equated with thai of tne deal. While ideal Giris : 11-13 years
Growth modification by means of
denotes the central tendency for the group, normal
refers to a range.
Another aspect of cranio-fccio! growth is that
normality charges with age. Thus what is normally
seen or is expected for one age group may not be
necessarily normel for a different age group.

Rhythm of growth
According 1o Noolon, Human growth is not c steody
and uniform process wherein all parts of the body
enlarge at tne same rate and the increments of one
year are equal to that of the preceeding or succeeding
year.' However there seems to be a rhythm during the
growth process. T n is growth rhytnm is most clearly
seen in stature or body height.
The first wave of growth is seen in both
sexes from birth to tne fifth or sixth year. It is most
intense and rapid during the first two yeors. There
follows a slower increcse terminating in boys c bout the
tenth to twelfth year and in girls no I c te r than the tenth
year. Then both sexes enter upon anotner period of

accelerated growrh corresponding to adolescence
functional and orthodontic app'iances elicit better a. The head takes up about 50% of the total body length
response during growth spurts. Surgical correction around the third month of intrauterine life. At the
involving the maxilla and mandibi'e should be carried time of birth, the trunk and the limbs have grown
out only after cessotion of the growth spurts. more than the head, thereby reducing the head to
about 30% of body length. The overall pattern of
Differential growth 200-
The human body does not grow at the same rate
throughout life. Different organs grow at different rates,
to a different cmount and c- different times. This is
termed differential growth.
Here it would be best to mention two
important aspects or growth, both of which help us
understand the concepts of diFerontial growth more -
clearly. These are :
1. Scammon's curve of growth
2. Cephalo-caudal gradient of growth

Scammon's curve of growth ; The body tissues can be i

broadiy classified into four types. They are lymphoid
tissue, neural tissue, general tissue and genital tissue.
Each of these tissues grow ot different times and rates Fig 1 Scammons growth curve
(fig 1). growth continues with a progressive reduction in
Lymphoid tissue oroliferctes rcpidly in late the relative size of the head to about 12% in the
childhood and reoches almost 200% of odulf size. This adult.
is an adaptation to protect children from infection as
they are more prone to it. By about 18 years of age,
lymphoid tissue undergoes involution to reach adult
Neurol tissue grows very rapidly and almost
reaches adult size by 6-7 years of age. Very little
growth ot neural tissue occurs after 6 - 7 years. This
facilitates intake of further knowledge. General tissue
or visceral tissue consists of the muscles, bones and
other organs. These tissues exhibit an "S" shaped
curve with rapid growth upto 2 - 3 years of age followed
by a slow phase of growth between 3-10 years. After
the tenth year, a raoid phase of growth occurs
terminating by the 18 r 20th year.
Genital tissue consists of the reproductive
organs. They show negligible growth until ouberry.
However they grow raoidly at puberty reaching adult
size after which growth ceases.

Cepria.'o-caudai gradient of growth : Ceo halo-caudal

gradient of growth simply means that there is an axis of
increased growth extending from head towards the
feet. A comearison of the body proportion between
pre-nctal and post-natal life reveals that post-natal
growth of regions of the body that are away from the
hypophysis is more.
This growth concept can be illustrated as
follows :
b. The lower limbs ore rudimentary oround the 2nd c. It is possible to get a large somple as the duration
month of intrc-uterine life. They later grow and of study is short.
represent almost 50% of the body length d. It is possible to repeat the study in case of any
ctadulthood. and Deuelopment - General Principles
flow. Thisand
mayConcepts 11in
not be possible a longitudinal
c. This increased gradient of growth is evident even study.
within the head and face. At the time of birth, tne
cronium is proportionally larger than the face. Sem/ - longitudinal studies
Post-natally the face grows more than the It is possible to combine the cross-sectional ond
cranium. longitudinal methods so as to derive the advantages of
both the systems of gathering growth dota.
The various growth studies can be broadly grouped as:
a. Longitudinal studies The physical growth can be studied by a number of
b. Cross sectional studies ways :
c. Semi - longitudinal studies
Longitudinal studies
Opinion is the crudest means of studying growth.
In this type of study, the observation and Opinion is a clever guess of on experienced person.
measurements pertcining to growth are made ori a This method of studying growth is not very scientific
person or a group of persons ct regular intervals overo and should be ovoided when better
prolonged period of time. Thus longitudinal studies arc
long term studies where the same sample is studied by
means of follow-up examination.
The longitudnal studies have the following advantages:
a. As the same subjects are followed up over a long
period, the specific developmental pattern of an
individual can be studied and compared.
b. Variation in development among individuals within
the sample can be studied.
The longitudnal studies have the following
disadvantages : a. Longitudinal studies ore carried out
over long periods of time. It often takes years or
decades to complete a study as the same sample is
studied ct regular intervals.
b. Longitudinal studies require maintenance of
laboratory research personnel and data storage
systems for a long period of time. Thus they can
be expensive.
c. As these studies are performed over prolonged
periods of time there is a risk of the sample size
reducing due to change of place, or other
unforeseen events.

Cross-sectional studies
Cross-sectional studies are carried out by observation
and measurement mode of different samples and
studied at different periods. Cross- sectional studies
offer the following advantages :

a. These studies are of short duration.
b. They are less expensive than longitudinal studies
as they are completed in c shorter span of time.
12 Orthodontics - The Art and Science

They are tests in which phys'cal characteristics such as

methods ore available.
weight, height, skeletal maturat'or and ossification are

Observat/ons measured and compared with standards based upon

the examination oc large groups of healthy subjects.
Another method of gathering growth related
information is by observation. They are useful in Vital staining
studying all or none phenomena such as presence or
In 1936, Belchieraccidental'y noted that bores of
absence of caries, presence or absence of a Class II
animals who had eaten madder plants were stained
mo ar relation, etc.,.
red. Subsequently, the dye in the madder plant, alizarin

Ratings and Rankings was identified and used fo- bone research.
This technique involves administration o*
Whenever quantification of a particular data is difficult,
certain dyes to the experimental animal which get
it is possible to adoot a method of rating and ranking.
incorporated in tne bones. It is possible to s'udy the
Rating makes use of standard,
manner in which bone is laid down, the site of growth,
conventionally accepted scales for classification.
the direction, duration and amount of growtn at different
Ranking involves the arrangement of data in an orderly
sites in the bone. The dyes used for this purpose are :
sequence based on the value.
Alizarin Red 5
Quanf/tat/ve measurements Acid Alizorin Blue C.
Trypon Blue
A scientific approach to study growth is ore thct is
d. Tetracycline
based on accurate measurements. The measurements
e. Lead acetate
made can be of three types.

?. Direc,1 Doio : Direct data are obtained from Radioisotopes

measurements that are taken on living persons or
Radioisotopes of certain elements or compounds,
cadavers by mecns of scales, measuring tapes or
when injected into tissue gei incorporated in the
calipers. developing bone and act as in vivo markers.
2. .Indirect Data ; The growth measurements can also
be had from images or reproduction of the person such
as photographs, radiographs or den to I cas's.

3. Derived Data : They are data that are den'ved after

comparing two measurements. These two sets of
measurements can be of different time frames or of two
different samples.


According to Profitt there are two main approaches to

studying ohysical growth.
I. Measurement aaproacnes
They comprise of rneasjrement techniques that are
corried out on living individuals. These metnods do not
harm the animal.
II. Experimental approaches
These are destructive technic u es where the onimal
that is studied is sacrificed. Experimental aoproacnes
are usually not carried out on humans.

Blmetrfc tests

Growth and Development - General Principles and Concepts

A process medial to the first molor. In case of tne

rig 2 Ares s where implarrs are places |A) & (B| in C) in mandible the implants are located as follows (fig 2.c):
1. Anterior ospect of symphysis, in the midline below
the root tips.
These radioiso'opes con larer be detected by tracking
2. Two pins on the right side of the mandibular body.
down the radioactivity they emit. The radio-isotopes
One pin under the first premolar and the other
used inc ude :
below the second premolar or first molar.
a. Technetium - 33
3. Ono pin on the external aspect of the right ramus
b. Calcium - 45
at the level of occlusal surface of molars.
c. Potassium- -32

Radiographic techniques
After Roentgen's discovery of X rays more than 100
Tne use of implants to study bone growth was firs*
years ago, different types of radiographic techniques to
introduced by Biork in 1969. It involves the implanting
study growth and development were devised. The
of small bits of biologically inert ciloys into growing
most commonly used techniques are cephalomerry
bone. These serve as radiographic reference points for
and hand-wrist radiographs.
serial radiograohic analysis. The metallic imp ants
used for studying growth are usually very tiny. They are
around 1,5mm in length and 0.5mm in diameter and
are made of Tantalum metal. These implants ere
embedded in certain areas of tne maxima end
mondible in order to study the growth of the skull.
The areas where the implants arc placcd in
the maxilla are (fig 2.a & b) :
1. Hard palotc behind the deciduous canines (prior to
eruotion of maxillan^ permanent incisors).
2. Below the anterior nasci spine (after eruption of
maxillary incisors).
3. Two implants on either side of the zygomatic
process of maxilla.
4. Border between hard palate and alveolar

of a bone can be used as
natural markers to study
growth by means of serial
radiographs. Natural
markers can be used to
study bone deposition,
Fig 3 Rodiograpnic
techniques of studying
bone growth £A) Using
Lateral cephalogrorrs (B)
Using Hand • Wrist

resorption and bone


Cepha/omefry : It is a standardized radiographic
technique of the cranio-focial region. After its Certain basic principles of growth that ore universol to
introduction by Broadbent in tne year 1931, this all species can first be studied on laboratory animals.
technique has contributed significantly to our
knowledge of human craniofacial skeletol growth {fig
3.a). Cephalometry makes it possible to take serial MECHANISMS OF BONE GROWTH
radiographs of a patient's skull in order to study the
growth changes taking place. Not only is this technique
useful in studying growth, it is also a valuable aid in Bone is a specialized tissue of mesodermal origin. It
orthodontic diagnosis, treatment planning, evaluation of
treatment results and for growth prediction. (More forms the structural framework of the body. Bone is a
details on cephalometry are given in chapter 12).
calcified tissue that supports the body and gives points
Hand-wrist X-rays : Radiographs of the hand- wrist
of attachment to the musculature. Normal bone
region are used to study the biological or skeletal age of
contains between 32 - 36% of orgonic mailer.
a person. The hand-wrist area has a number of small
spongy bones called carpels that have a definite Bone deposition and resorption
schedule of appearance and ossification (fig 3.b). Bone changes in shape and size by two bosic
mechanisms, bone deposition and bone resorption.
Natural markers
The process of bone deposition and resorption together
Normal bone has certain histological features such as is called bone remodeling.
nutrient canals, lines of arrested growth and certain
prominent trabeculae. These developmental features

Growth and Development - General Principles and Concepts

Fig 4 Example ot displacement (A) Primary displocemcnr maxilla of maxilla due 'o i'S OWN growrh |8)
dje to growth of the cran'cl l>ose Secondary displacement ot

Tne process of bone formation is colled osteogenesis.

The changes that bone deposition and resorption can
Bone formation takes place in two ways.
produce are :
1. Endochondral bone formation.
a. Change in size
2. Intra-mernbranous bone formation.
b. Change in shape
c. Change in proportion Endochondral bone formation
d. Change in relationship of the bone with adjacent In this type of osteogenesis the bone formation is
structures preceded by formation of a cartilaginous model which
is subsequently replaced by bone. Endochondral bone
Cortical drift
formation occurs as follows.
Most bones grow by interplay of bone deposition and
a. Mesenchymal cells become condensed at the site
resorption. A combination of bone deposition and
of bone formation.
resorption resulting in a growth movement towards the
b. Some mesenchymal cells differentiate into
depositing surface is called cortical drift. If bone
chondroblaslsand lay down hyaline cartilage.
depostion ond resorption on either side of a bone ere
c. The cartilage is surrounded by a membrane colled
equal, then the thickness of the bone remains constant.
perichondrium. This is highly vasculor
If in case more bone is deposited on one side and less
bone resorbed on the opposite side then the thickness
of the bone increases.

It is the movement of the whole bone cs a unit.
Displacement can be of two types. Primory
Dispfacement : If a bone gets displaced as a result of
its own growth, it is called primary displacement. For
example, growth of the maxilla at the tuberosity region
results in pushing of the maxilla ogainst the cranial
base which results in the displacement of the maxilla in
a forward and downward direction {fig 4.a).

Secondary Displacement r If the bone gets displaced

cs a result of growth and enlargement of an adjacent
bone, it is called secondary displacement. For
example, the growth of the cranial base causes the
forward and downward displacement of the maxilla {fig

and contains osleogenic cells.
d. The inter-cellulcirsubstance surrounding the THEORIES OF GROWTH
cartilage cells becomes calcified due to the
influence of enzyme alkaline phosphatase
secreted by the cartilage cells. Genetic theory
e. Thus the nutrition to the cartilage cells is cut off This theory simply states t'ncr all growth is controlled
leading to their death. This results in formation of by genetic influence and s pre-planned. This is one of
emp^y spaces called primen/ areolae. the earliest theories put forward.
f. The blood vessels and osteogenic cells from the
perichondrium invode the calcified cartilcginous Sufuraf theory
matrix which is now reduced to bars or walls due Sicher believed that cranio-fadal growth occurs at the
to eating away of the calcified mctrix. This leaves sutures. According to him paired parallel sutures that
large empty spaces between the walls called attacn facial areas to the skull anc the cranial base
secondary areolae. regior push the ncso-mcxillary complex forwards to
g. The osteogenic cells from The perichondrium
pace its growth with that of the mandible. This theory
become osteoblasts and arrange cior.g the
olso acknowledges the genetic influence of growth.
surface of these bars of calcified matrix.
A number of points were raised agains1 this
h. The osteoblasts lay down osteoid which later
theory. The following are some of them :
becomes calcified to form a Icmella of bone. Now
1. When on arec of the suture is transplanted to
another layer of osteoid is secreted and this goes
onother location, the tissue does not continue 'o
on and on. Thus the calcified matrix of cartilage
grow. This clearly indicates a ack of innate growth
acts as a support for bone formotion.
potential of the sutures.

intra-membranous bone formation 2. Growth takes place in untreated cases of cleft

oalate even in the absence of sutures.
In this iype of ossification, the formation of bone is not
3. Microcephaly and hydrocephaly raised doubts
preceded by formation of a cartilaginous model.
about the intrinsic genetic stimulus of sutures.
Instead bone is loid down directly in a fibrous
membrane. The intra-membranous bone is formed in
Cartilaginous theory
the following manner:
a. At the site of bone formation, mesenchymal cells
become aggregated.
b. Some mesenchymal cells lay down bundles of
collagen fiber.
c. Some mesenchymal cells enlcrge and ccquire a
basophilic cytoplasm and form osteoblasts.
d. These osteoblasts secrete a gelatinous matrix
called osteoid around the collcgen fibers.
e. They deposit calcium salts :nto the osteoid leading
to conversion of osteoid into bone lamella.
f. Now the osteob asls move away from the lamellae
and a new layer of osteo'd is secreted which aiso
gets calc'fied.
g. Some of the osteoblasts get entrapped between
two lamellae. They are called ostoocytes.
This theory was put forward by James Scott. According chewing, digestion, swallowing, speech and neural
to him intrinsic growth controlling factors are gresenr in integration.
cartilage and periosteum with sutures being only Each of these functions is carried out by a

secondary. He viewed the cartilaginous sites functional crania! component. Each functional17

througnout the skull as primary centres of growth. component consists of all of the tissues, organs,

Growth of the maxilla is attributed to the spaces and skeletal parts nccessary to carry o jt a
given funcrion. The functional cranial component is
nasal septoI cartilage. According to Scotr, the nasal
divided into :
septal cartilage is tne pacemaker for growth of the
1. Functional matrix
enrire naso-maxillary complex. The mandible is
2. Skeletal unit
considered as tne diaphysis of a long bone, henf into a
All the tissues, organs and functioning
horse-shoe shape with epiphysis removed so that
spaces taken as o whole comprise the functional
there is cartilage constituting half an epiphyseal plate
matrix, while the skeletal lissues related to this specific
at the ends which are represented by tne condyles.
functional matrix comprise the skeletal unit. All skeletal
Points in favour of this theory include :
tissues originate, grow and function completely
In many bones, cartilage growth occurs, while
embedded in their several matrices. Thus changes in
bone merely replaces it.
size, shape ond spatial position of all skeletal units
If o pai of on epiphyseal plofe is transplanted to c
including their very maintenance is due to the
different location, if will continue to grow in the
operational activity of their related functional matrices.
new location. This indicates the innate growth
potential of the cartilage.
Nasal seolal cartilage olso shows innate growth
potential on being transplanted to another site.
Experiments on rabbits involving removal of the
nosal septal cartilage demonstrated relcrded
mid-face develooment.

The functional matrix concept

The functional matrix concept o-r Melvin Moss
revitalized the studies on growth and development at a
time when the Sutural growth theory of Sicher and
Cartilcginous growth theory of Scott were severely
criric'zed for their inadequacy. Moss introduced rhe
doctrine of functional matrix complimentary to tne
original concept of functional cranial component by
Van der Klaous. The funcrionol matrix concept
attempts to comprehend the relationship between form
ond function.
The functional matrix hypothesis claims that
tne origin, form, position, growth and maintenance of all
skeletal tissues and organs ore always secondcry,
compensatory and necessary responses to
chronologically and morphologically prior events or
processes thot occur in specifically related non-skcieral
tissues, organs or functioning spaces.
• A number of relatively independent functions
are carried out in the cranio-facial region of tne human
body. Some of the functions corried out include
respiration, olfaction, vision, hearing, balance,
28 z unif:
The skeletal Orthodontics - The
All skeletal tissues Art and
associated with aScience
related functional matrix) which as a whole are
single function are called 'the skeletal unit'. The sandwiched in between two covering layers. In the
skeletal unit may be comprised of bone, cartilage and neuro-cranial capsule, the covers consist of the skin
tendinous tissue. When a bone is comprised of several and dura mater where as in the oro-facial capsule the
contiguous skeletal units, they are termed skin and mucosa form t ho covering.
'micro-skeletal units'. The maxilla and mandible are The neuro-cranial capsule surrounds ond
comprised of a number of sucn micro-skeletal units. protects the neuro-cranial capsular functional matrix
For example, the mandible has within it alveolar, which is the brain, leptomeninges and C.S.F. The
angular, condylar, gonial, mental, coronoid and basal neurocranial copsule is made up of skin, connective
micro-skeletal units. In case of the maxilla it is made up tissue, aponeurotic layer, loose connective tissue
of orbital, pneumatic, palatal and basal micro-skeletal layer, periosteum, base of the skull and the 2 layers of
units. When adjoining portions of a number of dura mater. The orofacial capsule surrounds and
neighbouring bones are united to function as a single protects the oro- naso-pharyngeal saaces which
craniol comoonent, we term this a 'macro- skeletal constitute the orofacial capsular matrix. The growth of
unit'. The entire endocranicl surface of the colvarium is the facial skull is influenced by the volume and patency
an example of a macro-skelctol unit. of these spaces.
The functiona/ matrix : The functional matrix consists
of muscles, glands, nerves, vessels, fat, teeth and the
van Llmborgh's theory
functioning spaces. The functional matrix is divided A m u Iti-factorial theory was put forward by van
into two r Limborgh in 1970. According to van Limborgh the three
1. Periosteal matrix popular theories of growth were not satisfactory, yet
2. Capsular matrix each contains elements of significance that cannot be
denied, van Limborgh explains the process of growth
1. Periosteal Matrices : The oeriosteal matrices ad
and development in a view that combines all the three
directly and octively upon their related skeletal units.
existing theories. He supports the functional matrix
Alterations in their functional demands produce o
theory of Moss, acknowledges some aspects of
secondary compensatory transformation of the size
Sicher's theory and at the same time does not rule out
and or shape of their skeletal units. Such
genetic involvement, van Limborgh has suggested the
transformations are brought obout by the interrelated
following five factors that he believed controls growth :
processes of bone deposition and resorption. The
periosteal matrices include the muscles, blood intrinsic genetic factors : They are the genetic control
vessels, nerves, glands, etc.,. These tissues oct of the skeletal units themselves.
directly on their related skeletal un:ts thereby bringing Local epigenetic factors : Borie growth is determined
about a transformation in *heir size and shape. This by genetic control originating from adjacent structures
transformation due to -he action of periosteal matrices like brain, eyes etc.,.
is brought about b. bone deposition and resorption. General epigenetic factors : They are genetic t'actors
2. Capsular Matrices : The capsular matrices oC determining growth from distant structures. E.g. Sex
fldescfy and passively on their related skeletal uni^i hormones, growth hormone etc.,.
p-odocing a secondary compensatory translator - Loccl environmental' factors : They are non- genetic
space. These alterations in spatial position cr s« e etal fcctors from loco external environment. E.g. habits,
units are brought about by the expansicr cr the muscle force, ctc.,.
oro-facial capsule within which the faco bones arise,
General' environmental factors : They are general
grow and are maintained. Theioocl skeletal units are
non-generic influences such as nutrition, oxygen etc.,.
passively and secondarily i—oved in space as their
The views expressed by van Limborgh can
enveloping capsule is expanded. This kind of
be summarized in the following six points :
translative growth is :>c' brought about by deposition
1. Chondrocrcniol growth is controlled mainly by the
and resorption.
intrinsic genetic factors.
The neuro-cranial capsule and the orofacial
2. Desmocrcnial growth is controlled by a few
capsule are examples of capsular matrices. Each of
intrinsic, genetic factors.
these capsules is an envelop which contains o series
of functional cranial components (skeletal units and
3. The cartilaginous parts of the skull must be 3. Middle craniol fossa and breadth of ramus a re
considered cs growth centres. counterparts.
4. Suturcl growth is controlled mainly by influences 4. Maxillary and mandibular arches are mutual
originating from the s*ul! cartilages and from other counterparts.
adjacent skull structures 5. Bony maxilla and corpus of mandible are mutual
5. Periosteal growth largely depends upon growth of counterparts.
adjacent structures. 6. Maxillary tuberosity and lingual tuberosity are
6. Sutural and periosteal growth are additionally counterparts.
governed by local non-genetic environmental



Enlow's expanding 'V' principle

Many facial bones or parts of bone have a V shaped
poltern of growth. The growth movements and
enlargement of these bones occur towards the wide
ends of the V as a result of differential deposition and
selective resorption of bone. Bone deposition occurs
on the inner side of the wide end of the V and bone
resorption on the outer surface. Deposition also takes
place at the ends of the 2 arms ot the V resulting in
growth movement towards the ends.
The V' pattern of the growth occurs in a
number of regions (fig 5) such as the base of the
mandible, ends of long bones, mandibular body, palate

Enlow's counterpart principle

The counterpart principle of craniofacial growth states
that the growth of any given facial or cranial part
relates specifically to other structural and
geometriccounterparts in the face and cranium.
There are regional relationships throughout
the whole face and cranium. If each regional part and
its particular counterpart enlarge to the same extent,
balanced growth occurs.
Imbalances in the regionol relationships are
produced by differences in :
a. Amounts of growth between the counterparts.
b. Directions of growth between the counterparts.
c. Time of growth between the counterparts.
The different parts & their counterparts
are ;
1. Nasomaxillary complex relates to the anterior
2. Horizontal dimension of the pharyngeal space
relates to the middle cranial fossa.
Neuro-viscera f frophism : The sal vary glands, fat
tissue and other organs are trophically regulated, at
least in port.
20 Orthodontics - The Art and Scicnce

1. Cong'clcsi, Moss. McAlamey, N' : Growth urd -rcst- ment

effects whn conventiona roentgenography cepholcmetry ond
F EM onalvs's. An .1 OrhoH 1994,
153-7 60
2. Lnlow : Hand boo< of focia growh, WB Sounders Company,
3. Enlow, Hen/old, Latham, Mcffi", Oristianscn and Hauscb :
Research on control of croniofac'al
normogenesis. Am J Orthcd 1977 ; 509-530
4. Grobcr TM : Orthodontics : Principles and practice. VVB
B Sounders,i 988
Fig 5 V Princio e of grov4h in (A) V.cndble 5. Mess : Genetics, epigere-ics, ond causat'on. Am J
(B) Moxillo Orthcd 1981 r 366-375
6. Moss and Sa entijn : The prima"/ role cf functional matrices in
ocia growth, Am „ Orthcd 1969 ; 20-31
Neurotrophic process In
7. Moss, Ska lak, Patcl, Sninozu<a, Mess-Sale nri n. anc
oro-facfal growth Vilrrann : An nllomet'ic ne\vork model of craniofacial growK
Air J Orhoc 1964 ,• 316-332
Neurotropism is a non-impulse transmifling neural 8. Moss, Skalok, Shinozuka, Fatcl, Moss-Sclen-"n, Vilmarn. end
function that involves axoplasmic transport and Mehta : An allometric centered model cf craniofacial growth.
Am J Orthcd 1983 ; 5-18
provides for long term interaction between neurons and 9. Profit! WR: Con-empora'y Ortnccont'cs, St Louis, CVMosby.l
innervated tissues that homeostatically regulates the 986.
10. Robert E Moye'S : Hand book of Orthodontics, Yccr boo<
morphological, compositionol and functional integrity of
medical pjblisners, "nc. 1988.
those tissues. The nature of neurotrophic substances 11. S-iaw Wc : Orthcdomic and Occlusal managemenr, Wright,!
and the process of their introduction into the target
tissue are unknown at present.
The different types of neurotrophic
mechanisms are:
1. Neuro-epithelial trophism
2. Neuro-visceral trophism
3. Neuro-musculartrophism Neuro-epitfie/ia/ trophism
; Epithelial mitosis and synthesis are neurotrophically
controlled. The normal epithelial growth is controlled by
releosc of certain neurotrophic substances by the
nerve synapses. If this neurotrophic process is lacking
or is deficient, abnormal epithelial growth, orofacial
hypoplasia and malformation etc., occur.
For example, the presence of taste buds is dependent
upon an intact innervation. The nen/es are not only
important for the sensation of taste but they also hcve
a neurotrophic effect in sustaining healthy growth of
the taste buds ond nearby epithelial tissue. If the taste
buds crede- innervoted, they became atrophic ond so
also the nearby epithelial cells.

Neuro-muscular trophism : Embryonic myogenesis is

independent of neural innervation and trophic control.
Approximately ot the myoblast stage of differentiation,
neural innervation is established without which further
myogenesis usually cannot continue.
wth and Development of
Cranial and Facial Region


rowth ond development of an individual growth of the cranio-faciol structures occurs resulting in
can be divided into prenatal and tne an increase in their size. In addition, a change in
post-natal periods. The pre-natal period of proportion between the various structures also occurs.
development is a dynamic phase in the development of
a human being. During this period, the height increases
by almost 5000 times as compared to only a threefold The earliest evidence of formation of the cranial base is
increase during the post-natal period. The prenatal life seen in the post or late somilic period (4th - 8th week of
can be arbitrarily divided into three periods : intro-uterine life). During this late somitic period
1. Period of the ovum mesenchymal tissue derived from
2. Period of the embryo
3. Period of the fetus

Period of the ovum

This period extends for a period of approximately two
weeks from the time of fertilization. During this period
the cleavage of the ovum and the attachment of the
ovum to the infra-uterine wall occurs.
Period of the embryo
This period extends from the fourteenth day to the fifty
sixth day of intra-uterine life. During this period tne
major part of the development of the facial and the
cranial region occurs.

Period of the fetus

This phase extends between the fifty sixth day of
intra-uterine life till birth. In this period, accelerated
22 Orthodontics - The Art and Science

the primitive streak, neuro^' crest and occipital

sclerotomes condense around the developing brain.
Thus a capsule is formed around the brain called
Ecfomenix or Ectomeningeal capsule. The basal
portion of this capsule gives rise to the future cranio.'
The development of the skull and :on7iation of
the cartilages of the cranial base is dependent upon the
presence of many other cranial structures like brain,
cranial nerves and • Thus evidence of skull
Fig t Cartilages of -he cranio I base : I. Nasa aacsu'e, 2. Prsspheno'c
formation is seen comparatively late after the primordia cortilage, 3. Qrbito - sphenoid enri nge, •1. Parachcrdu csrtilage, 5.
of many c*~e'cranial structures have developed. O'ic car'iage. 6. At! - spheroid ccrilnge, 7. Post - Sphenoid cart'lage

From around the fortieth day onwards,

- s ectomeningeal capsule is slowly converted rrx> which fuse together and form the anterior part of
cartilage. This heralds the onset of cranial rose body of sphenoid. Anteriorly, the pre- sphenoid
format'on. The conversion of mesenchymal cartilage forms a vertical cartilaginous plate
's into cartilage or chondrification occurs in 4 ons called mesethmoid cartilage which gives rise to
(fig 1) : 3 Parachordal r Hypophyseal the perpendiculor plate of ethmoid and cristagalli.
- Nasal (iii) Lateral to the pituitary gland chondrification
r Otic centres are seen which form the lesser wing
(orbito-sphenoid) and greater wing [ali- sphenoid)
of sphenoid.
7?-e chondrification centres forming around the —r-ial
end of the notochord are colled rcrschordal cartilages. Nasat
Initially during development, o capsule is seen around
the nasal sense organ. This capsufe chondrifies and
Zrzrk}\ to the termination c: nctochord, (which : — —e forms the cartilages of the nostrils which fuse with the
level of the oro-phcr'oeol membrane) ■fe -roophyseal cartilages of the cranial base.
pouch cevekscs which gives rise
- —e anterior lobe of the c gland. Otic
On either side of the b.-ccc - .iecl stem two A capsule is seen around the vestibulocochlear sense
-•oophyseol or post sc~-r--o d cortilages develop. organs. This capsule chondrifies ond later ossifies to
These carti'coes tacether and ryrr\ the posterior give rise to the mastoid and petrous
part <? the roc. o: sphenoid, i' Cranial to the pr_ -o
glond, two cresphenoid or trabec. c- oges develop
Growth and Development of Cranial and Facial Resion

portions of the temporal bone. The otic curtilages also (iii) The petrous part of temporal bone ossifies from 4
fuse with the caiti ages of the cranial base. endochondral centres that appear in the 5th
The initially separo'e centres of cartilage montn of infra-uterine life.
formation in the cronial base, fuse togetner into a single (iv) The styloid process ossifies from 2 endochondral
irregular and creatiy perforated crar'al base. Tne early centres.
establishment of the various nerves, blood vessels etc., EJtimoia1 Sor?e ; This bone shows only endochondral
from and to the brain results ir rurerous perfo'ations or ossification. It ossifies from three centrcs :
foramina in the developing cranial base. The ossifying (i) One centre located centrally that forms the median
chondro-crar'um meets the ossifying desmocrarium floor of the anterior cranial fossa.
(cranial vault) to form the neurocroniuTi. (ii) Two ateral centres in the nasal capsule.

Spncnoia' Bone : This bone ossifies both

Chondro-craniai ossification
intromembranously and endochondral^. There ere at
The cranial base which is now in a cartilcginous form
least 15 ossification centres.
uncergoes ossification. Tne oones of the crania base
(i) Lesser wing : Endochondral ossification occurs.
undergo both endochondral as well as
The ossification centre is seen in the
inlramembranous ossification. Occipffof Bone ; The
orbitosphenoid cartilagc.
occipital bone shows both endochondral and
(ii) Greater wing and ateral pterygoid plate : Two intra
nt-a-membranous ossification. Seven ossificction
membra nous ossification centres are seen in the
centres are seen, two intrcmernbranous and five
ciisphenoid carti:aoe. A part of the greater wirg
ossifies encochcndrally.. .
(i) The suoranuchcl squamous aart ossi'ies
(iii) Medial pterygoid plate : Ossifies endocnondrally
int'arncmb'anously from one pair of ossification
from u secondary cartilcgc in the hamular process.
ccntrcs whicn appear in the 8tn week of intra-uteri
(iv) Anterior part ot body of sphenoid : Ossifies
n e life.
endochondral^ from five centres (iwo paired and
(ii) The infranjchal squamous part oss'fies
one in the midline). The cenrrc of ossification is
encocnondrally from two centrcs which appear at
seen in pre-sphenoid cartilage.
the 10*h week of intrc-uterine life.
(v) Posterior pert or body o I sphenoid: Ossifies
(iii) The basil ar part ossifies endochondrallyfrom a
endochondrally from -our centres. The centre
s'rg'e ^edian ossificcr'on centre appearing in the
114i week ol 'ntra-uterire life. This gives rise to the
anterior portion of the occipital condyles and the
anterior boundary of foramen magnum.
(iv) A pair of endochondral ossification centres
appears in -he 12th week forming the lateral
boundary of foramen magnum and the posterior
no ii o n of occipital condyles.
Te.Tipo.ra.1 ; Tne temooral bone ossifies both
endochordrally and intrc-membranously from 1 1
(i) Squamous part of the temporal bone ossifies from
a single intramembrcnous centre that appears in
the 8th week of intrc-uterine life.

(ii) The tympanic ring ossifies from four
intramembranous centres that appear
in the 12th week of intra-uterine life.
24 Orthodontics - The Art and Science

of ossificotion is the post-sphenoid cartilage. forward displacement of the face during its growth from
Thecraniol bose orchondro-cranium is the cranial base.
important as a junction between the cron'al vault and At around the 1 Oth week of intro-uterine life,
the facial skeleton, being shared by both. The cranial the flexion of the bese is about 65". This flattens out a
bose is relatively stable during growth compared to the bit at the time of birth.
cranial vault and the face. Thus the cranial base can be
Uneven nature of growth of cranial base
taken as a basis against which the cranial vault and
facial ske/efon can be compared. The ebon d The growth of the cranial base is highly uneven. T.nis
ro-cranium is relatively stable. This aids in maintaining is attributed to the uneven nature of growth seen in the
the early established relationship of blood vessels and different regions of the brain. Thus the cranial base
nerves running to and from the brcin. The craniol base growth resembles the growth of the ventral surface of
of a newborn is small when compared to •he cranial the overlying brain.
vault that extends beyond the base laterally and The anterior end oosterior parts of the cranial
posteriorly. base grow at different rates. Between the 1 Oth and
the 40th weeks of intra-uterine life, the anterior cranial
Flexure of the cranial base
base increases in length end width by 7 times while,
During the embryonic and early fetal period, the cranial
during the same period the posterior cranial base
base becomes flexed in the region between the
increcses only five fold.
pituitary fossa and the soheno-occipita! •unction. The
face is hence tucked under the cranium. This flexure of PRENATAL EMBRYOLOGY OF MAXILLA
the cranial bose is accompanied by a corresponding
flexure of the developing brain stem. Thus the spinal Around the fourth week of intra-uterine life, a
chord and 'he foramen magnum which during the early prominent bulge appears on the ventrol aspect of the

stages of development were directed backwards now embryo corresponding to the developing brcin. Below

become directed downwards (fig 2). This the bulge a shallow depression which corresponds to
the primitive mouth appears called stomcdeum. The
floor of the stomodeum is formed by the
buccopharyngeal membrane which separates the
stomodeum from the foregut.
r By around the 4th week of intra-uterine life,
ig 2 Flcxu'e of 't c
crarial bass - arrow five branchial arches form in the region of the future
indicating the
head and neck. Each of these arches gives rise to
direction cf the
fororren magnum muscles, connective tissue, vasculature, skeletal
components ond neural components of the future face.
The first branchial

downward directed foramen magnum is an cdaptation

seen in man who, unlike animals, stands erect. This
flexure of the cronial base aids in increasing the
neurocranial co pa city. Another consequence of tne
flexure is the predominant downward rather than
Growth and Development of Cranial and Facial Region 25

Fronto-nasal process Medial nasal Process

Lateral nasal process Mandibular Process

Fig 3 Prenatal develccment of the rrcxTc ar.d the face

The palote is:ormed by contributions of the :
26 z Orthodontics - The Art and Science
a. Maxillary orocess
b. Palatal shelves given off by the maxillary process
c. Fronto-nasal process
The fronto-nasal process gives rise to the
premaxillan/ region while the pa'atal she'ves form the
rest o; the pc ate. As the palatal shelves grow medially,
their union is prevented by the presence of the tongue.
Thus iriiticlly the developing pa'atal shelves grow
vertically downwards towards the foor of the mouth (fig
4). Sometime during the seventh week o' intra-uterine
Ire, a transformation in the position o"" the palatal
shelves occurs. They change from a vertical to a
horizontal position. Thistransformo*'on is believed to
Fig A Cororcl sec'ion of tie hecid Slewing -ho pa ctcl
shelves growing vertically down towards tne foor of "he
Icke place within nours. Various reasons are given tc
mouth explain how this transformation occurs. They arc :
a. Alteration in oiochernical and physical consistency
arch is called the mcndibulcr crch and plays an important of tne connective tissue of the palatal shelves.
role in the develooment of the nasomaxillary region. b. Alteration in vasculature and blood supply to the
The mesoderm covering the developing palatcl shelves.
forebrain proliferates and forms a downward projection C. Appearance of an intrinsic shelf force.
that overlaps the upper part of stomodeum. This d. Rapid differential mitotic activity.
downward projection is cal ed fronto-nasal process. e. V uscu I a r move menrs.
The stomodeum is thus overlapped superiorly by f. Withdrawl of the em bryon ic face from ago i nst the
the fronto-nasal process. The mandibular arches of both heart prominence results in slight [aw opening. Tnis
the sides form the lateral walls of the stomodeum. The results in wilhdrawl of the toncue from between the
mandibular arch gives off u bud from its dorsal end called palatal shelves and aids in the elevation of the
the mcxillon," process. The moxillan/ process grows polatal shelves from a vertical to a horizontal
ventro-medio-crarial to the main part of the mandibular position.
arch which is now called the mandibular process. Thus at The two palatal shelves, by 8 1/2 weeks of
this stage the primitive mouth or stomodeum is intra-uferine life, are in close approximation with each
overlapped ^rom above by the frontal process, below by other. Initially the two palatal shelves are covered by an
tne mandibular process and on either side by 'he maxillary epithelial lining. As they join, the epithelial cells
processes. degenerate. The connective tissue of the pclatal shelves
The ectoderm overlying the fronto-nascl orocess intermingle with each other resulting in their fusion.
shows bilateral localized thickenings obove the The entire palate does not contact and fuse at
stomodeum. Tnese are called the nasal placodes. These p the same time. Initially contact occurs in the central
acoces soon sink and form the nasal aits. region of the secondary palate posterior to the
The fomction o-*these nasal pits divides the :'onto- nasal premaxilla. From this point, closure occurs both
process into two parts : anteriorly and posteriorly. The mesial edges of the
a. The medial nasal process and palatal processes fuse with the free lower end of nasal
b. The lateral nasal process septum and thus separates the two nasal cavities from
The two mandiou'a r processes grow each other and the oral cavity.
medicllyand fuse to form the iower lip and lower jow. As
the maxillory process undergoes growth, the fronto-nasal Ossification of palate
process becomes narrow so that the two nasal pits come Ossificalion of the palate occurs from the 8th week of
closer. The line of fusion o- the maxillary process and the intra-uterine life. This is an intra membra nous type of
medial nascl process corresponds to the naso-'acrimal ossification. The palate ossifies from a single centre
duct. derived from the maxilla. The most posterior part of the
palate does not ossify. This forms the soft polate. The
mid-palalal suture ossifies by 12-14 years.

The maxillary sinus and Development
forms sometime of
around the 3rd month Cranial and Facial Region \ 27
of irilra-uterine life. It develops by expansion of the nasal
mucous membrane into tr*e maxillary bone. Later the
sinus enlarges by resorption of the internal wall of maxilla.

About the 4th week of intra-uterine life, the developing

brain and the pericardium form two prominent bulges on
the ventral aspect of the embryo. These bulges are
separated by the primitive oral cavity or stomodeum. The
floor of the stomodeum is formed by the bucco-pharyngeal
membrane, which separates it from the foregut.
The pharyngeal arches are laid down on the
lateral and ventral aspects of the cronialmost part of the
foregut which lies in close approximation with the
stomodeum. Initially there are six phan/ngecl arches, but
the fifth one usually disappears as soon as it is formed
leaving only five. They are separated by four branchial
grooves. The first arch is called the mandibular arch and
the second arch, hyoid arch. The other arches do not have
any specific names.
Each of these five arches contain :
1. A central cartilage rod thatforms the skeleton of the
2. A muscular component termed as branchiomere.
3. A vascular component.
4. A neural element.
The mandibular asch forms the laterol wall of the
stomodeum. It gives off a bud from its dorsal end. This bud
is called the maxillary process. It grows ventro-medially,
cranial to the main part of the arch, which is now called the
mandibular process. The mandibular processes of both
sides grow towards each other and fuse in the midline.
They now form the lower border of the stomodeum i.e.
the'lower lip and the lower jaw.

/WecJce/'s cartilage
The Meckel's cartilage is derived from the first branchial
arch around the 41st - 45th day of
lingula of mandible to the spnenoid bone also fonns a
remnant of tne Meckel's cartilage.

Endochondral bone formation

Endochondral bone formation is seen or y in 3 areas of
the mandible :
1. The condylar process
2. The coronoid process
3. Tne menlc' region

Condylar procoss : At about the 5th week of

intra-uterine life, an area of mesenchymal
Fig S IA) Meckel S cati'age (B.I
Inferior olveolcr rerve (C) Initiction of condensation car be seen above rhe ventral part of *he
ossificate n orojrc -he Meckel's developing mandible. Tnis develops ir*o c cone -
shaped cartilage (:ig 6) by abcu- 10th week and starts
ossification by T 4th week. It then migrates infer'orly
intra-uferine life. It extends and fuses with the mandibular ramus by abou* 4
from the cartilaginous otic capsule to the midline or monlns. Much o: tne cone - shaped cartilage is
symphysis ard provides a temolare for guiding the growth rep'aced by bone by the middle of fetal life but its upper
of the mandible (fig 5). A major portion of the Meckel's end pe-sisfs irrt> aduHooc' f acting both asa growth
cartilage disappears during growth and the remaining part cartilagoand cn articular cartilage.
develops into the following structures:
Coronoid process : Secondary accessory cartilages
1. The mental ossicles
appear in rhe region of the coronoid orocess by ooou'
2. Incus and Malleus
the 10-14 week of intra-uterine fe. This secondary
3. Spine of sphenoid bone
cartilage of coronoid process is believed to grow as a
4. Anterior rgament of malleus
response to the developing temporalis muscle. The
5. Spheno - mandibular ligament
coronoid accessory
The first structure to develop ir the primordium of
the lower jaw is the mandibular division of the trigeminal
nerve. This is followed by the mesenchymal condensation
forming the first branchial arch. Neurotrophic factors
coduced by the nerve induce osteogenesis in the
ossification centres. A single ossification centre hr each
half of the mandible arises in the 6th •ve-ek of
intra-uterine life in the region of 4he b 'urcation of the
inferior alveolar nerve into —ental ond incisive branches.
The ossifying membrane is located latercl •o 'He
Meckel's cartilage and its accompanying reuro-vascular
bundle. From this primary centre, ossification spreads
below and around the inferior cveolar nen/e and its
incisive branch ond upwards to form a trough for
accommodating *he developing tooth buds. Soread of the
intramembrcnous oss"fica4ion dorsally ard ventrally forms
the body and rcmus of the mandibe.
As ossif'carion continues, the Meckel's
cartilage becomes surrounded ard invaded by oone.
Oss'fication stops at the site ^har will ! ater become the
mandibular lirgula from where the Meckel's cartilage
continues into the middle ear ana develops into the
auditor/ ossicles i.e. malleus & incus. The
spnenomandibulc ligament wh'ch extends from the

cartilage becomes incorporated into the expanding processes occurring ot the cranial base con affect the
intramembranous bore of the ramus "d disappears before placement of maxii.'a and the mcndible.
Growth and Development of Cranial and Facial Region \ 29
birtn. The cranial base grows post-narally by-

venfo/ region : In the mental region, on either side of the complex interaction between the following three growth

symahysis, one or two small cortilages rspeorand ossify in processes.

the 7th month of irtra-uterine a. Extensive cortical drift and remodeling

b. Elongation ot synchondroses
c. Sutural growth

Cortical drift and remodeling

Remodeling refers to a process where bor.e deposition
ard resorption occur so as to bring about change in s'ze,
shape ana relationship of the bone. The cranium is
divided into a number of compartments by bony
elevations and ridges present 'n the cranial base. These
elevated ridges end bony partitions show bore
deposition, while Ihe predominant part ot the floor shows
bone resorption (fig 7). This intracranial bone resorption
helps in increasing the intracranial space to
accommodarethc growing brain.
The cranial base is perforated by the passage
of a number of blood vessels end nerves communicating
with the brain. The foramina that allow the passage of
these nen/es and blood vessels undergo drifring by bone
deposition and resorption so as to constantly maintain
their proper relationship with Ihe growing orain.

Fig 6 Corey cr cart lags ceveloos

rria'ly cs c seoa'cts area and
fuses with tne mardibtlar body
oiround Ihe fcjrti rnont.n ot intra
.re'ine life

life to form vcriable numbers of mental ossicles in the

fibrous tissues of the symphysis. These ossic es become
incorporated into the intramembranous bore when the
symphysis ossifies completely during tne firstyecrof
post-natol life.



The maxil a is at-ached to tne cranial base by meens of a

number of sutures. The mandible too is ottached to Ihe
cranial base at the temporo- mendibu ar joint. Tnus growth
Orthodontics - The Art and Scicncc

The struclure of a synchondrosis is like 2

epiphyseal plates positioned back to back and

Fig 7 Bone remodeling seen in cranial bcse.

Elongation at the synchondroses

Most of ihe bones of the cranial base are formed by a
cartilaginous process. Later the cortilage is replaced by
bone. However certoin bands of cortilage remain at the
junction of various bones. These areas are called
Synchondroses. They are important growth sites of the
cranial base. They are primary cartilages. The important
synchondroses found in the cranio! base are :
a. Spheno-occipital synchondrosis
b. Spheno-ethmoid synchondrosis Fig 8 (A) Spheno occipital - synchondrosis (BJ
c. Inter-sphenoid synchondrosis O > owl h ol Sphcrio - occipital synchondrosis
results in increase iri length and width of
d. Intra-occipital synchondrosis
sphenoid and occicitol bones

Spbeno-ocdprfa/ synchondroses r It is the cartilaginous

junction between the sohenoid and the occipital bones (fig
8.a). The spheno-occipital synchondrosis is believed to be
the principal growth cartilage of the cranial base during
childhood. It is considered to be Ihe most important growth
site of the cranial base. The spheno-occipital
synchondrosis is believed to be active up to the age of
12-15 years. The sphenoid and the occipital segments
then become fused in the midline area by 20 years of age.
The spheno-occipital synchon-drosis provides a
pressure or compression adapted bone growth, in
contrast to the tensron adapted growth seen in sutures.
This is because the cranial base supports the weight of
the brain and face which bears down on the
synchondros:s in the midline of the cranial base. As
endochondral bone growth occurs ctthe spheno-occipital
synchondrosis, tne sohenoid and the occipital bones are
moved aport. At the same time new endochondral bone is
laid down in the medullary region, and cortical is
formed in the endosteal and periosteal regions. Thus the
sphenoid and occipital bones increase in length and width
(fig 8.b).
separated by a common zone of reserve cartilage. 7ns is simply moved anteriorly as Ihe middle cranial fossa
direction of growth of the spheno-occipital synchondrosis grows «n that direction. The passive disp'acement of the
Growth and Development of Cranial and Facial Region \ 31
is upwards. It therefore carries the anterior part of the maxilla is an importantgrowth mechanism during the
cranium bodily forwards. The growth at the syncondrosis primary dentition years but becomes less important as
continues till the cbliteration of the some by formation of growth of cranial base slows.
bone. Sadies by various scientists have shown that the In addition, a primary type of displacement is
dosure of ihe syncnondrosis occurs on an average c: also seen in a forward direction (fig 9.a). This occurs by
13-15yecrsofage. growth of the maxillary tuberosity in a posterior direction.

Sp/ieno-etfimoia' synchondrosis : This is a ccrtilaginous This results in the whole maxilla being carried anteriorly.

bond between the sphenoid and eihmoid bones. It is The amount of this forward displacement equals the

believed to ossify by 5-25 .ears of age. amount of posterior lengthening. This is a primary type of
displacement as the bone is displaced by its own
/nter-spheno/da/ synchondrosis : It is a cartilaginous band
betwoen the 2 parts of the sphenoid bone. It is believed to
ossify at birth. Growth at sutures
Intra-occ/pital synchondrosis : This ossifies by 3-5 The maxillo is connected to the cranium and cranial base
years of age. by a number of sutures. These sutures include : a.
Fronto - nasal suture
Sutural growth
The cranial bcse has a number of bones that are joined to
one another by means of sutures. Some of the sutures
that are present include : o. Spheno - frontal
b. Fronto - temporal
c. Spheno - ethmoid
d. Fronto - ethmoid
e. Fronto - zygomatic
As the brain enlarges during growth, bone
formation occurs at the ends of the bone (thot is at either
ends of the suture).

Timing of cranial base growth

a. By birth, 55-60% of adult size is attained.
b. By 4-7 years, 94% of adult size is attained.
c. By 8-13 years, 98% of adult size is attained.

The growth of the n aso-maxillary complex is produced by

the following mechanisms
a. Displacement
b. Growth at sutures
c. Surface remodeling

Maxilla is attached to the cranial base by means of a
number of sutures. Thus the growth of the cranial base
has a direct bearing on the nasomaxillary growth.
A passive or secondary displacement of the
naso-maxillory complex occurs in o downward and
forward direction cs the cranial base
grows. This is a secondary type of
displacement as the actual enlargement of these parts is
not directly involved (fig 9.b). The naso-maxillary complex
/^Orthodontics - The Art and Science

the orbital rim leading to latere movement ol Ihe

eye ball. To compensate, *here is bone deposition
on the medial rir of the orbit end on Ihe external
surface of the lateral rim.
i11 (2) The floor of the orbit faces superiorly, latere11 y ond
A anteriorly. Surface deposition c-ccurs here ond
-ig 9 ;A; P'ima7 displocener or moxil results in growth in a superior, Ictercl and anterior

b. Fronto - maxillary suture direction.

c. Zygonatico - temporal suture (3) Bore deposition occurs along Ihe posterior margin

d. Zygomatico-maxi!'ary suture of the mcxiiIory tuberosity. This causes

e. Pferygo - palatine suture lengthening of the den*al arch and enlargement of

These sutures arc cII ob ique and more or less the antero-oosterior dimens'on of Ihe entire

parallel to eacn ctne'. This allows the downword and maxillary body. This helps to accomodctc the

forward reoositioning of the maxilla c s growth occurs crjpting molars.

at these sutures. .As growth of the surrounding soft (4) Bone resorp-ion occurs on the lateral wall of the

tissue occurs, the maxilla is carried downwards and nose leading to an ircrease in size of tne nasal

forward. This leads to opening up of space at tne cavity.

sutural attachments. New bone is now formed on {5) Bone resorption is seen or the floor cf the nosal

either side of the suture. Thus the overall size of the cavity. To compensate there is bone deposition on

bones on either side increases. Hence a tension the palalu side. Thus a nel downward shift occurs

related bone formation occurs at the sutures. leading to increcse in maxillary he'ghl.
(6) The zygomatic bone moves in a posterior direction.
Surface Remodeling
This is achieved by reso'ption on the an*erior
In addition to the growth occurring ct the sutures, surface end deposition on Ihe posterior s J rfacc.
massive remodeling by bone deposition and resorption (7} The fcce en'arges in width by bone formation
occurs to bring about :
Increase in size
Change in shcoe of bone
Change in funcional relationship
The following ore the bone remodeling
changes that are seen in ihe naso-maxillcry complex
{fig 10):
(1) Resorption occurs on the lateral surface of

(B) Secondary disc ocemert cf no*'Ila
Growth and Development of Cranial and Facial Region \ 33

........ Resorption
+ 4+ Deposition

Fig 10 Surface re mode ng changes in *iic micr'ac© (A| Bene remoceling seen n the mid:acial region (B & C) Bono remodeling
of tne palate resulting 'n irs dov/nward displacement (D) G'Owth of the palcto exhibiting V pattern of gro'.vlfi (t) 3onc
remodeling o* the Zygomatic process


on the lateral surface of the zygomatic arch and

resarplion on its medial surface. Of the facial bones, the mandible undergoes the largest
(8) The anterior nasal spine prominence increases amount of growth post-natalfy and also exhibits the
due lo bone deposition. In addition there is largest variability in morphology. While the mandible

resorption from the periosteal surface of labiol appears in the adult as a single bone, it is

cortex, /vs a comuensalory mechanism, bone developmental^ and functionally divisible into several
deposition occurs on the endosteal surface of tne skeletal sub-units. The basal bone or the body of the
labial cortcx and periosteal surface of the lingual mandible forms one unit, to which is attached Ihe
cortex. alveolcr process, the coronoid process, the condylar
(9) As the leeln start erupting, bone deposition occurs process, the angular process, the ramus, the lingual

at the alveolar margins. This increases the tuberosity and the chin. Thus the study of post-natal
maxillary heignt and the depth of the palate. growth of the mandible is made easier and more
(10) The entire wall of the sinus except the mesial wall meaningful when each of the developmental and
undergoes resorption. This results in increase n functional parts are considered separately (fig 11).
size of the maxillary antrum.
The ramus moves progressively posterior by a
combination of deposition and resorption.
Resorption occurs on the anterior part of the ramus
while bone deposition occurs and
on theDevelopment
posterior region. of Cranial and Facial Region 35
This results in a 'drift' of the ramus in a posterior
direction. The functions of remodeling of the ramus are
1. To accommodate the increasing mass of
masticatory muscles inserted into it.
2. To accommodate the enlarged breadth of the
pharyngeal space.
3. To facilitate the lengthening of the mandibular
body, which in turn accommodates the erupting

Fig 71 Posi - natal deve'opmen- of mand:ble (A & B) 8one remodeling seen in mandible (CJ Bone rcrnodcl ng seen ir lingucl tuberosity and lingulo
{D) Bone resorption Jeoding to formation of antiponial notch jE) Mancibtlor growth following V put'ern |F) Cross-section of rarrvjs showing bone

Corpus or the body of mandibfe

As observed earlier, the anterior border of the adult
ramus exhibits bone resorption while the posterior
border shows bone deposition. That is, the
displacement of the ramus results in the conversion ol
former ramal bone into the posterior part of the body of
mandible. In this manner the body of

combination of resorption in the fossa and deposition
on the medial surface of the tuberosity itself
accentuates the prominence of Ihe lingual tuberosity.

The alveolar process

Alveolar process develops in response to the presence
of tooth buds. As the teeth erupt the alveolar process
develops and increases in height by bone deposition at
the margins. The alveolar bone adds to the height and
thickness of the body of the mandible and is
particularly manifested as a ledge extending lingual to
the ramus to accommodate Ihe 3rd molars. In case of
absence of teeth, the alveolar bone fails to develop
and it resorbs in Ihe event of tooth extraction.

The chin
The chin is a specific human characteristic and is
found in its fully developed form in recent man only. In
Fig 12 (A) Mandibular growth due to bone -Jepos'tion
ar -r>2 condylar cartilage (B) Maildibu'cr crcwth at the infancy, the chin is usually underdeveloped. As age
condyle •allowing 1ne downworc disp acerrent of the advances Ihe growth of chin becomes significant. It is
ma-id b^e due to soft tissue growth
influenced by sexual and specific genelic factors.
:ne mandible lengthens. Thus additional space made Usually males are seen to have prominent chins
available by means of resorption of the anterior border compared to females. The mental protuberance fomns
of the ramus is made use of to accommodate the by bone deposition during childhood. Its prominence is
erupting permanent molars. accentuated by bone resorption that occurs in the
olveolar region above it, creating a concavity. The
Angle of the mandible deepest point in this concavity is known as 'point B' in
On the lingual side of the angle of mandible, resorption cephabmetric terminology.
lakes place on the posterio-inferior aspect while
deposition occurs on the antero- superior aspect. On
the buccal side, resorption occurs on the
anterio-superior part while deposition takes piace on
Ihe postero-superior part. This result in flaring of the
angle of the mandible os age advances.

The Ungual tuberosity

The lingual tuberosity is a direct equivalent of the
maxillary tuberosity, which forms a major site of growth
for the lower bony arch. It forms the boundary between
the ramus & the body.
The lingual tuberosity moves posteriorly by
deposition on its posteriorly facing surface. It can be
noticed that the lingual tuberosity protrudes noticeably
in a lingual direction and that it lies well towards the
midline of the ramus. The prominence of the
Tuberosity is increased by the presence of a large
resorption field just below it. This resorption field
produces a sizable depression, the lingual fossa. The
2. Bcrnabei arc Johis'on : T ic g-Owlh n situ of isola'ed mairJiojIar

Growth and Development of Cranial and Facial Region 37

The condyle segments. Am J Ortnod 1973 ; 24-35

3. Bha cjhi SI : Dental Anatomy, Histology and Devel- opment,
The mandibular condyle has been recognized as an Arya publishing house. New Delhi, 1993
important growth site. The head of Ihe condyle is 4. Bprk : P'ec'iction of mandibular growth rota-ion. An J Orthod
1969 ;3?-53
covered by a thin layer of cartilage called the condylar 5. Ejscncna, Tcnauay, Dcrrirjian, LuPalme, and Goldsieir :
cortilagc. The p'escncc of the condylar cartilage is an Modeling longitudiral mandibular growth. Am J Orhoc 1939
adaptation to withstand Ihe compression that occurs at 6. da Silva, Nlonrcndo, and Cupu oiza : "nflcence cf deft type on
the joint. Tne role of the condy'e in the growth of ncndibUar growth. Am J 0*tnod 1993 .-269-275
7. Erlow : Horn nook of r'cria growh, WB Saunders Conpcny,
mandible has remained a controversy. There are two 1962
schools of thought regarding the role of the condyle. 8. G'obsr TM : Orhocontics : Principles and practios. WB
Sounders,T 933
a. It was earlier believed that growth occurs at the 9. -egg ond Ahstrom ; Estirrotec mandiojlor growth. Am J Orthcd
surface of the condylar cartilage by means of bone 1992 ;146-152
10: Herneber<e nnd Prahl-Anderser : Cranicl base growth. Am J
deposition. T n us the condyle grows towards the
Olhod 1994 ; 503-512
cranio I base. As the condylc pushes against Ihe 11. Koski : Cronia growth centers: Facts or *'a lades? Am J
crania! base, the entire mandible gets displaced Orthod 196B ; 566-583
12. Kraut end K-orman : Relaiionsh p octwcen potency ot max'l
forwards and downwards (fig 12.a). c.rf s'nus ard cran'ofadal growfn in 'obbit. Am J Orthod 193B .
b. It is now believed that the growth of soft tissues 467-476
13. Mi tani : Prepubertal growh of rnendibulo' prcgnoth'sm. Am J
including Ihe muscles and connective tissues
Orthod 1981 ; 5^6-553
carries the mandible forwards away from the "4. Mi tani, Scto, and Sugav/aro : lals grawtn of mandibular
prognctnlsm. Am J Crthcd 1993 ; 330-336
cranial base (carry away phenomenon). Bone
growth follows secondarily at the condyle to 15. Nielsen, Biovo, ond Miller : Nomial rroxiltary ond mandibular
growth a id dcntoalveola' deve'opirent
maintain constant contact with the cranial base. in Macaco mulatto. Am J Orthod 19B9 . 405-415
16. Nielsen, B'avo, ore Miller ; Normol moxil'ory end mandibular
The condylar growth rate increases at
growth and Hentonlveola' development
puberty reaching a peak between 12 1/2 - 14 years. in Macaco mulatto. Am J Orhoc 1969 r 405-415
The growth ceases around 20 years of age. 17. Prof it V-/R: Confcmpo'ary Oihodontics, S' lou s, CV
13. Robert E Moyers : Hand book 0; Orthodontics, Year book
The coronold process medical publishers, inc,l 986.
19. Rossovw, Lomba'd, and Han-is : Frontal sinus and
The growth of the coronoid orocess follows the mano'ibula' growth prediction. Am J O-tnod 1991 ; 542-546
enlarging V principle. Viewing, the longitudinal section 20. Sclzmar JA . Pracioe of Orlhodortics, J B L'ppincott ccmpony,
of the coronoid process from the posterior aspect, it
21. Ter cate AR : Oral Histology : Development Siruc •Lre and
can be seen that deposition occurs on the lingual Function, C.V.Mosby, Si lo>jis,19B0

(medial) surfoces of the left and right coronoid process.

Although additions takes alace on the lingual side, the
vertical dimension of the coronoid process also
increases. This follows the V principle. Viewing it from
the occlusal aspect, 'he deposition on the linguol of the
coronoid process brings about a posterior growth
movement in tne V pattern. Briefly tne coronoid
process has a propel er-iike twist, so 'hat its lingual side
faces three general directions all at once, i.e
posteriorly, superiorly and medially.

*. Avotb or d V.os'afo : .Vcndibdo' growth. An J O-triad 1992 r


he embryonic oral cavity is lined by stratified
squamous epithelium known as the oral
ectoderm. Around the 6th week of intra-uterine
life, the infero-latercl border of Ihe maxillary arch and
the supero-lolerci border of the mandibular arch show
localized proliferation of the ore' ectoderm resulting in
the formation of a horse-shoe shaped band of tissue
called the dental lamina (figl). This dental lamina ploys
an important role in Ihe development of the dentition.
The deciduous teeth are formed by direct proliferation

Development of Dentition
and Occlusion
of the dental lamina. The permanent molars develop as
a result of its distal proliferation while the permanent
teeth mat replace deciduous teeth develop from a
lingual extension of the dental lamina. Thus all teeth
originate from the denial lamina.
. '.-'-V-V •'.■"•".v'.vVl
The ectoderm in certain
areas of the dental lamina proliferates and forms
knob-like structures that grow into the underlying
mesenchyma. Each of these knobs represents a future
deciduous tooth and is called the enamel organ. The
enamel organ passes through a number o~ stages
ultimately forming the teeth. Based on the shape of the
enamel organ, the development of teeth con be divided
into three stages. They are the bud, cap and the bell

Fig 1 Dental larnino

BUD STAGE The stellate reticulum expends further due to
39 z Orthodontics - The Art and Science
continued accumulation of intra-cellularfluid. The cells
This is the initial stage of tooth formation where the
of this area are star shaped, having large processes
enamel organ resembles a small bud (fig 2.a). During
that anastomose with those of adjacent cells. As the
the bud stage, the enamel organ consists of
enamel formation starts, the stratum reticulum
peripherally located low columnar cells aria centrally
collapses to a narrow zone thereby reducing the
located polygonal cells. Tne surrounding
distance between the outer enamel and inner enamel
mesenchymal cells proliferate, which result in their
condensation in two areas. The area of condensation
The cells of the outer enamel epithelium
immediately below the enamel organ is the dental
flatten to form low cuboidal cells. The outer enamel
papilla. The ectomesenchymal condensation that
epithelium is thrown into folds which are rich in
surrounds the tooth bud and the dental papilla is the
capillary network. This provides a source of nutrition
dental sac. The dental papilla as well as the de.ntol sac
for the enamel organ. Before the inner enamel
are not well defined during the bud stage. They
epithelium begins to produce enomel, the peripheral
become more defined during the subsequent cap and
cells of the dental oapilla differentiate into
bell stages. The cells of the dental papilla form the
odontoblasts. They are cuboidal cells that later
dentin and pulp while the dental sac forms cementum
assume a columnar form and produce dentin.
ond periodontal ligament.
The dental sac exhibits a circular
CAP STAGE arrangement of its fibres and resembles a copsule
around the enamel organ. The fibres of the dental sac
7r*9 tooth bud continues to proliferate resulting in c cap form the periodontal fibres that span between the root
shaped enamel organ (fig2.b). This is crcccterized by a and bone. The junction between the inner enamel
shallow invagination on the ■j-rier surface of the bud. epithelium and odontoblasts outlines the future
The outer cells of the cap covering the dentino-enomel junction.
coTvezrty are cuboidal and are called the outer enamel
epithelium. The cells lining the concavity of the cap
become tall columnar and are referred to as the inner
enamel epithelium. The central area of the enamel
organ between the outer ond inner enamel epithelium
which initially consisted of polygonal cells, accquire
more inter-cellular fluid and forms a cellular network
called the stellate reticulum. The stellate reticulum
reveals a branched network of cells. The
ectomesenchymal condensation i.e. the dentol papilla
and dental sac are pronounced during this stage of
dental development.

Due to continued uneven growth of the enamel organ it

acquires a bell shape (fig 2.c). The celfs of the inner
enamel epithelium differentiate prior to amelogenesis
into tall columnar cells called ameloblasts which lay
down enamel. The cells of the inner enamel epithelium
exert a strong influence on the underlying
mesenchymal cells of the dental papilla.
A few layers of flat squamous cells are seen
between the inner enamel epifhelium and the stellate
reticulum. This layer is called the stratum intermedium.
It is believed to be essential for enamel formation.
Fig 2 (A) Bud iloge [3) Ccp stage \C; Ball stogo (D) Root formation

ROOT FORMATION 4. The permanent dentition period.

Root development begins after -he dentin and enomel

formation reaches the future cemento- enamel junction.
The outer and inner enamel epithelium join and form a
sheath that helps in molding the shape of the root. This
sheath is called the Hertwig's epithelial root sheath.

Occlusal development can be divided into Ihe following

developmental periods:
1. Pre - dental period.
2. The deciduous dentition period.
3. The mixed dentition period.

Fig 3 G u-n pads (A) Maxillary (B; Mcmdi bu la'

PRE - DENTAL PERIOD there is a complete over jet all around. Contact occurs
between the upper and lower gum pads in Ihe first
This is the period after birth during which the neonate
molar region and a space exists between them in the
does not have any teeth. It usually lasts for 6 months
anterior region (fig 4). This infantile open bite is
after birth.
considered normal and it helps in suckling.
Gum Pads
The alveolar processes at the time of birth are known
as gum pads. The gum pads arc pink, firm and are
covered by a dense layer of fibrous periosteum. They
are horse-shoe shaped and develop in two parts (fig 3).
They are the labio- buccal potion and the lingual
portion. The two portions of the gum pads are
separated from each other by a groove called the
dental groove. The gum pads are divided into ten
segments by certain grooves called transverse
grooves. Each of these segments consists of one
Fig ^ Relation between j c per and lower gum pods o I birth
developing deciduous tooth see.
The gingival groove separa^s the gum pad
from the palate and floor ol the mouth. The transverse
groove between the canine and first deciduous molar
segment is called the lateral sulcus. The lateral sulcii
ore useful in judging the :nter-arch relationship at a very
early stage. The lateral sulcus of the mandibular arch is
normally more distal to that of the maxillary arch.
The upper and lower gum pads ore almost
similar to each other. The upper gum pad is both wider
as well as longer than the mandibular gum pad. Thus
when the upper and lower gum pads are approximated,
The status of dentition Spacing In deciduous dentition
Tne neonate is without teeth for about 6 months cf life. Spacing usually exists between the deciduous teeth.

AT birth the gum pads are not sufficiently ^ide to These spaces are called physiological spaces or
Development ofdevelopmental
and (fig
Occlusion 41
5). The presence of spaces
cccommodate The developing incisors which are
crowded in their crypts. During the first year of life the in tne primary dentition is important for the normal

gum pads grow rapidly permitting the incisors to erupt development of the permanent dentition. Absence of

in good alignment. spaces in the primary dentition is an indication that

Very rarely teeth are found to have erupted ct crowding of teeth moy occur when the larger

the time of birth. Such teeth that are present at the time permc.nent teeth erupt.

of oirtn are called nctal teeth. Sometimes teeth erupr at Spacing invariably is seen mesial to the

an early age. Teeth that erupt during the first month of maxillary canines and distal to the mandibular canines

age are called .neonatal teeth. The ncral and neonatal (fig 6). These physiological spaces are called primate

teeth are mostly loccted in the mandibular incisor spaces or simian spaces or anthropoid spaces as they

region and show a familial tendency. ore seen commonly in primates. These spaces help in
placement of the canine cusps of the opposing arch.

The initiation o" primary tooth buds occurs during the

first six weeks of intra-uterine life. Tne primary teeth
begin to erupT at the age of about 6 months. The
eruption of all primary teeth is completed by 2 1/2 • 3
1/2 years of age when the second deciduous molcrs
come into occlusion.

Eruption age and sequence of

deciduous dentition ■Sg 6 ^rirnatft spores
The mandibular central incisors are the first teeth to
erupt into the oral cavity. They erupt around 6 -7
months of age. The average age of eruption of the
deciduous dentition is given in Table I. The timing of
tooth eruption is nighly variable. A variation of 3 months
from the mecn age has been accepted as normal. The
sequence of eruption of the deciduous denlition is : A -
The primary dentition is usually established
by 3 years of age on eruption of the second deciduous
molars. Between 3 - 6 years of age, Ihe dental arch is
relatively stable and very few changes occur.

Fig 5 Spacing in dco'duous dentition
52 z Orthodontics - The Art and Science

flush terminal plane

The mesio - distal relation between the distal surfaces
of the upper and lower second deciduous molars is
called the terminal plane. A normal feature of
deciduous dentition is a flush terminal plane where the
distal surfaces o1 the upper and lower second
deciduous molars are in the same vertical plane.

Deep bite
A deep bite may occur in the initial stages of
development. The deep bite is accentuated by the fact
that the deciduous incisors are more upright than their
successors. The lower incfsal edges often contact the
cingulum arec of the maxillary incisors. This deep bite
is later reduced due to the following factors.
a. Eruption of deciduous mo'ars.
b. Attrition of incisors.
c. Forward movement of the mandible due to


The mixed dentition period begins at aporoxi.motely 6

years of age with the eruption of the first permanent
molars. During the mixed dentition period, the
deciduous teeth along with some permanent teeth are
present in the oral cavity.
The mixed dentition period can be classified
into three phases.
1. First transitional period
2. Inter-transitional period
3. Second transitional period

First transitional period

The first transitional period is characterized by the
emergence of the first oermanent molars and Ihe
exchange of the deciduous incisors with the
F'g 7 (A; Flusl- termircl plcne (B) Dislal step terrninol plane (Cj Mes
permanent incisors. cl step termina clone
Development of Dentition and Occlusion \ 43
Emergence of the first permonont molars: The leeway space. This occurs in the late mixed dentition
mandibular first molar ist'ne first permanent tooth to period and is thus called late shift.
erupt at around 6 years of age. Tne location and S. Mesra/ step terminal plane : In this type of relationship
relationship of the first permanent molar depends the distal surface of the lower second deciduous molar is
much upon the distal surface relationship between the more mesial than that of the upper (fig 7.c). Thus the
upper ond lower second deciduous molars. The first permanent molars erupt directly into Angle's Class I
permanent molars are guided into ihe dental arch by
occlusion. This type of mesial step terminal plane most
the distal surface of the second deciduous molars. The
commonly occurs due to early forward growth of the
mesio-distal relation between the distal surfaces of the
upper and lower second deciduous moiars can be of
three types.

A. Piush terminal plane: The distal surface of the

upper and lower second deciduous molars are in one
vertical plane (fig 7.a). This type of relationship is
called flush or vertical terminal plane. This is a normal
feature of the deciduous dentition. Thus the eruping
first permanent molars moy also be in a flush or end on
relationship. Forthe transition of such an end on molar
relation to a Class I molar relation, the lower molar nas
to move forward by about 3 - 5 mm relative to the upper
molar (fig 8).This occurs by utilization of the
physiologic spaces and leeway space in the lower arch
Fig 8 (AJ Ecrly shift of -ha erupting firs' permanen? molars moving
and by differential forward growth of the mandible. B
utilizing the primate spaces (B) Lata shift by utilization of tha leeway
The shift in lower molar from a flush terminal spaco
plane to c Class I relotion can occur in two ways. They
are designated as the early and the lale shift.
Early shift occurs during tne early mixed
dentition period. The eruptive force of the first
permanent molar is sufficient to push the deciduous
first and second molars forward in the arch to close the
primato space and thereby establish a Class I molar
relationship. Since this occurs early in the mixed
dentition period it is called early shift.
Many children lock the primate space

and thus the erupting permanent molars are unable to

move forward to establish Class I relationship. In these
cases, when the deciduous second molars exfoliate
the permanent first molars drift mesially utilizing the

44 z Orthodontics - The Art and Science

mandibular arch. The incisal liability is overcome by

the following factors :

A. Utilization of intera'enfa/ spaces seen in

primary dentition : The physiologic or the
developmental spaces tha* exist in -he orimary
dentition ore utilized *o partly accojnt for the incisal
liability. The oermanent ircisors are much more easily
accommodated in normal aligrment in cases exhibit'ng
cdequate inter-dental spaces than in an arc.n thaA has
no space.

S. Increase in inter - ccmirte width : During the

transition from the primary incisors to 'he permanent
incisors an increase in in-er-canme width of both the
maxillary as well as the mandibular arches has been
obse^/ed. This is on important fcctor which allows the
much larger permanent incisors to be accommodated
in the arch previously occupied by tne decidjous

C. Cna.nge i.n incisor inc/ination : One of 'he

mandible. H the differential growth of the mandible in a differences between deciduous crd permanent
forward direction persists, it car lecd to an Angle's incisors is their inclination. The primary incisors are
Class III molar relation. If Ihe forward mandibular more upright than Ihe permanent incisors. Since Ihe
growth is minimal, itccn estcblish a Class I molar permanen- incisors erupt more labially inclined they
relationship. tend to increase Ihe dental arch perimeter. This is
C. Dis.'ai step fermina/ p/ane : This is characterized by another factor that helps in accommodating the larger
the distal surface of the lower second deciduous molar permanent incisors.
being more distal to that of the upper (fig 7.b). Thus the
Inter • transitional period
erupting permanent molars maybe in Angle's Class II
occlusion. In this per'od the maxillan/ and mandibular arches

The exchange of incisors ; During the first transitional consist of sefs of deciduous and permanent teeAh.

period the deciduous incisors are replaced by the Between the permanent incisors and Ihe first
permcrent molars are the deciduous molars and
permanent incisors. The mandibular central incisors
canines. Tnis phase during the mixed dentition
are usually the first to erupt. The permanent incisors
are considerably larger than the deciduous teeth they
replace. This difference between the amount of space 'J U
for the accomodation of the inciso's and the
cmountof space available for this is called incisal
liabi ity. The irciscl liability is roughly about 7 mm in
the maxillan/ arch and about 5 mm in the
Completed Hard Tissue Formation Amount of Enamel Enamel Completed Eruption Root

Begins Formed at Birth


Central mclsor 4 mos. in utero Five sixths 1 1/2 mos 71/2 mos 1 1/2 Yrs
Laterai incisor 4 1/2 mos. in utero T//o thirds 21/2 mos 9 mos 2 Yrs
Cuspid 5 mos. in utero One third 9 mos 18 mos 3 1/4 Yrs
First molar 5 mos. in utero Cusps united 6 mos 14 mos 2 1/2 Yrs
Sccond molar 6 mos. in utero Cusp tips still isolated 11 mos 24. mos 3 Yrs

Central incisor 4 1/2 mos. in utero Three fifths 2 1/2 mos 6 mos 1 1/2 Yrs
Lateral incisor 4 1/2 mos. in utero Three litths 3 mos 7 mos 1 1/2 Yrs
Cuspid 5 mos. in utero One third 9 mos 16 mos 31/4 Yrs
First molar 5 mos. in utero Cusps united 5 1/2 mos 12 mos 2 1/4 Yrs
Second molar 6 mos. in ulero Cusp tips stilt isolated 10 mos 20 mos 3 Yrs
Amount of Enamel Eruption Root
Hard Tissue
Tooth Enamel Complet Completed
Formation Begins
Formed at Birth ed

7 - 8 Yrs 10 Yrs
Central incisor 3 - 4 mos.
8 - 9 Yrs 11 Yrs
Lateral incisor 10-12mos.
Cuspid 4 -5 mos.
First bicuspid 11/2 - 1 3/4 Yrs.
Second bicuspid 2 - 2 1 / 4 Yrs
First molar at birth
Second molar 21/2 - 3 Yrs

Central incisor 3 - 4 mos.
Lateral incisor 3 - 4 mos.
Cuspid 4 -5 mos.
First bicuspid 13/4 - 2 Yrs.
Second bicuspid 21/4 -2 1/2 Yrs
First molar at birth
Development of Dentition and Occlusion 47

12 Yrs 13-15 Yrs 1 0 - 1 1 Yrs

12 -13 Yrs 1 0 - 1 2 Yrs
12-14 Yrs 6 - 7 Yrs 9-10

Yrs 11- 13 Yrs t4

- 1 6 Yrs
Second molar 21/2 - 3 Yrs

Some times a trace

6 - 7 Yrs 9 Yrs
7 - 8 Yrs 10 Yrs
9 - 1 0 Yrs 12-14
'fW/ififj'//'1': Yrs 10 - 12 Yrs 1 2 - 1 3 Yrs
1 1 - 1 2 Yrs 1 3 - 1 4 Yrs
Some times a trace 6 - 7 Yrs 9 - 1 0 Yrs
1 1 - 1 3 Yrs 1 4 - 1 5 Yrs
Development of Dentition and Occlusion 48

Fig 10 Ugly duckling stage > the development of dentition. Note l ow lho erupting ccninc causcs the displacement of 'he roo'S
of the latera arc central ncisor mesially resuming in a midline diastema which corrects inter by f jrtner erjp-ion of the canines.
Orthodontics - The Art and Science

period is relatively stable and no change occurs.

molars. Tne mean eruption dates of the permanent

The second trans/t/o n a/ period dentition is given in Table II.

The eruption sequence of the permanent
The second transitional period is characterized by the
dentition may exh ib it va riation. The freq uent ly see n
replacement of the deciduous molars and canines by
sequences in the maxillan/ arch are : 6 - 1 - 2 -
the premolcrsand permanent cuspids respectively.
4 - 3 - 5 - 7 o r 6 - 1 - 2 - 3 - 4 - 5 - 7 .
The combined meslo-distc! width of the permanent
In case of the mandibular arch the sequence
canines and premolars is usually 'ess than that of the
is :
deciduous canines and molars. The surplus space is
6 - 1 - 2 - 3 - 4 - 5 - 7
called leeway space of Nance (fig 9). The amount of
o r
leeway space is greater in the mandibular arch than in
6 - 1 - 2 - 4 - 3 - 5 - 7 .
the moxillary arch. It is about 1.8mm (0.9 mm on each
side of the arch) in the maxillory arch ond about 3.4mm
(1.7mm on each side of the arch) in the mandibular fteferences
arch. This excess space available after the exchange
1. BMojii SI : Dsrto' Anctomy, Histology and Development. Arya
of the deciduous mo'ars and canines is utilized for publishirg house. New Delhi, 1998
mesial drift of the mandibular molcrs to establish Class 2. Raoerr E Mayers : Hard book of Orthodontics, Year book
medicol publishers, he/988.
I molor relation.
3. Ten cote AR : Oral Hista'ogy : Development Structure and
The ugly duckling stage : Sometimes a transient or self Function, C.Wosby, St Louis,198C
A. Van der Lir den : Developmen* of ine dentition, gu ntessence,
correcting malocclusion is seen in the maxillary incisor
Chicago, 1983
region between 8 - 9 years of age. This is a particular 5. Van rier Lirden, F.RG.Vi. and DuteHco HS : Development cf the
human dentition: An ctlos : Ho'per and Rev/, 1976
situation seen during the eruption of the permanent
canines. As the developing permanent canines erupt,
they displace the roots of the lateral incisors mesially.
This results is transmitting of the force on to the roots
of the central incisors which also get displaced
mesially. A resultont distal divergence of the crowns of
the two central incisors causes a midline spacing. This
situation has been described by Broadbent os the ugly
duckling stage as children tend to look ugly during this
phase of development. Porents are often
apprehensive during this stage and consult the dentist.
This condition usually corrects by itself when the
canines erupt and the pressure is transferred from the
roots to the coronal area of the incisors.

The permanent dent'tion forms within the jaws soon

after birth, except for the cusps of the first permanent
molars which form before birth. The permanent
incisors develop lingual or palatal to the deciduous
incisors and move labiallyas they erupt. The premolars
develoo below the diverging roots of the deciduous

he orofacial region perorms a wide range of to use the lips to keep the food from being forced out of
-unctions such cs mastication, swallowing, The mouth. The bolus of food is mixed with salivo by
respiration and speech. It is now an accepted the oction of the tongue and is forced between the gum
fact tnat form and function are interrelated. Normal pads or the occlusal surfaces of the erupting teeth.
development of The orofacial region is to a large extent Tne mastication of food in an adult occurs in
dependent upon normal function.Tne functions of the the following six phases as outlined by iViurphy.
oro-facicl region include mastication, swallowing,
respirotion, speech, facial expression and maintanance Preparatory phase
of mandibular position. In this chapter we study some of During this phese, the ingested food is positioned by
the important functions of Ihe oro-facicl region end their the tongue towards the chewing side and the mandible
role on development. moves to the same side.

MASTICATION Food contact

This phase is characterised by a momentary pause in
Mastication is a complex activity aimed at breaking
the mastication. During this period, the sensory
down and insalivalion o; tne food, preparatory to
rcceptors evaluate the apparent viscosity of the
swallowing. In infants, the food is taken in by sucking as
ingested food and the probable load on the masticalory
their diet is mostly confined to liquids. Thus masticction
in the true sense is nor present in infants. As the infant
switches on to solid or semi-solid food, it quickly lecrns
Crushing phase infantile swallow
Tne food is crushed by equal activity on bo+h sides of The ability to feed from the breast is oresent in the new
the dentcl arch. Tne crushing rarts with a high velocity born child. During the process of suckling, the nipple is
and gradually slows down. drawn into the mouth by negative pressure from within.
The tongue lies over the lower gum pads and protrudes
Tooth contact between the nioplc and lower lip.
During this phase tne teeth come in contact and The milk is directed continuously to the
signifies the end of the crushing phase. pharynx by an automatic peristaltic movement of the
tongue and mylohyoid muscle. During this process,
Guiding phase regular breathing continues. The milk passes between
During this phase, the contcct becomes unilateral and the fa u c ia I pillars and the lateral cnannels of the
there is transgression of the mandibular mo'ars across pharynx. Any excess milk in the mouth dribbles down
the maxillary counterparts. the chin.
The chorac'eristics of cn infantile swcltaw as
Centr/c occlusion outlined by Moyers is as follows :
a. The jaws are apart and the tongue is placed
The teeth come to a definite and distinct stop.
between the upper and lower gum pods.

DEGLUTITION b. The mandible is stabilised by the contraction of the

muscles of the seven-h cranial nerve and the
Deglutition or swallowing is an im portent function
interposed tongue.
carried out by the stomatognathic system. The
c. The swallow is guided and to a large extent
swallowing pattern in infants is different from that seen
controlled by sensory interchange between he lios
in adults. Thus two main forms of swallowing are
and tongue.
recognised. They are the infantile swallow and the
As the infant begins to eat solid food, there is
mature swallow.
a distinct change in tne swallowing pattern. The tongue

is contained within the denial arches and the mandiblo
is ro longer protruded. This here Ids tne onset of the
mature swallow. Functional Development x 51
Mature swallowing
Mature swallowing is seen after a year of life. The
infantile swallow gradually disappecrs with the eruption
of the buccal teeth in the primary dentition. The
cessation of Ihe infanti e swallow and the appearance
of the mature swa low occur groduolly. During the
transitional period, characteristics of both; infantile and
mature swa low ccn be observed.
Deglutition occurs in four phases :
1. The preparatory swallow
2. The oral phase
3. The pharyngeal phase
4. The oesophageal phase

Trie preparatory swa'fow r The food after mastication is

assembled asa compact bolus on the dorsum of Ihe
tongue. In order ^o achieve this the teeth are parted a
little and the cheek muscles contract. The teeth are
then broug.nt into occlusion to stabilize the jaws and to
close the oral ccvily properly and isolate it from the
labial vestibule. The posterior aspect of the tongue
presses agains* the soft palate to isolate the oral cavity
from the pnarynx. Thus at this time, the
spontaneously at birth and is oided by Ihe posture ol the
mandible and hyoid bone. Normal oro-facial
development is to a large extent dependent upon
presence of normal respiration.

Fig 1 Pariant habituated to noj-h breathing Note the ■larroWing ot the

mcxillary arch producing posterior cross b te. lateral cephalogram rcvecls a
land face and vertical growth potfern.

oral cavity forms a sealed unit.

The oral phase : The soft palate is raised to seal off the
nasal cavity arid Ihe posterior pari ol me tongue drops
down. These movements create a smooth path for the
bolus as it is pushed into me pharynx by tne peristaltic
action ol the tongue.

The pharyngeal phase ; The pharyngeal phose begins

as soon as the food pesses through the faucial pillars.
As the food reaches Ihe pharyngeal walls, there is a
reflex upward movement of the entire pharyngeal
complex. When the pharyngeal walls touch the soft
palate a peristaltic movement sets up to move the food

The oesophageal phose : This phase commences as

soon as Ihe food passes the cricopharyngeal sphincter.
Peristaltic activity of the oesophogcal wolls occur to
pass tne food into the stomach.
The tongue and the palate return to their
original position to start the next cycle.


Respiration is an inherent reflex activity. The newborn

infant is basically a nasal breather. Breathing is evoked
Functional Development x 53

Fig ? Paiienl v/'th o n Icy og ossio of tongue. Note -he na-row mcxilla'y arch ard widening O" mcrcibular orch dje to lowered tonouo position

In potients having partial or total nasal PASSIVE MUSCLE FUNCTION

obstruction, nasal breathing may not be possible. A number of muscles exert force on the developing
These patients breathe through the mouth. The jaws. There has been obsen/ed to be a strong
alteration in breathing pattern brings obout a lowered inter-depend e nee between the bone and the muscles.
mandibular and tongue oosition. Thus theoro-facial Although the bone is one of the hardest tissues in the
muscular balance is lost leading to abnormal body, it is most responsive to environmental factors
development of the dental arches. including musculature.


Speech is largely a learned activity. The first sounds

produced by a child is often the baby cr/. The
mechanism of crying is intimately related to respiration
with laryngeal and pharyngeal coordination.
Speech is an acquired skill that involves
production of basic notes in the larynx known as
p'nonalion, and modification of these sounds by
changing the shape of the cavities in Ihe mouth, nose
end throat, which is known as articulation.
A lorge number of muscles are involved in
production of speech. They include the muscles of the
wall of Ihe torso, resp;ratory tract, the pharynx, the soft
palate, the tongue, lips and foce. Speech does not
moke gross demands on the oeri-oral musculature and
hence speech defects are rarely a cause for
The teeth and the supporting structures are holes assumed a linear form in the direction of the
blanketed from all directions by muscles. Thus -«e bony trabeculae. These were called Benninghoff's
integrity of the denrol arches and the relationship of the lines or trajectories which indicate • the direction of Ihe
teeth with each other and with sseth of the opposing functional stresses.
arch is to a large extent nfluenced by muscles.
Trajectories of the maxilla
The dentition is covered by a continuous
muscle band that encircles it starting with the fibers of The trajectories of Ihe maxilla can be broadly
the lips, the muscles run laterally and posteriorly classified as vertical and horizontal trajectories. The
around the comer of the mouth, joining the fibers of vertical trajectories include the fronto-nasal bullress,
buccinator which insert into the pterygomandibular the malar-zygomatic buttress and the pterygoid
raphoe. These fibers intermingle with the fibers of the buttress.
superior constrictor and continue posteriorly and Fronto-nasaf buttress : This trajectory originates from
medially to anchor at the origin of the superior Ihe incisors, canines and the first maxillory premolar
constrictor i.e. at the pharyngeal tubercle. The and runs craniallyalong the sides of the piriform
dento-alveolar region is thus encircled from the buccal aperture, the crest of the nasal bone and terminates in
aspect by this band of muscles and this phenomenon the frontal bone.
is referred to as the bu cc i n otor mechanism.
Molar- zygomoi/c buttress : This trajectory transmits
Opposing the buccinator mechanism rrom
the stress from the buccal group of teeth in three
within is a very powerful muscular organ, me tongue.
Tne dentition is in a constant state of dynamic
a. Through the zygomatic arch to the base of the
equilibrium. There is o balance of forces
b. Upward to the frontal bone through the lateral
walls of the orbit.
c. Along the lower orbital margin to join the upper
port of the fronto-nasal buttress.

?:g 3 Trajeriores of force (A) Fronto-noso buttress ■S/

Molar-zygotrolic buttress (C) Pterygoid buttress D. Mend ibu la r

between muscles that is believed to influence the

position and stability of the dentoolveolar complex.


The trojectorial theory of force states that the lines of

orientation of the bony trobcculae correspond to the
pathways of maximal pressure and tension ond tnal
bone trabeculae are thicker in the region where the
stress isgreoter.
Benninghoff studied the naturol lines ol
stress in the skull by piercing small holes into a fresh
skull. Later as skulls were dn'ed, he observed that the
Pterygoid buttress : This trajectory transmits the 1. Graber TV. : Orthodontics : Principles end practice. WB
Saurdsrs. 198S
stress from the second and third molars to the bcse of 2. Guytcn AC, Hall JE: Tex'book of Medical Physiology,
Saunders. 1996.
P'ofi-t VV3: Con-err pa ra'v Orhedontics, St Louis, CV Mosby,
55 z Orthodontics - The Art and Science 3.
the skull. 4. Rcoert E Vioyers : Hand boc< ol Orthodontics, Year book
medico I publ'she's, inc. 1988.
The horizontal trcjectories of the maxilla
5. Salzman JA : Practice of Orthodontics, JB lico'ncot: com cany.
include : 1966

a. Hard palate
b. Orbital ridges
c. Zygomatic arches
d. Palatal bones
e. Lesser w i ng s of sphenoid


A line of stress extends from one condyle to the other
passing along the symphysis. A number of vertical
trajectories rcdiate down below the roots of the
mandibular teeth.
The lower border of the mandible and the
mylohyoid ridges are the other prominent buttresses of
the mandible.



Bone, unlike other connective tissues responds to mild

degrees of pressure and tension, by changes in its
form. Those changes are accomplished by means of
resorption of existing bone and deposition of new bone.
This may take place on the surface of the bone under
the periosteum, or in the case of cancellous bone on
the surface of the trabeculae, or on the walls of marrow
spaces or air sinuses. The architecture of a bone is
such that it can best resist the forces which are brought
to bear upon it with the use of as little tissue as possible.
In this respect bone is more plostic than any other
connective tissue. It has been found that bone is
formed in just the quantity and shape that will enab'e it
to withstand tne physiccl demands made upon it, with
the greatest amount of economy of structure. This is the
basis of Wolffs
law of transformation of bone
Thus, not only is the quantity of bone tissue
the minimum that would be needed for function
requirements, but olso its structure is such that it is best
suited for the forces exerted upon it. If a long bone such
as the femur is cut open, it will be found that dense
cortical bone is on the outside and spicules ot the cance
lous bone within are arranged in such a way that they
support the cortical bone along well defined paths of
stress and strain.

he study of occlusion is on important aspect of Physio/ogic occ/usr'ort ; This refers to an occlusion that
d entistry. The study and practice of most deviates in one or more ways from ideal yet it is well
branches of dentistry should be based on a adapted to that particular environment, is esthetic and
strong foundation of the knowledge of occlusion (fig 1). shows no pathologic
Orthodontics is no exception to this as great many
changes occur in the occlusion during orthodontic
thcropy. The orthodontist should know what constitutes
in order to
be oble to


The term 'occlusion' has both static and
dynamic aspects. Static' refers to the form, alignment
and articulation of teeth within and between the arches,
and the relationship of teeth to their supporting
structure. 'Dynamic' refers to the function of the
slomatognathic system as a whole comprising teeth,
supporting structure, temporomandibular joint,
neuromuscular and nutritive systems. The terms
'normal' and malocclusion'as used in orthodontics refer
mainly to the static aspect or the form of the dentition.
Angle defined occlusion as the normal
relation of Ihe occlusol inclined planes of the teeth
when the jaws are closed. This definition is an
over-simplification of what it actually constitutes.
Occlusion is a complex phenomenon "involving the
teeth, periodontal ligament, the jaws, the
temporomandibular joint, the muscles and the nervous
system. The aim of this chapter is to throw light on
normal occlusion and to highlight the orthodontic
aspects of occlusion.


ldea( ocelusion : It is a pre-conceived theoretical

concept of occlusol structural & functional relationships
that include idealized principles & characteristics that
an occlusion should have.
manifestations or dysfunction. the lower teeth while the lower stamp cusps fit into all
the upper fossae except the distal ones of bicuspids.
Ba/anced occlusion : An occlusion in which balanced
This kind oz a-rangement where contacts occur
and equal contacts are maintained throughout Ihe
between single opposing teeth is called a cusp-fossa
entire arch during all excursions of the mandible.
occlusion or a tooth to tooth arrangement.
Fufrcffonaf occlusion ;• It is defined as an arrangement
of teeth which will provide the highest efficiency during Cusp-embrasure occiusion
all the excursive movements of Ihe mandible which are Another type of occlusion between the upper and
necessary during function. lowerteeth is called the cusp-e m bras u re or tooth to
ihorapewtic oco'us/on : An occlusion that has been two teeth occlusion. In this type of arrangement, each
modified by appropriate therapeutic modalities in order tooth occludes with two oppos'ng teeth.
to change a non-physiological occlusion to one that is
at least physiologic if not ideal.
Travrnotic occ/usion : Trcumatic occlusion is an
abnormal occlusal stress whicn is capable of producing
Curve of Spee
or has produced an injury to the periodontium.
It refers to the antero-posterior cun/ature of the
Trauma from occ/usion : It is defined as peridontial
occlusal surfaces beginning at the tip of the lower
tissue injury caused by occlusal forces through
cuspid & following the cusp tips of *he b'cuspids &
abnormal occlusal contacts.
molars continuing cs an arc through the condyle (fig 1

TYPES OF CUSPS .a}. If the curve is extended, it would form a circle of

about 4 inch diamete'.
The human posterior teeth constitute two types of
cusps. They arc the centric holding cusps and the non-
supporting cusps.

Centric holding cusps

The facial cusps of mandibular & palatal cusps of
maxillary posterior teeth arc called the centric holding
cusps. They occlude into Ihe central fossae and
marginal ridges of opposing teeth. They are also called
the stamp cusps.

Non - supporting cusps

The maxillary buccal and mandibular lingual cusps are
called non-supporting cusps. They contact and guide
tne mandible during lateral excursions & sheer food
during mastication. Hence they are also called
shearing orgu'dirig cusps.


Human dentition exhibits two types of -ooth

arrangement when the uaper end lower teeth occlude
wit.n one another. They are :
a. Cusp- fossa occlusion
b. Cusp-embrasure occlusion

Cusp- fossa occlusion

In this type of occlusion, the stamp cusp of one tooth
occludes in a single fossa of a single opponent. The u o
per stamp cusps fit into all exceol the mesial fossae of
The curve results from vcriatiors n axial
alignment of the lower reeth. Tne long axis of each
lower tooth is aligrcd nearly parallel TO its .--dividual arc
of closure around the condylar axis. This requ>es a
gradual progressive increased mesial tilting ofreetn
towards molars which creates •ne curve of Spee.

Curve of Wilson
This is a curve that contacts ihe buccal & lingual cusp
tips ol Ihe mandibular buccal teeth (fig 1 .b}. Tne curve
of Wilson is medio-lateral on eccn side of the arch. It
results from inwerd inclination of •ne lower posterior
teeth. Cu've of Wilson nclps in two wcys :
a. Teeth are aligned parallel to -he direction of medial
pterygoid for optimum resistance :o masticctory

Fig {A) Cur/8 of Spee (B; Curve o: Wilson

b. The elevated buccal cusps prevent food from
going past the occlusal table.

Curve of Monson
The cun.'e of Monson is obtained by extending the
curve of Spee & curve of Wilson to all cusos & incisol

Centric relation is the relation of The mandible to tne

maxilla when the mandibular condyles are in tne most
superior and retruded position in their glenoid fossa
with the articular disc properly interposed. Centric
relation is clso called ligamentous position or terminal
hinge position. At centric relation both the condyles are
simultaneously seated most superiorly in their glenoid
fossa. In trying lo obtain centric relation the mandible
may be forced too far back, thus the term 'unstrained'
appears in some definitions.
Centric occlusion is that position of Ihe
mandibular condyle when the teeth ore in maximum
intercuspation. Centric occlusion is also called
inter-cuspal position or convenience occlusion
Centric relation and centric occlusion should
coincide in order to have perfect harmony between the
teeth, the temporomandibular joint and the
neuromuscular system. Some studios have shown thai
majority of the population have a maximum
inter-cuspation 1-2 mm toward of centric.
Posterior centric contacts

The posterior centric contacts consist of the fccial

range of contacts and Ihe lingual range of contacts.
Fccicl range of posteriorcentre contacts involve the
mandibular facial cusp tips contacting the central
"fossae and mesial marginal ridges of the opposing
maxillary teeth. Lingual range of posterior centric
contacts involve the maxillary lingual cusp tips
contacting the central fossae and distel marginal
ridges of the opposing mandibular teeth.

Anterior teeth have only one range of centric contacts

and are in line with tne facial range of posterior centric
Posterior centric contacts result in oxiolly
directed forces as convex cusp tips occlude on an
opposing tooth area thot is perpendicular to the force.
However centric contacts often occur on inclines of
posterior teeth. These contacts that occur on inclines
are called poded centric contacts. The contacts
occurring on inclines should be balanced by on equal
contoct on an opposing inclinc to resolve the forces in
an axial direction. If Ihe contact occurs on two inclines,
the contoct is termed bi-poded contact. Contacts thot
Fig 2 Centric contacts
occur on three inclines are called tri-poded contacts.
Maximum intercuspation can also occur Contacts that occur on four inclines are called
without the condyles being in centric. This is called quadro-poded conlocls.
maximum intercuspation, habitual occlusion or
acquired occlusion.

CENTRIC CONTACTS Eccentric occlusion refers to contact of teeth that

occurs during movement of the mandible. Eccentric
They are areos of the teeth that contact the opposing occlusion can be of two types :
teeth (fig 2). Centric contacts have been classified into a. Functional occlusion
posterior centric contacts and anterior centric contacts. b. Non-functional occlusion
Anterior centric contacts
Functional occlusion Occlusion - Basic Concepts
teeth is brought about by condylar
Functional occlusion (also cclled working side
guidance and incisal guidance
ocdusion) refers to tooth contacts tnat occur in -5
Condylar guidance refers to the downward
segment of Ihe arch towards which the :-cndib!e
movement of both the condyles along the slopes of the
moves. F jnctional occlusion can oe of -«•o types:
articular eminence during protrusive movements
era/ functional occlusion : It includes tooth
leading to separation of the posteriors. In case of
contacts the* occur on canines ond posterior teeth cn
lateral movements, the condyle on the non-functioning
the side towards which rhe mondible moves. Tne latere
side translates toward olong the eminence while the
I functioncl occlusion can be of two -.oes: condyle on the functioning side pivots in its fossa
Canine guided occlusion : During lateral -andibular leoding to disclusion of posteriors on the
movement, the opposing upper & '■owe r canines of the non-functional side.
working side contact thereby causing disclusion of oil Anterior guidance refers to anterior tooth
posterior teetn on the working & balancing sides. functions which separate the posterior teeth during
Conine guided occlusion is usually seen in young eccentric motions of the jaw. During protrusive and
individuals with unworn dentition. In a ccnine guided lateral movements of the mandible, the lower anterior
occlusion, me mandibular canine cusp tip tracks from teeth track downward from their area of centric contact
the centric contact point at the mesial marginal ridge towards the incisal edges of maxillary teeth while
•owards the cusp tip of the maxillary canine. disoccluding the nonfunctional posterior teeth.

2. Grouped lateral occlusion : In addition :o canine Condylar guidance has its greatest influence

guidance, certain other posterior teeth on the working on discluding the most distal posterior teeth, while the

side also contact during lateral movement of the incisal guidance provides discluding effect on the more

mondible. Such a type of contact during lateral mesial teeth. The condylcr guidance is a fixed
anatomic factor that cannot be controlled by the dentist
movement is colled grouped lateral occlusion.
while the incisal •guidance can be controlled by
Protrusive funcfjono/ occasion ; It includes eccentric
modifying the form and arrangement of the anterior
contacts that occur when the mandible moves forward.
Ideally the six mandibular anterior teeth contact along
the lingual inclines of Ihe maxillary anterior teeth while ANDREWS' S/X KEYS TO NORMAL
the posteriors disocclude. OCCLUSION

Non-functional occlusion Andrews during the 1970's put forward the six keys to
They are tooth contocts that occur in the segment normal occlusion after studying models of 120 patients
awoy from which the mandible moves. For example if with ideal occlusion. Andrews considered the
the mandible is moved to the left side, contacts occur presence of these features essential to achieve on
on the right side of the arch. optimal occlusion. The six keys to

The term disclusion is used to describe disocclusion or

separation'of non-functional posterior teeth during
eccentric motions of the jaw. Disclusion of posterior
F y 3 And'ews six <©ys tc normal occ Lsion Key 1 (A)
deal Class 1 molar ctioniB; Motor relation not Class I
Key 'l (Cj V.esooista crown anci. la-ion cea (D)
iVlesod's'al c'Own engulotien not ide-ol Key 3 (E) Ideal
lobio-lingjal crown rclinat on Key 4 (F| Idecl a ig n merit
of -octh without 'otot'ons ;Gi Rota-ed tooth not sctis'V'ng
key &
Occlusion - Basic Concepts

ig 3 Andrews six <eys to normal occlusion Kay S (H) deal «itncj- spacing |IJ Scaccd deivilion no1 sctisfy'ng key 5 <oy 6 ;ji
Ideal curve of Scee

1 Andrews IF : The six keys to normal occlusion. Am J Orthcd!972 ; 63 : 296

normal occlusion are considered under the "lowing
headings :
1. Molor inter-orch relationship
2. Mesio-distal crown angulation
3. Labio-lingual crown inclination
Absence of rotation
5. Tight contacts
6. Curve of Spee

Molar Inter-arch relationship

The mesio-buccal cusp of tne upper first molar should
occlude in the groove between rhe mesial and medial
buccal cusp of the lower first molar. The mesio-lingual Occlusion - Basic Concepts
cusp of Ihe upper first molar should occlude in the
central fossa ol lower first molar. The crown of the
upper first molor must be ongulated so that the distal
marginal ridge occludes with tne mesial marginal ridge
of lower second molcr.

Mesio-distal crown angulation

The second key makes use of a line thai passes clong
the long axis of the crown through the most prominent
part in the center of the labial or buccal surface. This
line is called the long axis of the clinical crown.
For the occlusion to be considered normal,
the gingival port of the long axis of the crown must be
distal to the occlusal part of the line. Different teeth
exhibit different crown angulation.

Labio-ilngual crown Inclination

The crown inclination is determined from a mesial or
distal view. If the gingival area of the crown is more
lingually placed than Ihe occlusal area, it is referred to
as positive crown inclination. In case the gingival area
of the crown is more labially or buccally placed than the
occlusal area it is referred to os negative crown
Tne maxillary incisors exhibit a posilive
crown inclination while the mandibular incisors show a
ven/ mild negative crown inclination. The moxillary and
mandibular posteriors have a negative crown

Absence of rotation
Normol occlusion is characterized by absence of any
rotation. Rotated posterior teeth occupy more space in
the dental arch while rotated incisors occupy less
space in the arch.

Tight contacts
To consider an occlusion as normal, there should be
tight contact between adjacent teeth.

Curve of Spee
A normal occlusal plane according to Andrews should
be flat, with the curve of Spee not exceeding 1.5 mm.


alocclusion can present itself in malocclusions into simpler or smaller groups. In
numerous ways. Classification involves order to have a system of classification, standords
the grouping together of various should be set up that represent normalcy. The
deviations from the accepted norms should also be
grouped into various smaller divisions or categories.
The advantages of classifying malocclusion
is as follows ;
a. Classification helps in diagnosis and planning
treatment for the patient.
b. Classification helps in visualizing and
understanding tne problem associated with that
c. Classification helps in communicating the
d. Comparison of the various malocclusions is made
easy by classification.

Malocclusion can be broadly divided into :

i) Intra-arch malocclusions that include variations in
individual tooth position and malocclusions
affecting a group of teeth within an arch.
ii) Inter-arch malocclusions that comprise of
rnalrelotion of dental arches to one another upon
skeletal bony bases which may themselves be
normally related
iii) Skeletal malocclusions which involve the
underlying bony bases

Malocclusions can occur in various

combinations and therefore it may be very difficult to
classify the malocclusion into intra- arch, inter-arch
and skeletal malocclusions. The above mentioned
catagoriztion of
fig Orthodontics - The Art and Scicnce

malocclusion gives us an idea of the possible types of Lmguai' displacement : This is a condition where the
malocclusion that can occur in an individual. entire tooth is disolcced in a lingual direction.

Buccoi displacement : This describes a condition

where the tooth is displcced bodily in o labial or. buccal
A tooth can be abnormally related to its neighboring direction.
teeth. Such abnormal variations are called individual /nfraversiori or infra - occlusion : The terms
teeth malpositions. The individual teeth malposition infraversion or infra-occlusion refer to a too+h that has
can be obnormal inclination (or tipping) of the teeth or not erupted enough compared to the other teeth in the
abnormal displacements. Abnormal inclination arch.
involves the abnormal tilting of the crown, with the root
Supravers/on o,r supra - occlusion : This is a tooth that
being in normal position. Bodily displacement involves
has over-erupted as compared *o other teeth in the
abnormal location of the crown as well cs the root in the
arch. It is also called suprc- occlusion.
same direction.
Intra-arch malocclusions con also include .Rotations : This term refers to tooth movements

condition like spacing o r crowding within the dental around its long axis.

arch. D/sto - Z/nguaf or mes/o - buccaf rotah'o.n: This

Some of the commonly seen individual teeth describes a tooth which has moved around its long axis
malpositions are (fig 1): so that the distal cspect is more linguclly placed.

A'lesro - /ingua/ or disto - buccal rotat/on: This is a

Distal inclination or distal tipping ; This refers to a
condition where the tooth has rotated around its long
condition where the crown of the tooth is tilted or
axis so that the mesial aspect is more linguclly p'aced.
inclined distally.
Transposition : This term describes a condition where
Mesial inclination or mesial tipping : This is a
two teeth have exchanged places.
condition where the crown of the tooth is tilted or
Lingua/ mc/fnaf/on or lingual tipping .-This is an
These malocclusions are characterized by abnormal
abnormal lingual or polatal tilting of the tooth. This
relationship between two leet.nor groups of teeth of
condition is also called' retroclination j
one arch to the other arch. These inter-arch
8ucca/ inclination or buccal tipping : This refers to
malocclusions can occur in the sagittal, vertical or in
labial (in case of anterior} or buccal (in case of
the transverse planes of space.
posterior) tilting of the tooth.This condition is also

Mesial displacement : This refers to a tooth that is

bodily moved in a mesial direction towards the midline.
Distoi1 displacement : This refers to a tooth that is
bodily moved in a distal direction away from the

Classification of Malocclusion Mi

Fig 2 (A} formal vertical re clior» between the upper ond lower crches. '(B) Open bite (C) Deeo bi'e

Sagittal plane malocclusions Transverse plane malocclusions

TT^S includes conditions where the upper and the c*er The transverse plone inter-arch malocclusion includes
arches are abnormally relored to eachother in c various types oflcrossbites? The term crossbitc refers
sagittal plane. to abnormal transverse relationship between the upper
-norma/ occhsion): This term refers to a condition and lower arches.
where the lower arch is more forwardly pcced when
the patient bites in centric occlusion.

Post-norma/ occ/usior? ) This is a condition ».nere the They are malocclusions caused due to abanormalities
lowerarch is more distally placed when tre patient bites in the maxilla or mandible. The defects can be in size,
in centric occlusion. position or relationship between the jaws. The skeletal
rha I occlusions can also occur in the three planes of
Vertical plane malocclusions
space namely sagittal, vertical and transverse planes.
Tnese malocclusions include deep bite and open z '.e In the sagittal plane, the forward placement of a jaw is
where an abnormal vertical relation exists oetween the referred to as prognathism while retrognalhism refers
teeth of the upper and lower arch. to a more backward placement of a jaw. These sagittal
Deep bite or increased overbite : It is a condition abnormalities can occur in one or both Ihe jaws and
where there is excessive_verticaI overlap oetween the can occur in various
upper and lower anteriors (fig 2.c)

Open bite : This is a condition where there is no

vertical overlap between the upper andjower teeth.
Thus a space may exist between the upper and lower
teeth when the patient bites in centric occlusion. The
open bite con be in the anterior or the posterior region,
(fig 2.b)
Fig 3 Diogromcric representa'ion of the possible skeletal relationships in the anlcro-postcrio' or sogittol o'ene (A|« Norrral Class I (B) Bimax llary
protrusion (C) Bimaxillary retrusion (0) Maxillary prognatnism (EjMandibu'ar retrognalVsn JFJ Moxilary prograthism end mandibu cr retropna'hisn
(G) Max'l'oiy rclrogrohism (H) Mandibulo' prognaihisn (I) Mcxilla'y rctrogn'Ot'nism or.d mandibular prognathism.

Classification of Malocclusion


?g 4 Diayramatc re o reservation of the possible skeletal relationships r

the transverse plcne f.A^i Normal rransverse -elation (B; Un'latera
crossbite (CI Bictoral crossa'te (DJ Bucccl non-occiusion fEJ Lingual

combinations. Figure 3 gives you the possible sagittal Angle's classification was based on the
skeletal malocclusions. mesio-distal relation of the teeth, dental arches and the
Skeletal malocclusions in the transverse jaws. According to Angle, the maxillary first permanent
plane are usually a result of narrowing or widening of molar is the key to occlusion. He considered these
the jaws. They can be described as narrow moxilla, teeth as fixed anatomical points
wide mandible etc. Those transverse malocclusions are
usually referred to as crossbites (Fig 4).
In the vertical plane abnormal variations n the
vertical measurements of the jaws can affect the
lowcrfacial height.

Edward Angle introduced a system of classifying

malocclusion in the year 1899. Angle's classification is

still in use after almost 100 years of its introduction due
to its simplicity in application.
within the jows. Based on the relation of the lower first lower arches ore forwardly placed in relation to the
permanent molar to the upper first permanent molar, he facial profile.
classified malocclusions into three main Classes

division 1 (C! Class II, d'f/is'or 2 (Di Class III.
Fig 5 Angle's classfica'ion (A) Clcss I J3) Class II,

designated by the Roman numerals I, II, and III.

Angle's Class I
Angle's Class I malocclusion is characterized by the
presence of a normal jnter-arch molor relation. The
mesio-buccal cusp of the maxillary first permanent
molar occludes in the buccal groove of mandibu I or first
permanent molar, (fig 5.a) The patient may exhibit
dental irregularities such as crowding, spacing,
rotations, missing tooth etc.,. These patients exhibit
normal skeletal relation and i also show normal muscle
function/ Another malocclusion that is most often
categorized under Class I is bimaxillary protrusion
where the patient exhibits a normal Class I molar
relationship but the dentition of both the upper and

Angle's Class If
Fig 6 Pafent having Angle's Clussll, division I
malocclusion (A) Buccal view showing tne
Class I! mo or relation ond the inc.'eased
oyerjet (B) labia view (C) Increases overiet and
prodinalion of upper onleriors (DJ Radiograph
of the patient. Note Ihe severe prodi nation of
buccinator activity. The unrestrained buccinotor activity
the upper an'c.'ics.
results in -narrowing of Ihe upper arch at the premolar
This group is characterized by a Class II molar relation and canine regions thereby producing a V-shaped
where the disto-buccal cusp of the upper first upper arch. Another muscle aberration is a hyperactive
permanent molar occludes in the buccal groove of the mentalis activity. The muscle imbalance is
lower first permoncnt molar (fig 5.'b). Angle hos
sub-classified Class II malocclusions into two divisions :

Class II, division 1

The Class II, division 1 malocclusion is characterized

by prodined upper incisors with a 'esuliflnt increase in
overjet (fig 6}. A deep incisor overbite can occur in the
anterior region. A characteristic feature of this
malocclusion is the presence of abnormal muscle
activity. The upper lip is usually hypotonic, short and
fails to form a lip seal. The lower lip cushions the palatal
aspect of the upper teeth, a feature typical of a Class II,
division 1 referred to as lip trap'. The tongue occupies a
lower posture thereby foiling to counteract the

- The Art and Science

e / (A) Class I bimaxillary protrusion (B) C ess II, division 1 malocclusion (C! Class I , divsion 2
moloccljsion (D) Class III mal occlusion'(E) Anterior open u to (F) Poslerio' open b'te (GJ Crossbite |H)
Fig 8 ;A; Anterior crossbi1e(B) Posterior cossbile (C) Anterior s'ngle tooth crossbile (D) Midline diostemo (F) Deep bile (h) Scissors bi'c'JG) Ro 'otion ironspojition01 prcmola'
and nno!c:r
74 / Orthodontics - The Art and Science

Classification of Malocclusion Mi
vV? /


F g 9 Clcss II, division 1 malocclusion associated

whh lowe'ed tongue posture ond ihcreforc ur
restricted buccal muscle activity causing cons'ridior
ol llie ueocr arch.

produced by a hyperactive buccinator and mentalis

Class III malocclusion

ond an altered tongue position that accentuates the This malocclusion exhibits a Class III molar relation
narrowing of the upper dental arch (fig 9). with the mesio-buccal cusp of the maxillary first
permanent molor occluding in the interdental space
Class H, division 2 between the mandibular first and second molars (fig
As in Clcss II, division 1 malocclusion, the division 2 5.d). Class III malocclusion can be classified into true
also exhibits a Class II molar relationship. The classic Class III and pseudo Class III.
feature of this malocclusion is the presence of lingually
inclined upper central incisors ond labially tipped upper
lateral incisors overlapping the central incisors (fig 5.c).
Variations of this form are lingually inclined central ond
lateral incisors with the canines Icbially tipped. The
patient exhibits a deep anterior overbite.
The lingually inclined upper centrals gives the
arch a squarish appearance, unlike the narrow
V-shaped arch seen in division 1. The mandibular
labiol gingival tissue is often traumatized by the
excessively tipped upper central incisors. The patient
exhibits normal perioral muscle activity. An abnormal
backward path of closure moyalso be present due to
the excessively tipped central incisors.

Fig 10. Closs II, division 2

Class tl, Subdivision

When a Class II molar relation exists on one side and a
Class I relotion on the other, it is referred to as'.Class II,
subdivision^ Bosed on whether it is a division 1 or
division 2 it can be called Class II, division 1,
subdivision or Class II, division 2, subdivision.
True C/ass MJ Although Angle's classification has been used for
This is o skeletal Clpss III malocclusion of genetic almost a hundred years now, it still has a number of
origin that can occur due to the following causes: drawbacks thai include :
a. Excessively large mandible a. Angle considered malocclusion only in the

Comparison belwoen Angle's Class II, division 1 and division 2

Feature Division 1 Division 2

Overjet increased Decreased

Profile Convex Stragh; or mi idly convex

Lips Short, incompetent Normal

Arch form V shaped, narrow U shaped and square

Palate Deep Normal depth

Muscle activity Increased mentalis and buccinator Normal muscle activity

Path of closure Norma! Backward

Lower facia) height Normal or increased Decroased

Malar process Not prominent Prominent

b. Forwardly placed mandible antero-posterior plane. He did not consider

c. Smaller than normal maxilla malocclusions in the transverse and vertical
d. Retropositioned maxilla planes.
e. Combination of the above causes b. Angle considered the first permanent molars as
The lowerjncisors tend to be lingually fixed points in the skull. But this is not found to be
inclined. The patient can present with a normol so.

ove"rjet,)an'.edge to edge incisor relation'.or on c. The classification cannot be applied if the first

(anterior crossbite.ji The space available for the permanent molars are extracted or missing.

Tongue is usually more. Thus the tongue occupies a d. The classification cannot be applied to the

lower position, resulting in a narrow upper arch.

Pseudo Class III

This type of malocclusion is produced by a fqn«ord
movement of the mandible during jaw closure, thus it
is also called 'postural' or 'habitual' Class III
malocclusion. The following are some of the causes of
pseudo Class III malocclusion:
a. Presence of occlusal prematurities may deflect
the mandible forward.
b. In case of premature loss of deciduous
posteriors, the child tends to move the mandible
forward to establish contact in the
anterior region, c. A child with enlarged adenoids
tends to move the mandible forward in an ottempt to
prevent the tongue from contacting the adenoids.

Class III, Subdivision

This is a condition characterized by a Class III molar
relation on one side and a Class I relation onjhe
other side.

Drawbacks of Angle's classification

Classification of Malocclusion Mi

deciduous dentition.

Fig 1.1 Class III r-ialoccljsicn. (A)

and |B) Buccal occlusion view
showing class III molar relction
ond anterior cross- bte tendency.
[CJ Anterior view fD) Lateral
cephclogrcn of ihe same pa lien'.

e. The classification does not differentiate between

skeletal and dental malocclusions.
f. The classification does not highlight the etiology of
the malocclusion.
g. Individual tooth malpositions have not been
considered by Angle.

Dewey proposed a modification of the Angle's

classification of malocclusion. He divided Angle's Class
I into five types and Angles Class III into three types.
CLass I modifications of Dewey (fig 12). Simon's system of classification mode use of
"ce 1 : Class I malocclusion with bunched or redded three anthropometric planes i.e., the Frankfort
anterior teeth. - horizontal plane, the orbital plane and the mid-sagittal
T»pe 2 : Class I with protrusive maxillary incisors. jjpe3 plane. The classification of malocclusion was based on

-.Class I malocclusion with anterior crossbite. Tv?e 4 : abnormal deviations of the dental arches from their
Class I molar relation with posterior rrcssbite. Classification of Malocclusion
normal position in relation to these three planes.
~upe 5 : The permanent molar has drifted mesially D.e
to early extraction of second deciduous molar IT
Frankfort horizontal plane

second premolar. This is a plane that connects the upper margin of the
external auditory meatus to the infra-orbital margin.
Class III modifications of Dewey This plane is used to classify malocclusions in a vertical
T,ce 1 : The upper and lower dental arches when . plane. Two terms are used to describe any abnormal
ewed separately are in normal alignment. But •nen the relation of the teeth to this plane. When the dental arch
orches are made to occlude the patient STOWS an edge or part of it is closer than normal to the Frankfort plane,
to edge incisor alignment, suggestive of a forwardly it is called attraction. When the dental arch or part of it
moved mandibular rental arch. is farther away from the Frankfort horizontal plone, it is
Tfpe 2 : The mandibular incisors are crowded end are called abstraction.
in lingual relation to the maxillary incisors. ~fpe 3 : The
maxillary incisors are crowded and ere in crossbite in
relation to the mandibular cnteriors.


Lischer substituted the term Class I, II ond III given by

Angle with the terms neutrocclusion, distocclusion and
mesiocclusion. In addition to these, he added a few
more terms which designated certain other
malocclusions. Neufrocc/usr'on : Synonymous with
Angle's Class I malocclusion.
Distocclusion : Synonymous with Angle's Class
II malocclusion.
Mes/oc/usiori ; Synonymous with Angles Class
III malocclusion.
Buccocc/usron ; Buccol placement of a tooth or a
group of teeth.
i-inguocdusion ; Lingual placement of a tooth or o
group of teeth.
Supraocc/usion : When a tooth or group of teeth have
erupted beyond normal level. Jnfraocc/usjon ; When a
tooth or group of teeth have not erupted to normal level.
M estovers ion : Mesial to the normal position.
Drstoversion : Distal to the normal position.
Tronsversion .-Transposition of two teeth. Axiversion :
Abnormal axial inclination of a tooth
Torsivers/on ; Rotation of a tooth around its long axis.


Malocclusion can occur in a n tero-posterior,

transverse and in the vertical planes. Simon hod put
forward a craniometric classification of malocclusion
that related the dental arches in all these three planes
Orbital plane Norman Bennet classified
This plane is perpendicular to the Frankfort horizontal
plane, dropped down from Ihe bony orbitol margin
directly under Ihe pupil of the eye. According to Simon,
this plane should pass through the distal third of the
upper canine. This is called Simon's Law of Canine.
This plane is used to describe malocclusion in a
sagittal or antero-posterior direction. When tM<^enf? I
arch or part of it is farthor from the Ojrf^fpldfce,; it is
called protraction. When th&Ofch or part of it is closer
or more posteriorly placed in relation to this plane, it is
called retraction. \

MId-saglttal plane

The mid-sagittal plane is used to describe

malocclusion in the tronsversc direction. When a part
or whole of the arch is away from the mid- sagittal
plane it is called distraction. When the arch or part of it
is closer to the m id-sagittal plane it is called

malocclusion based on its etiology.
Class I - Abnormal position of one or more teeth due to
local causes.
Class II - Abnormal formation of a part of or whole of
either arch due to developmental defccts of bone.
Class III - Abnormal relationship between upper ond
lower arches, and between either arch and facial
contour and correlated abnormal formation of either



Ackerman and Profitt in 1960 proposed a

diagrammatic classification of malocclusion to

Fig 12 Simons classification fA) F.H. plane (B> Orbital plane (C!
Mid-Sagittal plane.
Transverse Deviation Sagittal Deviation
Buccal Palatal Trans- Class I
Unilateral Bilateral sagittal Class II division 1
Skeletal yf Class II division 2
Dental / Trans- Skeletal \
sagitto Dental
transverse vertica

Convex [" Sagitto-

Concave I verrical
Straight \
Anterior ^
Intfa^rcb ^divergent
Vertical Deviation Open
bite anterior Open bite
posterior Deep bite
anterior Collapsed bite
posterior Skeletal /
Dental /

Fig. 13 Vern symbolic diagram - Ackcrmon Profitl Classification

overcome the limitations of the Angle's classification.
Salient features of Ihe classification mclude :
a. Transverse as well as vertical discrepancies can
be considered in addition to anteroposterior
b. Crowding and arch osymmetry can be evaluated.
c. Incisor protrusion is taken into account.
This system of classification is based on the
Venn symbolic diagram {fig 13) that identifies five
major characteristics to be considered and described
in the classification.

Step 1 (Alignment)
The first step involves assessment of the alignment
and symmetry of the dental arch. It is classified as
80 Orthodontics - The Art and Science

ideal / crowded / spaced.

Step 2 (Profile)
It involves Ihe consideration of the profile. The profile is
described as convex/straight/concave. The facial
divergence is also considered i.e., anterior or posterior

Step 3 (Type)
The transverse skeletal and dental relationship is
evaluated. Buccal and palotal crossbites if any are
noted. The crossbite is further sub-classified as
unilateral or bilateral. In addition, differentiation is
mode between skeletal and dental crossbite.

Step 4 (C/ass)
This involves the assessment of the sagittal
relationship. It is classified as Angle's Class I / Class II /
Closs III malocclusion. Differentiation is made between
skeletal and dental malocclusion.

Step 5 (Bite depth)

Malocclusions in the vertical plane are noted.
They are described as anterior or posterior open »
bite, anterior deep bite or posterior collapsed bite. A
mention is mode whether the malocclusion is skeletal
or dental.
Etiology of Malocclusion

he orthodontic speciality deals with treatment teeth. The general factors on the other hand are those
of various malocclusions. Etiology of that affect the body as a whole and have a profound
malocclusion is the study of its cause or effect on the greater part of the dcnto-facial structures.
causes. Malocclusion can occur due to a number of
possible causes. Broadly speaking malocclusions are HEREDITY
caused by either genetic factors or by environmental
In everyday life, we come across quite a number of
factors.Comprehensive orthodontic management
families where the inmates hove o lot of resemblonce.
involves identification of the possible etiologic factors
Thus it is quite logical to assume that offsprings inherit
and an attempt to eliminate the same. Although it may
quite a few attributes from their parents. Heredity has
not be possible to eliminate the cause in most cases of
for long been attributed as one of the causes of
malocclusion, it nevertheless is of value in preventive
and interceptive orthodontic procedures where a
The child is o product of parents who
possible malocclusion is prevented or intercepted by
timely removal of the cause.
Development of normal dentition and
occlusion depends on a number of interrelated factors
that include the dentoalveolar, skeletal ond the
neuromuscular factors. Thus localization of the
possible etiology may be a very difficult task. A number
of classifications of etiologic factors o^ malocclusion
have been put forward (refer to table 1).
Graber has classified the etiological factors
as local and general factors. The loco! foctors
responsible for malocclusion produce a localized
effect confined to one or more adjacent or opposing
Etiology of Malocclusion 83
Orthodontics - The Art and Science 5. Habits
a. Thumb sutfrg and finger sucking
b. Tongue testing
1. Heredity c. Lip sucking and lip tiling
a. Neuromuscular System d. Poslure
Classifications of etiology of malocclusion e. Nail biting
b. Bone
c. Teelh f. Other habits 8. Diseases
d. Soft Parts a. Systemic diseases
2. Developmental defers of unknown cigin b. Endocrine disorders
3. Trauma c. Local diseases
a, Prenatal trauma and birth injuries i. Nasopharyngeal diseases anc disturbed
b. Postnatal trauma respiratory funclicn it; Gingiva'^ and periodontal
4. Physical agenls disease MTumors V'v:-S

a. P'enature extraction of primary teeth iv. Caries 7 Mafnutritlon

b, Nature ot tood


A. Dental base abnormalities

Anlerc-poslerior na'relationship
Velical malrelationstvo
Lateral malrelalic^ship
Disproportion of size between teeth
and basal fcons
Congenital abnormalities
B. Pre-eruptbn abnormalities
Abnormalities in pos'lion of
developing tooth germ
Missing teeth
Supernumerary leeth and teelh
abnormal In form
Prolonged retention of deciduous teeth
Large labial Irenum
Traumatic injur/ C. Post-eruption
1. Muscu'ar
a. Active muscle toroe
b. Best position of
' 2

o, Sucking habits d.
Abnormalites in path c?
2. Premature loss of deciduous teeth
3. Extraction ot permanent teeth. ■

2 Heredity
g.Resolralory abnormalities [mouth breathing
etc.,.! h Tonsi'-s a^d adenoids I, Psychogenic
tics;arid bruxism
Trauma and accidenls

1. Anomalies of number:
Supernumerary teeth, Missing
leeih [congenital absence or loss
due to accidents cares etc]
2. Anomalies of tooth si2e
3. Anomalies of looth shape
f,. Abnormal labial frenum : mucosal barriers
5. Premalure loss ot deciduous teeth
6. Profohgwl retention of dectiuous teeth
7. Delayed eruption of permanen teelh B. Abnormal
eruptive path
9. Ankylosis
10. Dental caries .
11. improper dental restoration
-c.e dissimilar genetic material. Thus the child -ray

I inherit conflicting traits form both the parents ^suiting

in abnormalities of the denlofacia region. Another
reason attributed for genetically 3e?ermined
malocclusion is tfie racial, ethnic and •egipnal inter-mixture
Congenital defects or developmental defects are
malfonnations seen crrhe time of birth. They may be
Etiology of Malocclusion 85
caused by a variety of factors including genetic,
radiologic, chemical, endocrine, infections ond
which migh: nave led to .rco-ordinated inheri-ance of teeth mechcnical factors.
and jaws. The congenital abnormalities that cause
According to Lundstrom there exists a malocclusion can be broadly classified as general end
-omber o^ human traits that ore influenced by genes locol congenital abnormalities.
that include:
General congenital factors
e Tooth size : The size of the dentition is to a c'ge
a. Abnormal state of mother during pregnancy
extent determined by genes. Abnormoiiries — rooth
b. Malnutrition
size such as microdontia and macrodontio
c. Endocrinopathies

! cre attributed to heredity.

Infectious diseases
Metobolicond nutritional disturbances
Accidents during pregnancy and child birth
a. Arc/t dimensions ; The dental arch length zr<d arch width g. Intro-uteri no pressure
are believed to be inherited. h. Accidental Iraumatization of the fetus by externol
Crowding / Spacing : Crowding and spacing of teeth are forces
believed to be of genetic --gin. Most of these conditions are
believed to a result of uncoordinated inheritance of arch
ength and tooth moteriol.

r Abnorma'.'ties of tooth shape : Anomalies cf tooth

shape such as tne presence of peg shaped cterals is
another trait that shows nigh genetic predisposition.

f Abnormalities of tooth number : Presence -•"either

more or less number of teeth con also be .-herited.
This includes condition such as cnodontia and

r. Over/et; The horizontal overlap of the upper cod

lower dentition referred to as the overjet is c<=!ieved to
be genetically influenced.

g. Intcr-arch variations : Discrepancies in -e

transverse, scgittal and vertical planes between —e
upper and lower jaws can be inherited.
h. Frenum ; The size, position and shape of the frenum is
said to be genetically influenced. Thus malocclusion such
as midline diostemo that may be due to abnormo ities of the
frenum are to a large extent determined genetically.
According to Harris and Johnson a number of
craniofacial parameters showed significcnt genetic
influence. These include the following cisrances : sella -
gnathion, sella - point A, sella - gonion, nasion - anterior
nasal spine, articulare - pogonion, bizygomatic width,
anterior facial height.
As so many traits show a strong genetic pattern a
njmoerof malocclusions can be pertly or solely attributed to
genetic factors. These genetic traits can be further
influenced by existing prenatal or post-natal environmental
a. Abnormalities of jaw development due to intra-uterine Various pre-notal and post-natal environmental factors
position can cause malocclusion.
b. Clefts of the face and palate
c. Macro a n d m ic rog I ossia Prenatal factors
d. Cleidocranial dysostosis The fetus is well protected against injuries and
Local congenital factors The following Cleidocranial dysostosis nutritional deficiencies
are some of the congenital conditions frequently during pregnancy. But there are certain factors, the
encountered by the orthodontist. presence of which can result in abnormal growth of the
oro-faciol region thereby predisposing to malocclusion.
Clefts of the Up and palate
Abnormal fetal posture during gestalion is
Clefts involving the lip and palate are the most commonly said to interfere with symmetric development of the
seen developmental defects that occur as a result of non- face. Most of these deformities are temporary and
fusion between the various embryonic processes. Cleft usually disappear as age advances.
patients may exhibit a number of dentcl problems including The other prenatal influences include
missing teeth, mobile teeth, rototions, cross bite, etc., maternal fibroids, amniotic lesions, maternal diet and
(discussed later as a separate chapter). metabolism.
Maternal infection such as German measles
Congenital syphilis and use of certain drugs during pregnancy such as
Syphilis of congenital origin is transmitted from the infected Thalidomide can cause gross co ng en into I
mother to the child. The child exhibits one or more of the deformities including clefts.
following features:
a. Hutchinson's incisors
b. Mulberry molars
c. Enamel deficiencies
d. Extensive dental decay
e. The maxilla may be smaller in size relative to the
f. Anterior cross bite

Maternal rubella Infections

Maternal rubella infections during pregnancy is believed to
cause widespread congenital malformations in the child.
The following are some of the feature that can be seen.
a. Dental hypoplasia
b. Retarded eruption of teeth
c. Extensive caries
This is a congenital condition characterized by unilateral or
bilateral, partial or complete absence of the clavicle. The
patient may exhibit the following features:
a. Maxillary retrusion and possible mandibular protrusion
b. Over retained deciduous teeth and retarded eruption of
permanent teeth
c. Presence of supernumerary teeth
d. Presence of short and thin roots

Cerebral palsy
This is a condition where in the patient locks muscular
co-ordination. It usually occurs due to birth injuries.The
uncontrolled ond oberrant muscle activity upsets the muscle
balance resulting in malocclusion.

that are
extra to

Fig 1 (A) and (8) Mcsiodons between the ncxilicry

control rncisore. Note how the exrra tooth has resulted
in crowding and rotarion of the cdjocent ccr.-ral incisor.
|C) Occlusal radiograph of the some oa'icnt.

Postnatal factors complement are termed s upem u mera ry teeth. These

The following ore some of the post-nalal factors that can teeth have abnormal morphology and do not resemble

cause malocclusion : C- Forceps delivery con result in injury norrnol leeth. Extra teeth that resemble normal

to the temporomandibular joint area wnich can undergo

ankylosis. Such patients show retarded mandibular growth
and thus have o hypoplostic mandible. z. Cerebral palsy is a
condition characterized by muscle inco-ordination. This
may occur due to birth injuries. The patient can exhibit
malocclusion due to loss of muscle balance.
c. Traumatic injuries that cause condylar fracture can
cause growth retardation resulting in marked facial
Presence of scar tissue such as those caused by burns
or as a result of cleft lip surgery may produce
malocclusion due to their restrictive influence on
e. Milwaukee braces are used for treatment of scoliosis.
These braces derive support from the mandible.
Prolonged use of these braces can cause marked
mandibular growth retardation.


In order to achieve good occlusion, the normal number of

teeth should be present. Presence of extra teeth or absence

of one or more teeth predisposes to malocclusion.

Supernumerary teeth
teeth are called supplemental teeth.
A frepuently seen supernumerary tooth is the

mesiodens which occurs in the maxillary midline(fig 1).

F;g 2 (A) A 10 year eld shewirg unerup'ed sypemvmora'y
They can occur singly or as a pair and are usually conical in '00-b in the uppsr central incisor region, blockiig tne
shape. Unerupted mesiodens is one of the causes of erjptici oi tne cert'cl inc sor (BJ Rad ocraph of the same
midline spccing. Supernumerary teeth can also occur in tne
premolar or third molar regions.
Supplemental teeth are most often seen in the c. Mandibular second premolers
premolar and lateral incisor region. It is not uncommon to d. Mcndibulor incisors
find an extra lower incisor. The supernumeran,> and e. Moxillary second premolars
supplemental teeth couse non-eruption of adjacent teeth Absence of teeth can be unilateral or
(fig 2)and ccn deflect the erupting adjacent teeth into sometimes bilateral. They may occur along with other
obnormal locations. In addition extra teeth occupy arch
onomalies such as presence of extra teeth. Absence of
length intended for normal complement of teeth. Thus they
one or more teeth predispose to spacing in the dental
can result in crowding and rotations of adjacent teeth.
arch. The adjacent 'eeth migrate and therefore cause
Unerupted supernumerary teeth pose a risk of cystic
abnormal location and axial inclination of teeth (fig 5).
Absence of a permanent tooth ouite often results in

Missing teeth over- retained deciduous teeth.

Congenitolly missing teeth are by far more common than

supernumerary teeth and can occur in either of the jaws,
The following ore some of the commonly missing teeth in In order to have normal occlusion, tnere should be
decreasing order of frequency: hcrmony between the +ooth size and arch length and
a. Third molars also between the maxillary and
b. Maxillary lateral incisors
Etiology of Malocclusion 89

Fig 3 (Aj & (B! S jpp emental Icreral incisor (C) & (D) 5tpfi'numerary ooth seen erupting palotaily (E) & |F; S jpp eTienlal
la"e:al incisor yG) & |H} Macrodontic supernumerary incisor n Ihe rn'r.lire
Orthodontics - The Art and Science

Fig 4 [A|- & (B) Missing lower incisor (Q & [D', Bilateral missing uppo' lateral inciscrs (EJ & (F) Bilateral missirg lower
second premolars (G) & (H) Bila'col massing upper lateral incisors.
Etiology of Malocclusion ^ 89

F g 5 |A) ond <BJ Upper left loleral incisor congenitally missing. Note tne resultant spacing of th.e maxillary arc/i and non coincident of i/Dper and
lov/er iri'd'ines. The
maxillary rigrr latere I is also micradoniic. JC) Radiograph of rhe same pntienl.

—andibular tooth size. An increase in size of ■sern results b. Another anomaly of tooth shape is the presence of an
in crowding while, smaller sized teeth -rsdispose to abnormally large cingulum on a maxillary incisor (fig
spacing. A commonly seen anomaly a me presence of 7). The presence
smaller sized maxillary lateral rcisors. Anomalies of size
can also occur in the f-cndibular premolars. Fusion
between two ^r!acent teeth or between a supernumerary
tooth z-.d a normal tooth may predispose to malocclusion.
Variations in size of tooth can occur ^ong with variations of
The size of teeth is to a large extent reiermined
genetically. Thus most of these conditions show a positive
family history.

Anomalies of tooth size and shape are very often

interrelated. Abnormally shaped leelh predispose to
malocclusion. The following are some of Ihe examples of
frequently seen tooth shape anomalies:
a. The presence of peg shaped maxillary lateral incisors
is often accompanied by spacing and migration of
teeth (fig 6).
of an exaggerated cingulum prevents establishment of
normal overbite and overjet. The involved tooth is

f Orthodontics - The Art and Science

Fig 6 !A) And <B) Upper left lateral incisor nicrodontic .

Reduced tooth mote'iol results in soacing of ihe dentition.
(Cl ond (D) Mocrcdoniic nobiliary right central incisor. E)
Lower peg incisors.

usually in labioversion due to the forces of occlusion.

c. The mandibular second premolars may rorely hove an
additional lingual cusp, thereby increasing the
mesio-distal dimension of the tooth.
d. Congenital syphilis is often associated with presence
of obnormal tooth form. Peg shaped laterals and
mulberry molars are classical findings in such patients.
e. Anomalies of shape can occur as o result of
developmental defects like amelogenesis imperfecta,
hypoplasia of teeth, fusion and gemination.
f. Dilaceration is described as a condition characterized
by an abnormal angulation between the crown ond
root of a tooth or angulation within the root. It usually
occurs due to a blow to a deciduous tooth which is
transmitted to the underlying permanent tooth bud.
Dilacerated teeth fail to erupt to normal level and can
thus cause malocclusion.
loss of

- z 7 Maxillary central incisors showing prominent c-gulum.

Abnormalities of the maxillary to
labial frenum ore :..*e often associated with a maxillary
midline scodng. Prior to the eruption of teeth, the
moxillary cc-icl frenum is attached to the alveolar ridge
«.-•n some fibers crossing over lingually to the -«c"on of
the incisive papilla. As the teeth start •erecting, alveolar
bone is deposited and the frenal —achment migrates
into o more apical position, icrely, a heavy fibrous
frenum is found attached x Tie interdental papillaFig 8 |A) Thick maxillary lebiai frenum causing a midline
c'iasremo (B) Radiograph shows a midline notching of rhe
region. This type of frenal zreenment can preventinrcrdcntcl alveolar bone.
the two moxillary central jrcsors from approximating malocclusion due to shifting of adjacent teeth into the
each other, {fig 8.a). space. Early loss of anteriors most often do not
This condition is diagnosed by a positive Dcnch produce any
test. When the upper lip is stretched for a period of time, a
noticeable blanching occurs over —.5 interdental papilla. A
midline intra-oral periapical radiograph usually exhibits
notching cf me inter-dental alveolar crest(fig 8.b).
Midline diastema may also occur due to o number
of causes including presence of .rerupted mesiodens,
anomalies of tooth size and -=«jnber.


refers to loss of a tooth before its permanent accessor

is sufficiently advanced in development and eruption to
occupy its ploce. Early, loss of deciduous teeth con cause
migration of adjacent teeth into the space and can
therefore prevent the eruption of the permanent successor
(fig 9).
Premature loss of an incisor seldom leads to
malocclusion. Loss of a deciduous second molar con
cause a marked forward shift of the permanent first molar
thereby blocking the eruption of the second premolar,
which either gets impacted or is deflected to an abnormal
The severity of malocclusion caused due to early
loss of a deciduous tooth depends on the following factors :
Orthodontics - The Art and Science

Fig 9 (A) and (B) FVerrcture loss of deciduous socord inolar Second permanent successors. Prolonged retention of buccal
premolar lias erupted inguolly due ro iradequote s
teeth results in eruption of the permanent teeth cither
bucally or ling u all y or may remain impacted within the
b. The earlier the deciduous teeth are extracted
before the successional teeth are ready to erupt,
Quite often certain parts of the deciduous
the greater is the possibility of malocclusion.
roots which arc away from the path of eruption of the
c. > In a person having arch length deficiency or permanent teeth fail to get resorbed thereby leaving
crowding the early loss of deciduous teeth may worsen the small fragments of the root within the jaw. These root
existing malocclusion. fragments can deflcct or block the adjacent erupting
The following are some of the reasons for
prolonged retention of deciduous teeth :
a. Absence of underlying permanent teelh(fig 10,11).
b. Endocrinol disturbances such as hypothyroidism
c. Ankylosed deciduous teeth that fail to resorb
d. Non - vital deciduous teeth that do not resorb

Fig 10 Ovcr-rc'a'ncd lower deciduous oen-rcl incisors due to

congenital absence of the permanent cenlrol incisors
lias resu ted in mesial migra-ion of the fret penronent -nolar. :ace.



This refers 1o o condition where there is undue

retention of deciduous teeth beyond the usual eruption
age of their permanent successors. A deciduous tooth
that fails to undergo resorption will prevent the normal
eruption of its permanent successor.
Prolonged retention of deciduous anteriors
usually results in lingual or palatal eruption of their

There ore a number of reasons (hot can delay the

eruption of permanent -eeih. The following are

Fig 11 Lowe' clccidjOv's second molar ovc lu'ahod lo ccngen tol absence ot ower righ- second premolar

some of them :
r Congenital absence o: the permanent tooth, r Presence of
supernumerary tooth can block the e-up:ing
Fig ' 7 Imcaced maxl or/ can ries. I lie uioxi lory canines are frequent
permanent tooth. Presence of a heavy mucosal barrier y impacted ond in ectopia ncsirici.
can prevent tne permanent tooth from emerging into
the oro: cav'ly. A surgiccl incision in most cases
accelerates the eruption. ± Premature loss of
deciduous loot h can result in delayed eruption of the
underlying permanent teeth due to formation of bone
over ihe erupting permanent tooth.
e. Endocrinol disorders such as hypothyroidism can
cause a delay in eruption of the permanent teeth.
f. Presence of deciduous root fragments that arc rot
resorbed can block the erupting permanent teeth.


One of the causes of malocclusion is cr. abnormal path of

eruption which could be due to arch length deficiency,
presence of supernumerary teeth, retained root fragments,
or formation of a bony bonier.
Tne maxillary canines develop almost near the
floor of the orbit and trcvel down to their final position in Ihe
oral cavity. Thus they are most often found erupting in an
abnormal position (fig 12).

Ankylosis is a condition wherein a part or whole of the root also causes food lodgement and periodontal weakening of
surface is directly fused to the bone with the absence of the teeth.
the intervening periodontal membrane. This most often
occurs as a result of trauma to the tooth which perforates PREDISPOSING METABOLIC
the periodontal membrane. Ankylosis can also be CLIMATE AND
ANKYLOS/Sassociated with certain infections, endocrinal DENTAL CARIES DISEASE
disorders and congenital disorde' such as cleidocranial
A number of endocrinal disorders, infectious conditions and
dysostosis. Clinically, these teeth foil to eruottothe normal
metabolic disturbances can predispose to malocclusion.
level and are therefore called submerged teeth (fig 13). At
times these ♦eeth ore totally submerged within the jaw Endocrine Imbalance
and therefore cause migration of adjacent teeth into the
Certain endocrinal disorders may result in malocclusion.
The following are some of Ihe endocrinal disturbances that
can cause malocclusion,

Fig 13. Maxillary |sft first pepr,oper;t rnolar is tinkybsed. Note the tpojh
is submerged and is infraocclusicn with ■lo rest of the defitl'i^n,

Caries can lead to premature loss of deciduous or

permanent teeth thereby causing migration of contiguous
teeth, abnormal axiai inclination and supra-eruption of
opposing teeth.
Proximal caries that has no^ been restored can
cause migration of the odjccent teeth info the space leadirg
to a reduction in arch length. A substantial reduction in arch
length can be expected if several adjacent teeth involved
by proximal caries ore le*t unresto'ed.


Improoer dental 'estorations may predisoose to

malocclusion. Over-contoured occlusal estorations cause
premature contacts leading to functional shift of the
mandible during jaw closure. Under-cortoured occlusal
restorations ccn perm": tne opoosing dentition to
suora-erupt. Proximal restorations thctare under-contoured
invariably result in loss of arch length due to drifting of ad
jacenf teeth to occupy the space. Poor oroximal contact
Hypothyroidism • Hypothyroidism is characterized by the associated with abnormal pressure and muscle imbalance
presence of one or more of -re following features: thereby increasing the risk of malocclusion. ">

; Retcrdation in rale of calcium deposition in Children who support their,head by resting the

bones and teeth, r Marked delay in tooth bud Etiology

chin on their of Malocclusion
hand and those who hang their head so that
formation and the chin rests against the chest are obsen/ed to have rnand

eruption of teeth z. Delayed carpel and epiphyseal ibu la r deficiency. Poor posture as a cause of malocclusion

calcification r. The deciduous teeth are often over-retained although not proved may nevertheless be an accentuating
and the permanent teeth are slow to erupt = Abnormcl factor for other malocclusions.
root resorption £ Irregularities in tooth arrangement- and
crowding cf teeth can occur
Children are highly prone to injuries ofthedento- facial
Hyperthyroidism : This condition is :~aracterized by
.region during the early years of life when they learn to
increase in the rate of —saturation, and an increase in
crawl, walk or during play. Most pf these injuries go
metabolic rale. Tne patient exhibits premature eruoTion of
unnoticed and may be responsible for non-vital teeth that
deciduous teeth, disturbed root resorption of deciduous
do not resorb and deflection of erupting permanent teeth
teeth and early eruption of permanent •seth. The oatient
into abnormal positions.
may have osteo- porosis which contra-indicates
orthodontic treatment.

-ypoporoihyroidism : This endocrinal disorder is

associoted with changes in calcium metabolism. It can
cause delay in tootn eruption, w'*ered tooth morphology,
delayed eruption of zeciduous and permanent teeth and
hypoplastic *eth.

Hyperparathyroidism : Hyperparathyroidism produces

increase in blood calcium. There is demineralization of
bone and disruption of trabecular pattern. In growing
children, interruption of tooth development occurs. The
•eeth may become mobile due to loss of cortical bone and
resorption of the alveolar process.

Metabolic d/stttrt>ances

Acute febrile diseases are believed to slow down tne pace

of growth and development- These conditions may cause a
disturbance in tooth eruption and shedding thereby
increasing the risk of malocclusion.

Diseases affecting the oro-facial muscles con

have a profound effect on the dento-alveolar complex
predisposing to malocclusion.



Nutritional deficiencies during growth may result in

abnormal development, causing malocclusion. These
diseases ore more common in the developing countries
than in the developed world. Nutrition related disturbances
such as ricketts, scurvy and beriberi can produce severe
malocclusion and may upset the dentol developmental time


Poor posturcl habits ore said to be a cause for

malocclusion. Although not substantiated, they may be
i' 'NU ..... lii'IW—HWIMFIII ........................... ........................ i'» 1

96 Orthodontics - The Art and Science

nclccclLsion. Am J O-thcd 1959 ; 192-199
23. Robert E Meyers : -crd book of O-thcdcn-ics, Year boo< ncdica
cua ishers, inc," 985.
24. Rocco J. D paolc, Dds : "noughts on Pa eta' Expansion . j C h
O-thcd 1970 ; 493-497
25. Sa'zman JA : e:feos c n occlusion of uncontrolled extract or of fi-st
eer-narent -no ars : Prevent'on aid Treatment. J Am Dent Assoc
1943: 30: 1681-1 69C
26. Solzmon JA : Practice cf Ortnodontics, -B tippincc*- compary, 1
27. Silvc, 8cos, and Ccpelczza : RME r prmary era mixed den-it ors.
Am J Orhod 1991:171-179
28. Thilander B Skagijs 5 : Orthodont'c Seauelae cf extract or, of
pe-monenl first melcrs : Alongi'udrcl study. Trans Eut Orthcd See i
97C; 429-^42.
29. ~ ask, Shcpi'o, crd Shaciro : E;tec*s o; allergic rnin'tis or dental and
skeletal development. Am J Orhod 1987; 256-293
30. Tulley : Adverse muscle :orces Their c'agnoslic significance. Am „
Orthod 1956 ,- 301-8'4
31. Urg. Koeng. Snapi'o, Shapiro, ara "-ask : Qjarti- fisd rasa ra-ion
and :acial :orm. Am J Ortnod " 990 ; 523-532
32. V g : Nasal airflow ir relation to toe 'c I rrorono ogy. Am J O-thcd
1981 ; 263-2/2
33. V'v'a-rer, Hatfield, and Da s-on . Nascl a'rwoy impairment. Arr J
O-t-ied "991 ; 346-353 Warren, Hnirf'e c, Seatcn, Mcr, arc Smith :
Nasal size and ncsal breathing. Arr J Orthod i 983 ;289- 293
35. Warren, Hersney, Turkey, H n to n, and Hairf e a : Nasa airwav
foHov/ng maxillary expansion Am J Orhoc
1987;! II.316
36 Warrer, Lehman, ond -inton : Analysis of s-imu- latea upper aiiwov
o-ea-hing. Ar J Orhod i 98^ ; 197-206
37. Weber, Preston, and Wright : Resistance to nasol airflow related
to charges in nead posture. Am J O-thcd 1981 ; 536-545
38. Wendell V Arrdt, Dds, Ms : N'ckel Titanium Polatol Expander . J
C'in Crthcd 1993 ; 129-137
39. William Christie S lio v/ : Orthodortics crd Occlusal management.
Wright, 1993
40. Wrtner : Surgically assisted pcla'al expansion. An J Orthod 1991;
41. Wccdside.linder-Aronson, Urdsirom, and McW'l iam : Wordibula-
end maxillary growtn a-ter changed node of breath'rg. Am J Orhod
1991 ; 1- 18

3 B'esoin, Shapiro, Snaairo, Cnacko, and Dassel : Mcu'h brecthirc in cllerg'c children. An J Orhod
1953 ,-334-340
2. E l'ngsen, Vandevanter, Shapiro, and Shapiro : Temporal vcr c t ion ir a-ea-hira. Air J Orhoc 1995 ;4' I - 417
3 Fielc's. Warren, Black, ana Fhillios : Vertical nor- aio'oey and respirat or in aoolescen's An J Orthod
"99" ; 147-154
4. Graber: ~ne 'three Ms': Musees. Malformation ond Ma OCCIJS or. Am J O-tnod 1963 ; -118-45C
5. Graaer TM : Orhocort cs : Principles arc practice. WB Sounde's,1988
6. Gross, Kalium, Morris, Franz, M'chas, Foster. Wa ke', and Bisnoo ; ^hincmetry and open-moj-h posture. An J Orhoc
1993 ; 526-529
7. Hannukselc and Vacrfinen : Predisposing factors fa' malocclusion as 'elotec lo atccic disaases. Am J Orthod 1987 ;
8. u
in-or, 'A'cren, end -ci-field : Upcor airway prss- SJre$ djring brceth rg. Am J Orhoc 1956 : ^92- 498
9. Jacchsor : Psychology and early ortnedentic t-eat- mert. Am J Or'hoc 1979 ; 5' 1-52?
10. Klein : Pressure habits, e-iological factors in ma occcljs'or . Am J Crthcd 1952 ; 569-587
ra r.ab'ts in children have a definite bearing on
the development cf occlusion. Frequency,
children acquire certain habits that may either
temporarily or permanently be harmful ro dental occlusion
end to the tooth supporting structures.
A habit can be defined as the tendency towards
an act tnai has become a repeated performance, relatively
fixed, cons'stentand easy to perform by an individual.
Habits are tnuS acquired as a result o: repetition.
In the initial stages there is a conscious effort to perform the
act. Later the act becomes less conscious and if repealed
often enougn may enter the realms of unconsciousness.
Habits can be classifiec in a number of ways. One
classification is to divide habits into pressure, non pressure
ana biting habits. I labits can also be classified as
compulsive and non-compulsive habits or empy and
meaningful hobits (refcrtable i fora detolledclassification).

Digit sucking is defined as placement of the thumb or one

or more fingers in varying depths into the mouth. Thumb
and digit sucking is one of the commonly seen habits that
most children indulge in. Reccnt studies have shown thai
thumb sucking may be practiced even during intrauterine
life. The presence o; this habit is considered quite normal till
the age of 3 1/2 - 4 years. Persistence of the habit beyond
this age con lead to various malocclusions.

A number of theories have been pul forward to exolain why
thumb sucking occurs. The following are some of the more
acceptea ones :

.'reuoVan theory : This theory was proposed by Sinmond

Freud in the early pari ol this century. He suggested lhat a
child passes through various distinct phases of
psychological development o^

Table 1 Classification ot habits
Phase f: (Normal and sub-clinically significant): The first
I. Useful and harmtul habits
phose is seen during the first three yeors of life. The
presence of thumb sucking during this phase is considered
98 Orthodontics - Ihe Art and Science
quite normal and usually terminates at the end of phase
Useful habits
These incline habits that are considered essential tor normal tunciion
such as proper positmrg of tte tor^iie. respiration and normal Phose (/ : (Clinically significant sucking) : The second
deglulition. Harmful habits
phase extends between 3 - 6 1/2 years of age. The
These include habits that have a deleterious effeci on the teeth and
oresence of sucking during this period is an indication that
Iheir supporting structures sutt as thumb sucking, tongue 1hrus:ing
the child is under great anxiety. Treatment to solve the
dental problems should be initiated during this phase.
II. Empty and Meaningful habits Empty habits

They are habits that are not associated with any deep rooted
psychological problems. Meaningful habits
They are habits that have a psychological bearing,

III. Pressure, non pressure and bitelng habits Pressure habits

These include sucking habits si># as thumb suctorg, lip sucking, linger
sucking and also tongue thrusting. Non - pressure habits
Habits which do not aoply a direct force or. the teeth or its supporting
structures are lermed non-pressure habits. An example of a
non-pressure habil is mouth breathing. Biting habits
These u>clude habits such as nail biting, pencil biting and lio Wing.

IV. Compulsive and Non compulsive habits Compulsive habits

These are deep rooted habits that have acquired a fixation m the child
to the extent that the child retreals lo the habit whenever te security is
threatened by events which occur around him. The child lends to sutler
increased anxiety when attempts arc made to correct the habit.
Non - compulsive habits
They are habits thai are easily learned and dropped as Ihe child
which -he oral and the anal phases are seer "n the first
three year o1 life. In +he oral ohose, the mouth is believed lo
be an oro-erotic zone. The child has Ihe tendency to place
his fingers or any other object into the oral cavily.
Prevention of such an act is believed to result in emotional
insecurity and poses the risk of the child diversifying into
other habits. Oro.f drive theory of Sears' Wise : Sears
and Wise in 1950 proposed that prolonged suckling can
lead to thumb sucking.

Be n io m in's rhe on/ : Benjamin has suggested that thumb

sucking arises from the rooting or placing reflex seen in all
mammalian infants. Rooting reflex is the movement of'he
infant's head and tongue towards an object touching his
cheek. Tne object is usuolfy the mothers breasl but may
also be a finae' or a pacifier. This "ooting reflex disappears
in normal infnnts around 7 - 8 months of age.

Psychological aspects : Children deprived of parental love,

care and affection are believed to resort to this habit due ro
a feeling of insecurity.

Learned pattern : According to some authors, thumb

sucking is merely c learned pattern with no underlying
cause or psychological bearing.

Phases of development
Ficj 1 Pholc-yfOphs o' a patient who
indt.lnec in llitwbsucking Mil thu cge ol
9 years [A!, IB) ond {C; Int'ao'ol
photographs (Dj .cloia! cepha'ocrarr.
ol lite scne aotient

Thumb and digit sucking are believed to cause a

Phase l/l r (Intractable sucking) : Any thumb sucking

the mandibular anteriors during tne sucking act. In
persisting beyond the fourth or fifth year o: life should such children lingual tipping
alert the dentist to the underlying psychological
aspects ot the habit. A psychologist might have to be
consulted during this phase.

Effects of thumb sucking

number of changes in the dental arch and the supporting
structures. The severity of the malocclusion caused by
thumb sucking depends on the trident of factors. They are :
a. Duration : The amount of time spent
indulging in the habit.
b. Frequency : The number of times tne habit is activated
in a doy.
c. JnferisiJy : The vigor with which the habit is performed.
The following are some ot the effects of
thumb sucking :
a. Labial tipping of the maxillary anterior teerh resulting
in proclination of maxillary arileriors.
b. The overjet increases due to proclination ol the
maxillary anteriors. Some children rest their hand on
Fig 2 Photographs d C pcriont who in'tiolly hod o thumosucking habit arr: loter diversified into -oi,nge "hvs' nabi*. Nore rha df.p.r. palote v/tli
rsrrowing ot "he maxi lary arrh wh ch ocojrs dje -o lev/Ore v to'iate posit'or associated with tie hcbi". A lixci; hobit brenkftf wos JSC d to irre'cep" rhe
'ounge hobil.

of the mandibular inc'so's can be expected which further

increases the overjet. Anterior operi bite can occur as a
result of restriction cf incisor eruotion and supraeruption of

d. tne buccal 'eeth (fig I), The cheek muscles contract during
thumb sucking resulting in a narrow maxillary arch
which predisposes lo posterior crossbites (fig2).

e. The child may develop tongue thrust hcbil as a result of

the open bite. The upper lip is generally hypotonic while the
lower part of Ihe face exhibits hyperactive menlalis activity.
Zagnosls These
consist of
a crib
palatal to

~-e parents should be
:khg end rorgue tirust'ng. [A; Rem ova b e hebi' breaker ;3)
'•z 2 ncbi" brea<ers jsec ir 1he ncnagarrant of rhumb si,: rabit breaker;

breakers can be of two types (fig 3).

quest'oned on Ihe frequency
a) Removable habit breakers : They are passive
[ 3 r d duration of tne habit. The child's emotional f s^r JS
removable appliances that consist of a crib and is
should be assessed by enquiring into such Ifetngs as:
anchored to the oral cavity by means of closps on the
; Feeding habits a. Porenral care of the child r. Wh elh
posterior teeth.
er tne pa ren ts a re wo rki n g
b) Fixed habit breakers: Heavy gauge stainless steel wire
An intra-oral clinica examination should
can be designed -o form a frame that is soldered to
oecord all the features seen such cs oroclination, bands on the molars.
icen bite etc.,. The child's fingers should be examined.
Other aids that can be used to intercept
Presence of clean nails and callus on ~e finger is
commonly associated with thumb :jcking.

Management of thumb sucking

Ps/cho/ogfco/ approach ; It is usually said —at
children lacking parental care, love and cnection
resort to this habit. Thus the parents should be
counseled to provide the child with idequate love and
affect on. The parents should iso be advised to divert
Ihe child's allention to other things such as play end
The success of any habit interception
oroceduro'largely depends uoon the subject's co-
operation and willingness to be helped to
discontinue his sucking habit. Thus the parents and the
dentist should seek to motivate :he cnild.
D jnlop out forward c theory called Beta
hypothesis that states that the best way to break a habit's
by its conscious, purposeful repetition. Dunlop suggests
thct the child snould be asked to sir in front of a large mirror
and asked losuck his thumb observing himself as he
indulges in the habit. Tnis procedure is very effective if the
child is asked to do the same at a time when he is involved
in on enjoyable activity.

Mechanical aids : They are basically reminding appliances

that assist the child who is willing to quit Ihe habit but is not
able to do so as tne habit has ertered a subconscious level.
the ho bit include bandaging the thumb, end ba n da g ing of Tongue thrust can also be classified as simple
the el bow. tongue thrust and complex tongue thrust.

102 Orthodontics - The Art and Science

Chemicai1 approach : Use of bitter tasting or foul smelling
preporation placed or the thumb that is sucked can make
the habit distasteful. The medicaments that car be used
include :
a. Pepper dissolved in a volatile medium
b. Quinine
c. Asafetia'a


Tongue thrust is defined as a condition in which the tongue

makes contact with any teeth anterior to the molars during

Etiology of tongue thrust

Fletcher has oroposed the following facrors as being the
cause fo>-tongue thrusting.

Genetic ioctors ; They are specific anatomic or

neuromuscular variations in the oro-facio region that can
orecipilate tongue thrust, e.g. Hypertonic orbicularis oris

Learned behavior (ha b ft) : Tongue th Tuscan be acquired

as a habit. The following are some of Ihe predisposing
factors that con iead to tongue thrusting :
a. Improper bottle feeding Tabfe
2 Braneram
b. Prolonged thumb sucking
c. Prolonged tonsillar and upper respiratory tract Type I: Non-determing tongue thrust Type I I :
infections Deforming anterior fcygje thrust Sub group t :
d. Prolonged duration of tenderness of gum or teeth can Anterior open bite Sub group 2 : Anterior
proclination Sub group 3 I Posterior crossbite.
result in a change in swallowing pattern to avoid
Type III : Deforming lateral longue thrust
pressure on Ihe lender zone
Sub group 1: Posterior open bite Sub group
Moiuraiionoi : Tongue thrust can present as part of a 2 : Posterior crossbite Sub group 3 : Deep overbite Type
normal childhood behavior that is grodually modified os ihe IV : Deforming anterior and lateral tongue thrusi
age advonces. The infnntile swallow changes lo a rnalure Sub group 1: Anterior and posterior open bite
Sub group 2 : Prodination ot anterior teeth Sub
swallow once the posterior deciduous teeth start enjpting.
group 3 : Posterior crossbite
Sometimes Ihe maturation is delayed and t.nus infantile
swallow persists for a longer duration of time.

Mecfidnicaf restrictions ; The presence of certain

conditions such as macroglossio, constricted dental arches Simple Classification of Tongue
and enlarged adenoids predispose to tongue thrust habit.
Simple tongue thrus! Complex tongue thrust
Neurological disturbance ; Neurological disturbances
affecting the oro-facial region such as hyposensitive palate
and moderate motor disability can cause tongue thrust

Classification of tongue thrust

Toblc 2 gives the James and Holt classification of tongue
thrust. The term non-deforming in this classification imolies
that the inter-digilafior of teeth and the profile ore
acceptable and within normal range. Deforming tongue
thrust is associated with some dento-alveolar defect.

Pig 'l Patient will anterior -oncjje tn'LS*

rsycnoge^ic factors : Tongue thrust con sometimes occur The tongue thrust can be intercepted by use of habit
as a result of forced dscontinuarion of other habits like breakers as described for thumb sucking. Both fixed
thumb sucking. - is often seen that children who are forced and removable cribs or rakes are valuable aids in
to ;eave thumb sucking habit often lake up tongue testing. brooking the habit.
The child is taught the correct method of swallowing.
SimpJe tongue thrust Various muscle exercise of the tongue can help in
The following features can be observed : c The simple training il lo adopt to the new swallowing pattern
tongue thrust is cnaracleri/ed by a normal tooth contact (Refer chapter 20).
during the swallowing act. Treatment of ma/ocdusion :' Once the habit is intercepted
c Presence of an anterior open bite, jc They exhibit good the malocclusion associated with Ihe tongue thrust is
inlercuspalion of teeth, z Tne tongue is thrust forward treoled using removoble or fixed orthodontic appliances.
during swallowing
lo help establish an anterior lip seal, e Abnormal
mentalis muscle activity is seen.

Complex tongue thrust

The following features are seen : c This kind of tongue
thrust is characterized by
a teeth apart swallow, c The anterior open bite con be
diffuse or absent.
c Absence of temporal muscle constriction
during swallowing. ^ Contraction of the circumorol
muscles during
swallowing, e The occlusion of teeth may be
Clinical features
The rongue thrust habit con be associated with the
following features:
a. Proclination of anterior teeth
b. Anterior open bite •
c. Bimaxillary prolrusion
d. Posterior open bite in case ot lateral tongue thrust
e. Posterior crossbite

Management of tongue thrust

The monagement of tongue thrust involves interception of

the habit followed by treatment to correct Ihe malocclusion.

Habr'f interception ;
MOUTH BREATHING HABIT b. Narrow nose and nasal passage C.
Short and fiaccid upper lip
Mouth breathing has been at'ibuted csa possible
d. Contracted upper arch with possibility of posterior
104 Orthodontics - The Art and Science
cross bite
etiologic factor for malocclusion. The mode of
e. An expressionless or blank face
resp'ration influences the posture of the jaw, the tongue
f. Increased overje* as a result of flaring of Ihe incisors
and to a lesser extent the head. Thus it seems ouite
g. Anterior marginal gingivitis can occur due to dn/ing of
logical "hat mouth breatning can result in altered jaw and
the gingiva (fig 6)
tongue posture whicn could alter the oro-fac'al
h. The dryness of the mouth predisoosestocaries i .
equilibrium thereby leadirg to malocclusion. Most
Anterior open bite con occur
normal people indulge in mouth brecthing when they are
under physical exertion such cs during strenuous 0/agnos/s of mouth breathing
exercise or sports activity.
History : A good history snould be recorded from the
C/ass/ftcae/ort of mowt/i fcreat/iers patient as well as parents. Clinical examination : Loo< out
for its various clinical leatures. A number ot simole tests
Mouth breathers can be classified 'nto 3 types :
can be carried out to diagnose mouth breathing such cs
a. Obstructive
the mirror test, wo tor test ctc. (Refer chapter 11}.
b. Habitual
c. Anatomic Cepho/omefrics ; Cephalometric examination
Obsfryctfve : Complete or partial obstruction of tne
nasal passage can result in mouth brecthing. The
following are so Tie of the causes ' o^ nasal obstruction:
a. Deviated nasal septum
b. Nasc' oolyps
c. Chronic inflammation of nasal mucosa
d. Localized benign tumors
e. Congenital enlargement of nasal turbinates
f. Allergic reaction of tne nasal mucosa
g. O bstru ctive a den o id s

Hobitooi : A nabitual mouth brcatner is ore who

continues to breathe through his mouth ever though the
nasal obstruction is removed. Thus mouth breathing
becomes a deep rooted he bit that is performed

Anatomic ; An anatomic mouth breather is ore whose lip

morn h o logy does not permit complete closure of the
moutn, such as a patient having short upper lip.
During oral respiratior, rhe following three charges in the
posture occur :
a. Lowering of the mandible.
b. Positioning the tongue dowrwards and forwards.
c. Tipping bcck cf the nead.
Lowering of the tongue ard mondible upsets the
oro-facicl equ'librium. There is an unrestricted buccinator
activity that influences -ne position of the -eeth ond o so
the growth of the jaws.

Clinical features of mouth breathing

Tne type of malocclusion most ofter associated with mouth
orccthing is called iong :aco syndrome or the clcssic
adenoid facies. These patienrs exhibit the following
featu'es :
a. Long and narrow face I'fig 5)
Orthodontics - The Art and Science

'ntercepfion of the habit : Mouth breathing can be

intercepted by use of a vestibular screen. Alternatively
adhesive tapes con be used to establish lip seal.
,Rop/d maxillary expansion : Patients with narrow,
constricted maxillary arches benefit from rapid palatal
expansion orocedures aimed at widening the arch.
Raoid maxillary exoansion has been found lo increase
the ncsal air flow and decreose the ncsal air

o. Occl usa I wea r facets ca n be o bse n/ed o n the

b. Fractures of teeth and restorations.
c. Mobility of teeth.
d. Tenderness and hypertrophy of masticatory
e. Muscle pain when the patient wakes up in the
f. Temporomandibular joint pain and discomfort can
Fig 6 Parent v/ith mouth breathing 'icbit exhibiting anterior mci'ginol occur,

helps in establishing' the amount of nasopharyngeal s

price, size of adenoids and also helps in diagnosing the
long face associated with mouth breathing.

Rhinomanomeir/ : It is the study of nasal air flow

characteristics using devices consisting of flow
meters'/and pressure gauges. These devices help in
estimation of air flow through the nasal passage pnd
nasal resistance.

Management ot rooatft fireaM/ng

Removal of nasal or pharyngeal obstruction: Any
nasal' or pharyngeal obstruction should be removed by
referring the patient to the E,N,T, surgeon.

Bruxism can be defined as the grirding of teeth for

non-functional purposes (fig 7) Some authors refer to
nocturnal grinding as bruxism while Ihe term
bruxomania is given for grinding during the day time.

'l. Psychological and emotional stresses have been
attributed as one of the causes of bruxism.
2. Occlusal interfere nee or discrepancy between
centric relation and centric occlusion can
predispose to grinding.
3. Pericoronitis, and periodontal pain is said to trigger
bruxism in some individuals.

Clinical features
This habit can be intercepted using lip
bumpers that not only keep the lips away but also
improve the axial inclination of the anterior-teeth due to
unrestrained action of the tongue.

Nail biting
Nail biting does not produce gross malocclusion. Minor
local tooth irregularities such as rotation, wear of
incisal edge and minor crowding can occur as a result
of nail biting. People in certain

rig 7 Pa-ient witn bruxism show rig ott.'it'on o ; teeth

Fig 8 Patieo.l Wi'h nut Uificvg habit exhibiting typical wear of ihe
leetlfand mild malalignment-
-istoryand clinical examination in most cases is
sjfficiont to diagnose bruxism. Occlusal crematurities
can be diagnosed by use of articulating papers.
Electromyographic examination can be carried out to
check for hyperactivity of the muscles of mastication.

Many cases of bruxism are associated with emotional
and psychological disturbances. Thus appropriate
psychological counseling by a psychiatrist maybe
initiated. Hypnosis, relaxing exercises and massage
can help in relieving muscle tension. Occlusal
adjustments have to earned out to eliminate
prematurities, Night guards or other occlusol splints
that cover the occlusal surfaces of teeth help in
eliminating occlusal interference, prevent occlusal
wear and break the neuromuscularadaptation, .


Lip biting

Lip biting and fip sucking sometimes appear after

forced discontinuation of thumb or finger sucking. Lip
biting most often involves the lower lip which is turned
inwards and pressure is exerted on the lirgucl surfaces
of the max ill o ry anteriors. The. patient may exhibit
the following features:
a. Proclined upper anteriors and retroclined lower
b. Hypertrophic and redundant lower lip
c. Cracking of lips
countries in middle east exhibit what :s called the nut
notch which is a wear of teeth in the form of c notch.

Orthodontics - The Art and Science

This is a result of cracking open and eating hard nuts
using the incisal edge of tne anteriors (fig 8). These
patients may exhibit mild irregularities and rotation of

19. Robert z Meyers : ^ard book of Crthodon-ics, Year boo< red ccl
publishers, inc. 1908.
20. T'osk, S napi'o, arc Shcpiro : Efects cf alle'eic rh nitis on oerol
ond s<ele'ol devs opr-fir. Am J Ortnod
1967; 286-293
21. " u 11 c v : Adverse muse o forccs Their diagnostic signif'cence.
Am - Orthcd 1956 ; 80'-814
22. Ihg, <oerig, Shac'rc. Snopi'o, and Tras< : Quon-i- fied
respiration end faciei form. Am - Orthod 1990 ; 523-532
23. Vig : Masai ci-flov 'ootor tc facial morphology. Am J Orhod '98' :
2^. Women, l la rfield, and Dolstor : Nasal air//ay im- paVncv Am J
Orthod 1991 ; 3^6 353
25. Worren, Ha'neld, Seaton, fv'iorr, end Smith : Nasal si2e arc
ncscl breaking. Am J Orlhod i 983 ;259- 293
26. Worrer, Hershey, Turkey, H'nton, end Hairf'eld : Nasal airway
follov/ng maxillary expansion. Am J Orhod 1987 ;111 -116
27. Wicrren, Lehman, and H'rton : Analysis of st'rru- cted upper
air.vav breohing. An J'Orhod 1934 ■ ' 97-2C6
23. Wo be, Preston, and Wr'gr : Resislcnce ro nascl
airflow reta'ec to changes r head postjre. Am J
Orhod 1981 ; 536-5-15
29. William Chris'ie Show : Orthodontics and OCCIJSOI r-enagenen\
Wright, 1993
30. VVooc'side,Lincer-A'onson, Lundstrom, ard McWilliarr :
Murdibtlar end maxillary grov.-tn a:ter rhnngeo nods of
brecthing. Am J Orthcd 1991 .'TIS
M any organized populationsurveys have
been carried oul in different parts of the
world with the objective of
srmating prevalence of
had Angles Class I malocclusion and " 7% had Angle's
Closs II malocclusion. The zrevolence of malocclusion
among Indian —ildren has been reported to be as low
as 19.6% in Madras by Miglani D.C. et al in 1965 and as
malocclusion and high as 90% in Delhi by Sidhu S.S. in 1968. Indians
cmodontic treatment
> t 4 t« ^ t ♦ t > }> t * I .-v j j A .. j - , - •» .AI ^uyi ^^
needs. Prevalence of
T-c!occlusion is it J u ^..„yy

estimated to be higher in exhibit a low incidence of variation in molar relation both

se.eloped countries o s in the mesial and distal direction. Disto-occlusion in
compared to developing India is very low in contrast to USA (34% in Whites and
under-developed 15% in Blacks) and Europe {29%).CIass III
malocclusion is also much less prevalent in Indio

idemiology of compared lo USA, Netherlands

Prevalence of malocclusion in a sample of leboncse
and Kenya.

locclusion schoolchildren was found to be about 59.5%. A

study conducted to determine the prevalence and
countries. severity of malocclusion in Arab urban children of 13 to
A number of studies 15 years age revealed that 85 percent had Angle Class
have been conducted •xz I malocclusion, 8.5 percent had Angle Class II, Division
Mil determine the prevalence of 1 malocclusion, 1.7 percent had Angle Class II, Division
malocclusion in nrerent countrios. The 2 malocclusion, and 1.3 percent belonged to the Angle
prevalence of malocclusion ™ong Chinese children Class III category. In a study done by the Federal
was estimated to be ;oout 67.82%in a study done by University of Rio d e Janeiro, Brazil the prevalence of
Peking «^..versity. In on epidemiological survey of malocclusion in Brazilian children was estimated to be
1,028 cr-dren carried out to assess the prevalence of 75.8%.
-ciocclusion in Nigeria, it was seen that children £-1.0%

4 983 ;334-340
2. El ingscn, Vancevon'er, Shoo rc.. and Shapiro : Ten- pcol
va'ianon ii breathing. An„ Orthod 1995 ,41 1 417
3. Fields, Werner, 3lack, and Phil ips : Vertical ~icr- pholcgy and
reso'raticn in adolescenls. An J Orhod
1991 ; 147-154
4. Graber: The 'three M's': Muscles, Malformation end
Malocclusion. Am J Orthod 1963 ; 418-450
5. Gross, Kalium, Morris. Franz. Michas, Fester, Wal<er, era D is
no c : Rhine rnetry and open-mouth pestjre. Am J Onhod 1993
6. Hcrrukse a and Vfifinfiner : Predisposing fac'o's for nolccclLsicn
as re cted to ctccic diseases. Am J
O-thod 1987 299-303
7. Hannukselo and Vacranen : Predisposing factO'S tor
nclcccusicn as 'elotec to otco'c c'isecses. Arn J Orthod 1987 ;
8. Hnton, Warren, rird Hoirfield : U peer ci'woy pressures durinq
breathing. Am J Orthod 1986 ; 492- 493
9. Jacobscn : Psychology and ear •/ 'orthodontic t'eat- ment Ani J
O-thod 1979 ; 511-529
. 1C. Klein : P'essure hebits, etiological factors in •maloccdusion . Am
J Onhod 1952 ,- 569-58/
11. Lersson and Danlin : Prevalence end etiology of inrial djrrmy-
and nnger-scckina habt. .Am J Orthod 1985
; 432-435
12. Lcrsson and Danlir : P'evclence end otology of iri'ia dummy-
and -inger-suckine han't. Am J Orthcd 1985 ; ^32-435
13. Leiter crd Baker. Partitionlrg of vent'latior and
nasal resistance. Am J Orhod 1989 ; 432-438
14. Marks ; Bruxism r ol'ergic chidren. Am J Orthod 1 98C /8-59
15. Meyers and Hertzhe'g : Hottle-feed'ng and irclocc usion. Am J
Orhod 1988 ; 149-152"
16. Ocaarc, Lcrsson, and L'rcs'en : Effect cf sucking habits on
posterior c-ossbite. Am J Orthod 1994 ;161- 166
17. Prcfitt WR: Contemaorary Orthodontics, St Louis,
18. Regan and Sublelny : Correction o ; severe Cess II
malocclusior. Am .1 Orthcd 1989 ; 192-199
110 r Orthodontics - The Art and Science
MEASUREMENT OF MALOCCLUSION The 'Handicapping La bio-Ungual Deviation Index1
(HLD Index) was developed by Harry L. Droker in 1960.
Malocclusion and dento-facicl deformity are conditions
The HLD index was proposed to select
that constitute a hazard to the maintenance of oral
subjects with severe or handicapping malocclusion and
health and interfere with the well being of the person by
dento-facial onomalies. The index is applicable only to
adversely affecting dento-fccial aesthetics, mandibular
function or speech. the permanent dentition. HLD index was the first

The measurement of malocclusion as a public orthodontic index designed to meet the administrative

health problem is extremely difficult since most needs of program planners.

orthodontic treatment is undertaken for oesthetic

reasons and it is very difficult to estimate the extent lo
The three planes commonly used for orthodontic
which molposed teeth or dento-fccial anomalies
constitute a psychological hazard. Malocclusion has orientation i.e. the sagittal plane, Ihe Frankfort

proved to be a difficult entity to define because horizontal plane and the orbital plane are the basis for

individual perceptions of what constitutes a the HLD index measurements. The main intention of the

malocclusion oroblem differ widely. As a result, no HLD index is to measure the presence or absence and

generally accepted epidemiological index of the degree of the handicap caused by the components

malocclusion has yel been devised. of the index. The HLD index is based on seven
According to Russell, an Index is defined as 'a components. All measurements are made with a Boley
numerical value describing the relative status of a gauge scaled in millimeters. The seven component
population on a graduated scale with definite upper and conditions of the HLD index are explained as
lower limits which is designed to permit and facilitate
comparison with other populations classified by the
same criteria and methods.
Jamison H.D. and McMillan R.S. have
proposed a list of requirements for an ideol orthodontic
index that can be used in the epidemiologic studies of
orthodontic problems, as follows:
1. The index should be simple, accurate, reliable and
2. The index should be objective in nature and yield
quantitative data which may be analyzed by
current statistical methods.
3. The index must be so designed as to differentiate
between handicapping and non- handicapping
4. The examination required must be one that can be
performed quickly by examiners even without
special instruction in orthodontic diagnosis.
5. The index should lend itself to modification for the
collection of epidemiological data, regarding
malocclusion other than prevalence, incidence,
severity e.g. frequency of molpositioning of
individual teeth. •
6. The index should be usable either on patients or on
study models.
7. The index should measure Ihe degree of handicap,
if any and avoid classifying 'malocclusion1.

Condition # 7 - La 6 ro-/in gua/ spread : To measuro
labio-lingual spread, the Boley gauge is used to
Conditions Observed determine the extent of deviation from a normal arch.
The total distance between the most protruded and the
Set pa/ate
lingually displaced anterior ismeosured.
«•.ere traumatic deviations
In the event of multiple anterior teeth
0»e*jet in mm Cvtfbite in mm
crowding, oil deviations from the normol arch should be
Vandbula' protrusion in mm
measured for labio-lingual spread, but only the most
Cpen bite m mm Eoopic
severe individual measurement should be entered on
eaiption. anteriors at/ e&tfi
tooth fcterior crpWding the index. This is done to give the patient the benefit of

Maxilla ........................ the greatest deviation.

Mandible .............. The above explained HLD index system is a
modification of an earlier used HLD index. The HLD
index used prior to the new HLD index i.e. before 1960's
made use of weighting factors developed by trial and
error. This index system had nine component conditions
measured. The conditions observed and scores
*ok»vs: assigned are given inTable II.
Conditio n # ?- Cleft Pa/ate : This condition a A score of 13 (tentative) and over constitutes a
described as malocclusions resulting from serious physical handicap'.
structural deformities involving growth and revslopment The following codes are used in the HLD
ol Ihe mandible and maxilla. The presence of cleft index.
palate is indicated by an "X1 in ire recording chart. O : Condition absent X :
Condition # 2 - Traumatic Deviations :The Toumatic Condition present
deviations referred to ore, for e.g. loss rra premaxilla
segment by burns or by accident, re results of
osteomyelitis or other gross pathology. The presence of
a traumatic deviation is also -Seated by an X' in the
recording chart.

Condition # 3 - Overjet : This condition is -veasured with

the patient in centric relationship. ~ne measurement
can be applied to a protruding angle tooth as well as to
the whole arch. The measurement is read and rounded
off to the -earest millimeter and recorded.

Condition # 4 - Overbite : This measurement ^ also

rounded off to the nearest millimeter and recorded.
Reverse overbite may exist in some conditions ond
should bo measured and recorded.

Condition # 5 - A'1anc/ibu/ar Protrusion : This is

measured from the labial of the lower incisor to the
labjal of the upper incisor. The measurement
in millimeters is recorded. A reverse overbite
if present should be shown under 'overbite'.

Condition # 6 - Open bite : This condition is defined as

the absence of occlusal contact in the anterior region.' It
is measured from edge to edge in millimeters and
V : Mixed dentition (to be indicated if
5. Tooth displacement
present) A : Clinical
6. Congenially missing teeth
approval D : Clinical disapproval
7. Unerupted central incisors
8. Mandibular prognathism
9. Mandibular retrognathism and
10. Posterior crossbite
The Orthodontic Treatment Priority Index (TPI) was TPI is based on a scale of '0 to 3", '4 to 6' and
developed by Grainger R.M. in 1967. The TPI was a 'over 6'. The TPI tends to give more consistent
revision/modification made by Grainger over the earlier percentage of prevalence, relative to age.
developed 'Malocclusion Severity Estimate1. TPI is' TPI scores can be expressed in the ranges
based on the study of interrelationships of 10 of:
manifestations of malocclusion. TPI includes seven 0-2.5 = Low 2.5-4.5 =
syndromes and quantifies oral inter-relations hips in Middle above 4.5 = High
terms of the seven syndromes. The 10 manifestations TPI serves as a guide for epidemiological
of malocclusion measured in TPI are : surveys of populations as well as an instrument for
1. Bimolar relationship screening. TPI has been used in national studies of
2. Maxillary overjet orthodontic needs of children.
3. Open bite 4: Overb/te

Count the number of teeth displaced or rotated.

Assessment of tooth displacement and rotation Is
qualitative -(all or none).

Malalignment Index by Vanklrk Tooth displacement and rotation were measured.Tooth

andPennel(1959) displacement defined quantitatively: <1.5mm or > 1.5mm.
Tooth rotation defined quantitatively: <45c or
Master and Frankel (1951)

Handicapping Lablo - Ungual deviations (all or none), overjet {mm), overbite {mm},
Deviation Index by Draker mandibular protrusion {mm), anterior cpen bite (mm),
(I960) arid labio-lingualspread (a measurement of tooth
Measurements include deft displacement in mm),
paJate (all or none), Iraumalic

Occlusal Feature Index by PouHon

Measurements include lower
anterior crowding, cifcpal
intendigitation, vertical overbite,
and horizontal overjet.
?.VS» >"••> SFIVVS'*

ogy of
indices'of occlusion-continued
Malocclusion Severity Estimate by Firstpermanentmolarrelationship 6. Posterior
linger (1960-61) crossbite- 7. Teeth displacement (actual and
Occlusion features measured potential).
and scored according to
defined criteria. Six malocclusion syndromes were defined:
Seven weighted and defined
measurements: 1 .Positive overjet and anterior open bite.
Overjet 2. Overbite 3. Anterior Posl1ive overjet, positive over bite, distal molar
open Me 4. CorxjerotalJy ' relationship. arid posterior crossbite with maxillary
missing maxillary incisors 5. teeth buccal to mandibular

Negative oveijet, mesial molar relationship, andposterior

aossbite with maxiUary teeth lingualto mandibular teeth.
Congenially missing maxillary incisors.
Tooth displacement
Potential tooth displacement.
Nine weighted and defined measurements ;
1. Molar relation 2. Overbite 3. Overjet 4. Posterior cross We
5, Posterior open bite 6. Tooth displacement 7. Midline
Occlusal Index by Summers (1966) relation 8. Maxillary median diastema 9. Congenitally
missing maxillary incisors.
Seven malocclusion syndromes defined:
1.Overjet and open bite.
2. Dislal molar relation, overjet, overbite, posterior
crossbite, midline diastema, and midline deviation.
3. Cor>genitalty missing
maxillary incisors; 43mdisplacement
(actualand potential).
«.Mesial molar relation, overjet, overbite, posterior crossbite,
midline diastema and midline deviation.
7. Mesial molar .relation, mixed dentition analysis
(potential tocth displacement), and ipoth displacement.
Different scoring schemes & iorms for different stages
ot dental development; deaduousdentition, mixed
dentition, a permanent dentition.

Treatment Priority Index by Grainger (1967) 11 weighted and defined measurements: 1. Upper anterior
segment overjet. : 2. Leaver anterior segment overjet 3.
Overbite of upper anterior lower anterior .4;Ar)ierarcpenbite
5. Congenital absence ot incisors:
6.Distal molar relation
7. Mesial molar relation

I \1
9. Posterior crossbite (maxillary leeth lingual lo normal)
10. Tooth displacement
11. Gross anomalies.
Handicapping Malocclusion Weighed measurements consist of three parts:
Assessment Record by 1. Intra-arch deviation- missing teeth, crowding,
Salzmann{1968) rotation.
Seven malocclusion syndromes were spacing.
defined: 2.Interarch deviation - overjet, overbite, aossbite,
1. Maxillary expansion syndrome cpen bite., mesicdistal deviation.
2. Overbite 3. Six handicapping dento-faclaideformi:ies.
3. Retrognathism 4; Open bite 1. Facial and oral clefts
5. Prognathism 2. lower lip palatal 10 maxillary incisors
B. Maxillary collapse syndrome 7. 3. Occlusal interference
Congenital^ missing incisors 4. Functional jaw limitation
5. Facial asymmetry
6. Speech impairment.

This part can only be assessed on live pat


Orthodontic Diagnosis
■■H B

rrhodontic diagnosis deals with recognition b) Bite wing
of the various characteristics of the c) Panoramic
malocclusion, h involves collection of 5. Facial photographs
pertinent data in a T»stema»ic mannerto nelp in
identifying rne nature and cause of the problem.
Ormcdontic diognosis should be based on sound
scientific knowledge combined at times with clinical
experience and common sense.
Diagnosis involves development of a
comprehensive data base of pertinent information. The
data is derived from case history, clinical exomination
and other diagnostic aids such as study casts,
radiographs and photographs. A systematic opproach
to the examination is essential to ensure that nothing is
overlooked. The purpose of this chapter is to describe
and illustrate fundamentals of gathering and
interpreting clinical information yielded from a
Comprehensive orthodontic diagnosis is
established by use or certain clinical implements called
diognostic aids. Orthodontic diagnostic aids are of two
types. They are the essentiol diagnostic aids and the
supplemental diagnostic aids.


They are clinical aids that are considered very important

for all cases. They are simple and do not require

expensive equipment. The following are the
essential diagnostic aids.
1. Case history
2. Clinical examination
3. Study models
A. Certain radiographs
a) Periapical radiographs
1601?" Orthodontics
DIAGNOSTIC AIDS- The Art andsocio-economic
Science status of the patient and parents. This
helps in selection of an oppropriate appliance. The
They are certain aids which are not address also helps in future correspondence such as
essential in all coses. They may require specialized to intimate appointments.
equipment that an average dentist may not possess. Chief complaint
The supplemental diagnostic aids include : The patient's chief complaint should be recorded in his
1. Specialized radiographs e.g. or her own words. This helps the clinician in identifying
a. Cep halo metric rodiogrophs the priorities and desires of the patient. Most patients
b. Occlusal intra-oral films seek orthodontic care for reasons of either esthetics or
c. Selected lateral jaw views impaired function.
d. Cone shift technique
2. Electromyographic examination of muscle activity
Medical history
3. Hand-wrist radiographs to assess bone age or Before orthodontic treatment is undertaken, a full
maturation age medical histony is recorded. Fortunately very few
4. Endocrine tests medical conditions contra indicate the use of
5. Estimation of basal metabolic rate orthodontic appliances. Most of these conditions may
6. Diagnostic setup require certain precautionary measures to betaken
7. Occlusograms prior to or during the orthodontic therapy. It is
advisable to delay orthodontic treatment in patients
suffering from epilepsy until it is controlled. Patients
with history of blood dyscrasias may need special
Case history involves eliciting ond recording of
management if extractions are planned.
relevant information from the potient and parent to aid
in the overall diagnosis of the case. The information is 'H f
gathered from the patient and parents. i

Personal details
Nome : The patient's name should be recorded for the
purpose of communication and identification. Most
patients like being called by their name. Addressing a
patient by his or her name has a beneficial
psychological effect as well. It gets the patient to think
that the clinician is interested in his well being. In case
of children it is wise to record their pet names. Age :
The patient's chronological age should be recorded.
Age consideration helps in diagnosis as well as
treatment planning. There are certain transient
conditions that occur during development that are
considered normal for that age. Thus knowing the age
helps in identifying and anticipating these condition. In
addition, there are certain treatment modalities that are
best carried out during the growing age. Growth
modification procedures using functional and
orthopaedic appliances are carried out during the
growth period. Surgicol resective procedures are best
carried out after the cessation of growth. Sex: The
patient's sex should be recorded in the case history.
This is important in planning treatment as the timing of
growth events such as growth spurts is different in
males ond females. Females usually precede males in
onset of growth spurts, puberty and termination of
growth. Address and occupation : Recording of the
address and occupation helps in evaluation of the
Orthodontic Diagnosis

Sex M F File No


Phone Number

Qfef Complaint

Medical History Dental History

Profile Mesocephalic
Extraoral Examination Dolicocephalic Brachycephalicj
Convex Concave Slraight
Shape of Face
Shape of Head

Facial Divergence
Anterior Posterior Straight Round Oval Square

Facial Symmetry
Symmetrical Asymmetrical
Competent Incompetent Everted

Nasolabial Angle Mentolabial Sulcus

Normal Acuie Obtuse;. Normal Deep Shallow

1601?" Orthodontics - The Art and Science


Tongue Size
Normal Small Large Normal Tongue thrusting

T.M.J Frenum

Norma Pain Clicking Normal Abnormal

Path ot closure Breathing

Normal Deviated'isft Deviated right Oral Nasal Oro-nasal

Intraoral Examination
Permanent dentition
8 v-' N 6 5 ' r • 3 2 1 1 2 3 4 5 6 7 8

@©©©©©©© @m@M@

Dec<Juou$ dentition.





Molar relation Canine relation

Details of malocclusion present

| ___| Rotations

I I Proclination

Crowding Anterior crossbile

Posterior crossbile

Diagnostic aids

| J Study models j j OPG | | Lateral cephalogram: | j BHewIng radiographs

| [ Occlusal radiographs j j Pholographs | | |j


Treatment Objectives

Treatment Plan

I consenf to the treatment plan described above by my

Orthodontist and have been notified of the possible side
effects and complications of the above treatment

Patient Signature Doctor's Signature

120 Orthodontics - The Art wmmsmm •
and Science

Diabetic patients can undergo orthodontic therapy if it is usually begins his general examination as soon as the
under control. Patients having rheumatic fever or patient enters the clinic.
cardiac anomalies require antibiotic coverage. Children
who are severely handicapped either mentally or Height and weight
physically may require special management. The height and weight of the patient are recorded.
The medical history should include They provide a clue to the physical growth and
information on drug usage. The use of certain drugs maturation of the patient which may have dento- facial
like aspirin may impede orthodontic tooth movement. correlation.
Patients who are suffering from acute, debilitating
conditions such as viraf fever should be ollowed to Gait
recover prior to initiating orthodontic treatment. It is the way a person walks. Abnormalities of gait are
usually associated with neuromuscular disorders
Dental history
which may have a dental con-elation.
The dental history of the potient should include
information on the age of eruption of the deciduous and Posture
permanent teeth, history of extraction, decay, Posture refers to the way a person stands. Abnormal
restoralions and trauma to the dentition. The past postures can predispose to malocclusion due to
dental history helps in evaluation of patient's and alteration in maxillo- mandibular relationship.
parents attitude towards treatment.
Body build (physique)
Pre-natal history It is possible to classify the physique into one of the
The pre-natal history should include information on the following three types:
condition of the mother during pregnancy and Ihe type a. Aesthetic : They have a thin physique and usually
of delivery. The use of certain drugs like thalidomide or posses narrow dental archos.
affectation with some infections during pregnancy like b. Pletoric : They are persons who are obese. They
German measles can result in congenital deformities of generally hove large, square dental arches.
the child.
Information should be gathered on the type of
delivery. Forceps delivery predispose to
temporomandibular joint injuries which can manifest as
marked mandibular growth retardation.

Post - natal history

The post - natal history includes information on the type
of feeding, presence of habits and on the milestones of
normal development.
Family history
Many malocclusions such as skeletal Class II, Class
III malocclusions and congenital conditions such as
clefts of lip and palate are inherited. Thus the family
history should record details of malocclusion existing
in othor members of the family.


The general examination comprises of the general

assessmentofthe patient. An observant clinician
c. Athletic : They ore considered normally built being The patient's facial symmetry is examined to determine
neither thin nor obese. They have normal sized disproportions of the face in transverse and vertical
dental arches. planes. In most people the right and left sides are not
Sheldon has classified the general body build identical (fig 2). Thus some degree of asymmetry is
into three types :

Fig 1 Clossificotion of Head types (A) Mesocepholic head (B| Brncnycaphalic: head (C! Dolicocephalic head considered normal.

a. Ectomorphic : Tall and thin physique Asymmetries

b. Mesomorphic : Average physique that are gross and are detected easily should be

c. Endomorphic : Short and obese physique recorded. Gross facial asymmetries can occur as a
result of:
a. Congenital defects
b. Hemi-facial atrophy / hypertrophy
c. Unilateral condylar ankylosis and hyperplasia
EXAMINATION Shape of the
Facial profile

The facial profile is examined by viewing the patient

from the side. The facial profile helps in
The head can be classified into one of the following
*hree types: (fig 1)
a. Mesocepholic: Average shape of head. They
posses normal dental arches.
b. Dolicocephalic : Long and narrow head. They have
norrow dental arches.
c. Brachycephalic: Broad and short head. They have
broad dentol arches.

Facial form
A simple way of describing the face is to classify it cs

either round, oval or square. A more scientific

classification is to classify face into the following three
a. Mesoprosopic : It is an average or normal face
b. Euryprosopic: This type of face is broad and short.
c. Leptoprosopic: It is a long and narrow face form.

Assessment of facial symmetry

Based on the relationship between these two
lines, three types of profiles exist.
Straight profife ; The two lines form a nearly straight line
Orthodontics - The Art and Science
(fig 3.a).
diagnosing gross deviations in the maxillo- mandibular

relationship. The profile is assessed by joining the Convex prof/,'e : The two lines form an angle with the
following two reference lines : concavity facing the tissue. This kind of profile occurs
1. A line joining the forehead and the soft tissue point as a resulf of a prognathic maxilla or a retrognathic
A (deepest point in curvature of upper I'P). mandible as seen in a Class II, Division 1 malocclusion
2. A line joining point A and the soft tissue pogonion (fig 3.b).
(most anterior point of the chin). Concave profile : The two reference lines form an
angle with the convexity towards the tissue.
Orthodontic Diagnosis 123

Anterior divergent ; A line drawn between the forehead

and chin is inclined anteriorly towards the chin (fig 4.a).

Posterior diverge/if : A line drawn between the foreheod

ond chin slants posteriorly towards chin (fig 4.b).

S/roignt or orthognathic ; The line between the

forehead and chin is straight or perpendicular to the
floor (fig 4.c).
The facial divergence is to a large extent
influenced by the patient's ethnic and racial
A background. .

Assessment of antero - posterior Jaw

The antero-posterior relationship between the upper
and lower jaw can be assessed to a certain extent
clinically. Ideally the maxillary skeletal base is 2 - 3 mm
forward of the mandibular skeletal base when the teeth
are in occlusion. Estimation is done by placement of the
index and the middle fingers at the soft tissue point A
and point B respectively. This can also be done in the
same way after retracting the lips. In skeletal Class II
oatients,the index finger is anterior to the middle finger
or the hand points upwards (fig 5.b). In a skeletal Class
III patient the middle finger is ahead of the forefinger or
the hand points downwards(fig 5.c). In a patient with
Class I skeletal pattern the hand is at an even level.(fig

ig 4 Facial divergence JA) Anterior D'vergcncc (B) fbstenor
divergence (C) Orthognathic

This type of profile is associated with a prognathic

mondible or a retrognathic maxilla as in a Class III
malocclusion {fig 3.c}.

Facial divergence
Facial divergence is defined as an anterior or posterior
inclination of the lower foce relotive to Ihe forehead.
Facial divergence can be of three types : \%3
1601?" Orthodontics - The Art and Science

Fig 5 Assessment of antero • posterior jaw relationship by

placement of the index and ihe middle fingers at the soft tissue point
A and point B (A) Ooss I skeletal pattern the nanri is at an even
level. (B| In Class II pcticn-s, the hand points jpv/ards. |C) In Class III
patienl the hand points downwards

planes meet beyond the occipital region, it indicates a

low angle case or a horizontal growing face. If the two
planes meet anterior to the occipital region it indicates a
high angle case or a vertical growing face.

Assessment of vertical skeletal

Normally, the distance from a point between the
eyebrows to the junction of the nose with upper lip will
be equal to the distance from the latter point to the
under side of the chin. A markedly reduced lower facial
height is associated with deep bites while increased
lower facial height is associated with anterior open
bites. Fig 6 Assessment of vertical focial height
The vertical skeletal relationship can also be
assessed by studying the angle formed between the
lower border of the mandible and the Frankfort
horizontal plane (a line between the most superior point
of external auditory meatus and inferior border of orbit)
(fig 6). Normally the two planes intersect at the occipital
region. In case the two
Evaluation of facial proportions
A well proportioned face can be divided into three equal
vertical thirds using four horizontal plones at the level of
the hair line, the supraorbital n'dge, the base of the nose

Fip 3 Assessment ol the I ps (A| Compeer) ips |f)) Incornoetert lips \C\
and the inferior border of chin. With i n the lower face, Everted lips

the up pe- "locc u p ies a third of the distance while the

chin c-tupies the rest of the space (fig 7).

Examination of Hps
Normally the upper lip covers the entire labial surface of
upper antcriors except the incisal 2-3 mm. The lower lip
covers Ihe entire labial surface of the lower anteriors
and 2 - 3 mm of the incisal edge of the upper anteriors.
Lips can be classified into the following four types :

Competent Zips ; The lips are in slight contact when the

musculature is relaxed (fig 8.a).

Incompetent Zips : They are morphologically short lips

which do not form a lip seal in a relaxed state. The lip
seal con only be achieved by active contraction of the
perioral and mentalis muscles(fig 8.b).

Potenlially rncompeJenf //ps : They are normal lips that

fail lo form a lip seal due to proclined upper incisors.
Everted lips : They are hypertrophied lips with weak
muscular tonocity (fig 8.c).

The malocclusions while recessive chins are common in
to a large Class II malocclusion

Nasolabial angle
It is the angle formed between the lower border of the
nose and a line connecting the intersection of nose and
upper lip with the tip of the lip (labrale superius) (fig 10).
This angle is normally 110°. It reduces in patients
having proclined upper anteriors or prognathic maxilla.
Fig 10
It increases in Assessment of nnso-labial
patients with angle maxilla or
retroclined maxillary anteriors.
F'g 9 iVIantolcb al sulcus

Examination of the nose

extent contributes to the esthetic

appearance of a face.

Nose size ; Normally the nose is one third of the total

fccial height (from hair line to lower border of chin).
Nose.1 contour : The shape of the nose can be straight,
convex or crooked as a result of nasal injuries.
Nostrils : They are oval and should be bilaterally
symmetrical. Stenosis of the nostrils may indicate
impaired nasal breathing.

Examination of chin
Mentolabial sulcus : The mento-labial sulcus is a
concavity seen below the lower lip {fig 9). Deep
menlo-lobial sulcus is seen in Class II, Division 1
malocclusion while it is shallow in bimaxillary protrusion.
Menfa/is activity : Normally the mental is muscle does
not show any contraction at rest. Hyperactive menlalis
activity is seen in some malocclusions such as Class II,
division 1 cases. It causes puckcring of the chin.
Chin position and prominence : Prominent chin is
usually associated with Closs III

Examination of tongue
Abnormalities of Ihe tongue can upset the muscle
balance and equilibrium leading to malocclusion.
Presence of an excessively large tongue is indicated by
the presence of imprints of the teeth on the lateral
margins of the tongue giving it a scalloped appearance. \ M
- \
A patient whose tongue can reach the -'o of Assessment of the dentition
the nose is said to have a long tongue. The :ngual The dental system is exomired and the following details
frenum should be examined for tongue -'e. In patients are recorded :
having tongue tie there is an alteration in the resting a. Teeth present inside the oral cavity
tongue position as well •as impairment of tongue b. Teeth uneruated
movement. c. Teeth missing
d. Status of the dentition i.e. of teeth thct have

Examination of the paiate
erupted end teeth not erupted.
The palate should be examined for the lowing e. Presence of caries, restorations, malformations,
findings : Variation in palatal depth occurs in hypoplasia, wear and discoloration.
association with vanotion of facial form. Most f. The pctient is asked to close the jaws in centric
dolicofacial patients have deep polates. r Presence of occlusion and the molar relation is determined.
swelling in the palate can be indicative of an impocted This is described as Angles Class I, II or III.
tooth, presence of cysts or other bony pathologies. - g. The overjet and overbite which represent the
Mucosal ulceration and indentations are a horizontal and vertical overlap of the upper ar.d
feature of traumatic deep bite, i Presence of clefts lower teeth are recorded. Variations such as
in Ihe palcte are associated increased overjet, deep bite open bite and cross
with discontinuity of the palate. = The third rugae bite should be recorded.
is usually in line with the canines. This is useful in the h. Transverse malrelations such as cross bite ond
assesment of maxillany anterior proclinalion. shift in the upper or lower midlines should be
K looked for.
Examination of gingiva i. Individual tooth irregularities sucn as rotations,

The gingiva should be examined for inflammation, displacements, intrusion and extrusion are noted.

session ond other mucogingival lesions. rT5sence of j. The upper and lower arches are examined individually

poor oral hygiene is usually associated «-h to study their arch form and symmetry. Arch forms
can be normal, narrow (V shaped] or square.
generalized marginal gingivitis. It is very r-mmon to
find anterior marginal gingivitis in —outh breathers due
to dryness of the mouth reused by the open lip
posture. Presence of roumatic occlusion is indicated It is now established that normal function of the
by. localized r-ngival recession. Abnormally stomatognathic system promotes normal growth and
hyperplastic crrgiva is seen in patients using certain development of the oro-facial complex. Improper
drugs ice Dilantin. functioning of the stomatognathic system can result in
vorious malocclusions.
Examination of frenai attachments Orthodontic diagnosis should not be restricted
'ne maxillary labial frenum can at times be thick, "brous to static evaluation of Ihe teeth and their supporting
and attached relatively low. Such an structures but should include tho examination of Ihe
attachment prevents the two maxillary central incisors various functional units of tho stomatognathic system.
from approximating each other thereby predisposing to The functional examination should include Ihe following

midline d'astema. :

Abnormal frenal attachments are diagnosed a. Assessment of postural rest position and inter-

by a blanch test wnere tne uoper lip is stretched occlusal space.

upwards ond outwards for.a period of time. The b. Path of closure

presence of blanching in 'he 'egion o~ the inter-dental c. Assessment of respiration

d. Examination of TMJ
pap'llc is diagnostic of an abnormal frenum.
e. Examination of swallowing
An abnormally high attachment of the
f. Examination of speech
mandibular labial frenum can cause recession of the
gingiva in that area. Assessment of postural rest position and
Inter - occlusal clearance
Examination of tonsils and adenoids
The postural rest position is the position of the mandible
The size and degree of inflammation if any of ihe tonsils
at which the muscles that close the jaws and those that
should be examined. Abnormally inflamed tonsils cause
open them are, in a state of minimal contraction to
alteration in tongue and jaw posture thereby upsetting
maintain the posture of the mandible. At the postural
the oro-facial balance !eadirg to malocclusion.
rest position, a space exists between tne upper and
lower jows. This space is called the inter-occlusal
clearance or the freeway space. Normally the freeway
space is 3 mm in the canine region.
There are various methods of assessing the
postural rest position. During examination, the patient
should be seated upright, with the back unsupported
and asked to look straight ahead. The following are
some of the methods used to record the postural rest

Phonertc mefhod : The patient is asked to repeat some

consonants like 'M' or 'C' or repeat a word like
Mississippi1. The mandible returns to the postural rest
position 1 -2 seconds after the exercise. The potient is
told not to change the jaw, lip or tongue position after the
phonation, as the dentist parts the lips to study the inter-
occlusal space.

Command mefhod : The patient is asked to perform

certain functions such as swallowing. The mandible
tends to return to rest position following this act.

Non-commond method : The patient is observed as he

speaks or swallows. The patient is not aware that he is
being examined. This is usually corried out by talking
about topics unrelated to the patient while carefully
observing him or her.
There are various methods employed to
measure the inter-occlusal clearance. The following are
some of them.

Direct infra - oral procedure r Vernier calipers can be

used directly in the patient's mouth in the canine or the
incisor region to measure the freeway space.

Drrecf extra - orol procedure : Two marks are placed

one on the nose and onother on the chin in the
mid-sagittal plane. The distance between these two
points is measured after
-struding the patientto remain at rest position, later the either no cnange in the external nares or they may
patient is osked to occlude the teeth and —e distance
between the two points is again measured. The
Orthodontic Diagnosis 129
difference between the two -eodings is the freeway
constrict during inspiration.

'"direct extra - oral procedure : The inter- occlusal Examination of T.MJ.

space is determined in a radiograph or ay The functional examination should routinely include
Kinesiograohy. Two lateral cepha log rams, at rest auscultation and palpation of the temporo-mandibular
position and other in centric occlusion can -elp joint and the musculature associated with mandibular
establish the freeway space. opening.
The patient is examined for symptoms of
Evaluation of path of closure
temporomandibular joint problems such as clicking,
~he path of closure is the movement of the —cndible
crepitus, oain of Ihe masticatory muscles, limitation of
from rest position to habitual occlusion, -bnormolities
jaw movement, hyper-mobility and morphological
of the oath of closure are seen in some forms of
The maximum mouth opening is determined
orward potk of closure ; A forward path of closure by measuring Ihe distance between the maxillary and
occurs in patients with mild skeletal zrenormalcy or
mandibular incisal edges with the mouth wide open. The
edge to edge incisor contact. In sbch patients, the
normal inter-incisal distonce is 40-45 mm.
mandible is guided to a more torward position to allow
the mandibular incisors to go labial to the upper Evaluation of swallowing

accfev/ard path of cfosure : Class II, division 2 cases

exhibit premature incisor contact due to "^oclined
maxillary incisors. Thus the mandible s guided
posteriorly to establish occlusion.

.c'erof path of c/osure : Lateral deviation of tfee

mandible to the left or the right side is associated with
occlusal prematurities and a -crrow maxillary arch.

Assessment of respiration
-^mans may exhibit three types of breathing : -csal,
oral and oro-nasal.
A number of simple tests exist that can rx
employed to diagnose the mode of respiration.

J V.'rror tesf ; A double - sided mirror is held ae*ween the

nose and the mouth. Fogging on
the nosal side of the mirror indicates nasal breathing
while fogging towards the oral side indicates oral

Cotton test: A butterfly shaped oiece of cotton is placed

over the upper lip below the nostrils. If the cotton flutters
down it indicctes nasal breathing. This test car be used
to determine unilateral nasal bockage.

Water test; Tne palien* is asked to fill his mouth with

water end retcin it for a period of time. While nasal
breathers accomplish this with ease, mouth breathers
find the task difficult.

Observafcon ; In nasol breathers the external nares

dilate during inspiration. In mouth breothers, there is
In a new born, the tongue is relatively large and
protrudes between the gum eads and takes part in
establishing Ihe lip seal. This kind ol swallow is called
infantile-awallowand is seen till 1 1/2 to 2 years of age.
Infantile swallow is replaced by the mature swallow os
Ihe buccal teeth start erupting. The persistence of tne
infantile swallowing can be a cau^e for malocclusion.
Thus the swallowing pcttem of the individual should be
examined. The persistence of infertile swallow is
indicated by tne presence of the "ollowing fecruries:
a. Protrusion of Ihe tip of the tongue
b. Contraction of perioral muscles during swallowing
c. No contact at the molar region during swallowing
F g 1 1 Orthodontic study models

Speech 4. They nelp in assessing the nature and severity of

Certain malocclusions may cause defects 'n spcech due malocclusion.
to interference with movement of the tongue and lips. 5. They are helpful in motivation ol the patient end to
This should be ooserved while conversing with the explain the treatment plan as well as progress to
potienl. The patieir can be asked to reac cut from a book the patient and parents.
or asked lo count from 1 - 20 while observing the 6. It makes it possible to simulate treatment
speech. Patients having toncue thrust habit tend to lisp procedures on Ihe cast such as mock surgery.
while cleft palate patients may have a nasal tone. 7. Study models are useful to transfer records in case
the patient is to be Ireoled by another clinician.
Details on the requirements of orrnodontic

Orthodontic study models are accurate plaster study models arid their fabrication ore given in chapter

reproductions of the teeth and tncir surrounding soft 39.

tissues. They ore an essential diagnostic aid t not

Gnattiostatlc models
makes it poss'ble lo sludy the arrangement of teeth and
I hey are orthodontic study models where the base of
ihe occlusion from all directions
(fig 11). the maxillary cast is trimmed to correspond to the
Uses of study models include : Frankfort horizontal plane.
1. They enable the study of the occlusion from all

2. They enable accurate measurements to be made The diagnostic setup was first proposed by H.D.
in a dental arch. They help in measurement of arch Kesling. The diagnostic set up is made from an extra set
length, arch width and loolh size. of trimmed and polished sludy models. The individual
3. They he p in assessment of treatment progress by teeth and their associated alveolar
the dentist as well as the patient.

Fig 13 Extra - oral photcgxphs |A; Frontal view (BJ Profile view |C) Oblque facial view. Intra • oral pho'ogroplis (0) Left latcrcl viev/ |E; Right laterall
view 'F) Frontal view (G) Maxillary occlusal vie»- (II) Mandibular occ Lsa view

processes are sectioned off and replaced on the model the various corrective procedures on the cast. 3.
base in the desired oositions. The diagnostic set up Tooth size - arch length discrepancies can be
thus helps in simulating the various tooth movements visuolized by means of a sel up.
that are planned for patients.
Uses of diagnostic set up The cast is cut using a fretsaw blade to se pa rare ihe
1. It is usefu1 :n visualizing and testing the effect ol individual teetn. A horizontal cut is made 3 mm apical
complex tooth movements and extractions on the to the gingival margin. Vertical cuts are made to
occlusion. separate the individual teeth. The individual teeth are
2. The patient con be motivated by simulating set in desired position using red wax (fig 14}.

FACIAL PHOTOGRAPHS AS muscle activity. Eledromyogram is a 'eccd obtained
A DIAGNOSTIC AID bysucna procedure. The adion potential is pic<ed up
by electrodes which are of two types:
facial photographs offer a lot of information on •he soft
Surface e.'ectrod'es : These eledrodes are used when
tissue morphology and fecial expression. Photographs
the muscle is superficially placed lust below tne skin.
should be taken in a standardized manner so that they
can readily be compared with similar photographs Needle electrodes : They are used when the muscle is

taken during or after •he treatment. placed deep inside e.g. Pterygoid musdes.

Both extra-oral as well as intra-oral Having picked up the action potential with

ohotogrophs are useful diagnostic records. Three surface or needle electrodes, it is recorded either with

extra-oral views are routinely taken (fig 13): the he o of a moving pen in the form of a grapn or

a. Frontal view recorded in the form of sound with the help of a

b. Profile view magnetic taoe recorder.

c. Oblique facial view EMG is used "o detect abnormal muscle

The extra-oral photographs are token by activity associated with certain forms of malocclusion.

positioning the patient in such a manner that the .H = a. In severe Class II, division 1 malocclusion the

plane is parallel to the floor. upper lip is hypo-functional. Thus during

The intra-oral photographs that are token swallowing, the lower lip extends upwards and

include : forwards to force the maxilla labially and a strong

a. Left and right lateral view mentalis activity is seen. EMG can be used to

b. Frontol view study such a condition.

b. Abnormal buccinator activity in Class II, division 1.
c. Maxillary and mandibular occlusal view Use c. Overclosure of jaws is associated with
accentuated temporalis muscle adivity.
of photographs
d. Children with cerebral palsy.
1. They are useful in assessment of facial symmetry,
e. EMG can be carried out after orthodontic therapy
facial type and profile.
to see if muscle balance is achieved.
2. They serve as diagnostic records.
3. They help in assessing the progress of the


Electromyography is a procedure used for recording

the electrical activity of the muscles. The resting
potential of a muscle fiber is 85 - 90 mV Voluntary
muscles consists of many contracting fibres supplied
by peripheral nerve terminals. The membrane of each
fibre is electrically charged with positive charge outside
and negativity of 85 - 90 mV inside. Upon receiving a
stimulus, there is a reversal of this potontic% resulting
in muscle contraction. This is called action potential
and denotes the mechanical activity of the muscle. The
electromyog'-apn is a machine which is used to
receive, amplify and 'eco'd the action potential during
RADIOGRAPHS USED IN 2. To establish the presence or absence of supernumerary
3. To determine the extant ot root resorption of deciduous
Orkhodonlics - The Ari and Science
William Conrad Roentgen discovered X-rays in 1895.
4. To study the exlent of root formation ol the permanent
There is no aspect of the medical field that is not
teeth. '
influenced by this discovery. Orthodontics is no
5. To confirm the presence and extent of pathological and
exception. Radiographs have established themselves
trao malic conditions.
as a valuable tool in orthodontic diagnosis. Table 1
6. To study the character of areolar bone.
gives the uses of radiographs in orthodontic practice.
7. They are a valuable aid in cranio-dento-faciai analysis.
Radiographs routinely used for diagnosis in
To confirm ihe axial inclination of Ihe foots of teeth. 9.. To
orthodontics can be classified into two groups:
assess teeth that are morpholc^caJly abnormal.
Intra-oral radiographs
Extra-oral radiographs
1. Paralleling technique
2. Bisecting angle technique
Paralleling technique ■: This technique is also called
Three types of intra-oral radiographs ore commonly right ongle or long cone technique. In this technique,
used. They are the periapical, bite wing and occlusal the X-ray film is placed parallel to the long axis of the
projections. teeth and the central ray of the X-ray beam is directed
at right angles to the teeth and film. This method is
Intra - oral periapical radiographs
believed to reduce geometric distortions and is
(1.0. P. A.)
therefore the preferred technique.
They ore rcdiographs that are used to view the teeth
Bisecting angle technique J In this technique, the
and their supporting structures (fig 14). Two inlro-oral
central roy is directed ot right angles to a plane
projection techniques are used for periapical
bisecting the angle between the long axis of the teeth
rcdiography. They ore :
p.* and the film.

Uses of intra-orai periapical radiographs: Full

mouth intra-oral periapical radiographs ore routinely
token prior to initiation of orthodontic treatment. The
*»iJv< v! following are some of the uses of IOPA.
:• v.-.v
If 1. To confirm the presence or absence of teeth.

m 2. To establish the presence or absence of


•N»:*'1 W" *,'

1I1 ijfjljl

Fig 14 Inlro-oral pe?iopicol radiograph

To assBss general development ot Ihe dentition, presence,

absence arri state ot eruption ot the teeth.

supernumerary teeth. 3. To assess the extent of f. To detect inte-proximal calculus.
calcification and root
formation of teeth, -i. To confirm the presence and
Orthodontic Diagnosis 135
Occ/asa/ radiographs
study the extent of periapical pathology and root
Intra-oral occlusal rodiographs enable viewing of a
relatively large segment of the dental arch, including
5. To study the alveolar bone and periodontal
Ihe oala^c or floo' of the mouth. Occlusal radiographs
ligament space.
are also useful in parents who are unable to open the
6. To study the height and contour of alveolar bone
mouth wide enough for periapica' radiographs. It is
possible to obtain occlusal p'ojeclion of the uppe' as
7. To assess the axial inclination of roots.
well as the lower arches {fig 16). The following are the
S. To detect retained root fragments and root stumps.
uses of occlusal radiographs :
?. To determine the size and shape of unerupted teeth.

Disadvantages of IOPA : The following are smeof the

disadvantages of intra-oral periapical 3ms:
Assessment of the entire dentition requires too
many radiographs. 1 Children may not allow olccement
of intraoral films.
2. They cannot be used in patients having high gag
reflex and trismus.

Advantages of fOPA : Although the IOPA n-c:ographs

have a number of drawbacks they r-^r some
advantages as well: - Low radiation dose.
: Possible to obtain localized views of the area of
EL They offer excellent clarity of teeth and their Fig 16 CCCIJSOI rnd ograph
supporting structures.

=/fe wing radiographs

5r» wing radiographs record the coronal part of 1fre
upper and lower dentition along with their sucoorting
structures (fig 15). The following are same of the uses
of bite wing radiographs : •z. ~o detect proximal
caries, ir To study Ihe height and contour of ii

Fig 15 Bits wing radiograph

alveolar bone.
c. To detect secondan/ caries below restorations.
d. To defect overhanging proximal restorations.
e. To detect periodontal changes.
F'g 17 Pai. i c radlograp>
1. To locote impacted or unerupted teeth. 3. To study the patn of eruption of teelh.
2. To locate superrumera^ teeth. 4. To diagnose the presence and extent of pathology
3. To locate foreign bodies in Ihe jaws and stones in and fractures of the jaws.
salivary ducts. 5. To diagnose the presence or absence of multiple
4. To study bucco - lingual expansions of cortical supemumeran/ teeth.
plate due to patho'ogy of the jew. 6. They are useful aids in serial extraction
5. To diagnose Ihe presence and extent of fractures. procedures to study the status of erupting teeth.
6. They are useful in orthodontics lo study the effects 7. They are useful in the mixed dentition period to
of arch expansion procedures. study the status of uncrupted teeth.

EXTRA-ORAL RADIOGRAPHS The advantages of panoramic

radiograpn include:
Extra-oral radiographs include all views made of the
1. A oroad anatomic area can be visualized.
oro-facial region with the film positioned extra- oral I y.
2. The potienl radiation exposure is low.
They are useful whenever large areas of Ihe face and
3. It can be used in patients who are unable to
skull are lo be visualized.
tolerate intra-oral films or unable to open the
Panoramic radiographs mouth.

Panoramic radiographs enable viewing of both The following are the disadvantage of

maxillary and the mandibular arches with their panoromic radiograohs :

supporting structures (fig 17). Thus a single image

covers a major part of the facial region. Uses of
Panoramic radiograph includes I. They are useful in
assessing the dental
development by studying deciduous root
resorotion and root development of permanent
2. They can be used lo view ankylosed and impacted
Fig "i 8 (A) LalS'cl cephalog'cms (B! Poste'o - aircrior cephologrcm

Distortions, magnifications and overlaoping of the Radiographs of the hand and wrist are useful in
structures occur. 2. The teeth and the suoporting estimating Ihe skeletal age of a person. The hand and
oeriodontal structures are not as clear as in periapical wrist region have a number of small bones whose
films. appearance and progress of ossification occur in a
* Inclination of anterior teeth cannot be visualized. predictable sequence. This enables assessment of the
Requires equipment that is expensive. ■ 5 skeletal age of a patient. They
Whenever details of a particular area are needed they
have to be supplemented by otner radiographs.

Cephalometric radiographs
are specialized skull rodiographs in which p*e
head is positioned in a specially designed bead holder
called cephalostat by means of ear —cis. Thus it is a
standardized technique where - -^e head is held in a
predetermined position. Ceohalograms are also used
for comparison of serial radiographs.
Cephalometric radiograpns are of two
Lateral cephalogram (fig 18.a)
Postero- anterior cephalogram (fig 18.b)
The use of cephalometric radiographs for
orthodontic diagnosis is discussed in detail in the
following chapter.

Hand - wrist radiographs
Orthodontics - The Art and Science

ore useful in assessing growrnfor planning growth 1. It exhibits high edge contrast due to a
modification procedures and surgical resedive phenomenon called edge enhancement. Tnis
procedures. facilitates perception of anatomic details.
2. The xeroradiographs image is on paper and is
viewed in refleded light. Thus no special
illumination is needed for viewing.
Orthodontics is a rapidly growing field with 3. Choice of positive or negative image is »
developments occuring almost every day. The possible.
improvements basicoily occur in two areas. The first is
an improvement in the materials and techniques used The advantages of Xeroradiography ore :

while the other is advcnces in the diagnostic aids. 1. Reduction in exposure time

Recent innovations in medical imaging has been 2. Ease in manipulation. No need of dark rooms for

adapted to dentistry ond find some applications in developing.

orthodontics as well. Some of these recently evolved 3. Ease of viewing. No special light source is

diagnostic aids are discussed in brief. required.

4. Edge enhancement effed. Boundary between
Xeroradiography structures is clear
Xeroradiograpny is a completely dry, non-chemical 5. Cephalometric landmarks are easily identified.
process which mokes use of the electrostatic process 6. Reconstruction of the cephalometric planes and
as in Xerox machines. It was invented by Chesrer F. points can be made directly on paper.
Carlson in 1 937 shortly before the II World War.
Dlgl Graph
Xeroradiography makes use of an aluminium
plate That is coated with a layer of vitreous selenium. The Digi Graph is a synthesis of video imaging,

The selenium particles are given a uniform electrostatic computer technology ond sonic digitizing. The Digi

charge. The charged plate is placed in a light tight, graph work station equipment measures 5' x 3 x 7. The

airtight cassette. When the film is exposed it causes a main cobinet contains the electronic circuitry. The Digi
Graph enables the clinician to perform non-invasive
selective discharge of the selenium depending upon
and non-radiographic
the amount of radiation used and relative density ol Ihe
object. This pattern of electric discharge on the plate is
called latent image.
The latent image is then converted into a
visible image by a process called development in a unit
called processor. The plate is exposed to charged
particles called toner. These particles adhere to the
charged areas in amounts proportional lo the quantity
of charge present. This image is now transferred on*oa
special kind of paper called Xerox opaque paper.
The unique feature of xeroradiography is that
it is possible to have both positive and negative image.
Once the latent image is converted to a real image on
to a poper the selenium plate can be discharged,
cleoned and used again. It can be reused as many as
1000 times.
Xeroxadiographic image differs from
conventional radiographs in the following ways:
cephalometric analysis. Cephalometric landmarks are magnetic field. If a coil is now wound around a volume
digitized by lightly touching the sonic digitizing arobe to of protons, they now progress at 90 degree around the
a point on the patient's skin corresponding it. This emits mognetic field at the same frequency and induce a
a sound, which is then recorded rv the microphone and minute current in the coil which when amplified can be
monitored as X, Y and Z co-ordinates. displayed over on oscilloscope. This energy is utilised
~he system allows cephalometric evaluation and in the scanning procedure.
-satment progress as often as necessary without The advantages of magnetic resonance
■odiation exposure. Feotures of Digi Graph system imaging are :
•xlude : 1. MRI does not have hazards as it uses non-
k ionising electromagnetic radiation.
A landmark can be identified as a point in three 2. Anatomical details are as good as in C.T. scan.
3. Greater tissue characterisation is possible.
A cephalometric analysis can be made independently
4. Imaging of blood vessels, blood flow, visualisation
of head position. 3 Parallelism of X-ray in mid - satgittal
of thrombus is possible.
plane and symmetry of anatomic morphology between
The disadvantages of MRI include :
left and right sides is not necessary.
1. Time taken is more.
The Digi Graph work station's hardware r-rd software
2. Not used in patients with cardiac pace maker.
i enable the performance of rsohalometric analyses,
3. Non visualisation of bone makes it useless in bony
tracing, superim position and visual treatment
objectives. The programme pable of 14 analyses.
Measurementsforony ed analysis can be displayed on
the monitor trd the observed values are shown along
with -^e patient norm adjusted for age, sex, race and
-«cdsize including standard deviations. Optional nents
include : A consultation unit: It transports information
into the operatory, doctor's office / consultation area,
thus allowing viewing and comparison of information
ond the development of visual treatment objectives. A
high - resolution video camera with a •elephoto lens for
taking intra-oral views by ^eze framing the video
image. A light box for X - rays and a study model holder
for video imoging that will be included in the floppy
disk. * Camera and video printer for producing copies
of video monitor information.
The Digi Graph allows all patient's models,
radiographs, photographs, cephalo- grams and
tracings to be stored on one small disk, thereby
reducing storage require-ments. Furthermore it is a
valuable tool for improving communication among
clinician, patient and staff.

MRI (Magnetic Resonance tmaglng)

Magnetic Resonance Imaging makes use of two
fundamental properties of protons, i.e. spin and small
magnetic movements. The proton of hydrogen ion
which is in water (woler being the major component of
body) is utilised in M.R.I. The protons behave like
small spinning magnets and when placed in a
magnetic field they fend to move parallel to the field.
Because of the spin the protons respond differently
within their axis progressing obout the direction of the
Tomography 2. The computer programming makes it possible to
Conventional rad'oaraphs ore images in which oil view the images in different shades and
objects between the X-ray source and film are densities. This helps differentiate fat and blood.
superimposed. Thus the clarity of a specific
radiographic finding depends on both its location and
the degree to which its density differs from that of It is a tracing of a photograph or a photocopy of a

surrounding objects. In some situations dental arch. Occlusograms are used for Ihe following

superimposition of objects interferes with an observer's purposes:

ability to clearly discover the obiect of interest. In these a. To estimate occlusal relationships

instances tomography can be used to visualise a b. To estimate arch length & width
c. To estimate the tooth movements required in all
section or slice of the object and thereby eliminate
3 planes of space
undesirable overlap.
d. To estimate spacing & crowding
Tomographic can be conventional or
e. To estimate anchorage requirements
computed tomography.
Occlusograms can be obtained in two
Conventor?a/ Tomogroohy: Tnjs is a process by which
a layer of an image within Ihe body is produced while
1. The occlusal surfaces of the upper ond lower dental
ihe images of structures above and below that layer are
casts are photographed in a 1:1 ratio and a tracing of
made invisible by blurring. Blurring of image outside the
the photograph is made.
plane of interest is accomplished by simultaneous
2. The casts are photocopied on a xerox machine and
movement of tne X-ray lube and film during the
the occlusal photocopy is used lo obtain a tracing.
exposure. The tube and film are connected so that
movements occur around a point or fulcrum. As the Digital Subtraction Radiography
distance from the point of rotation increases, the In conventional radiographs the background structures
amount of image blurring also increases. Thus objects such as alveolar bone and adjacent
close to Ihe point of rotation are more sharp and
objects farthest are blurred. As the angle between the
source / film and tissue increases the thickness of the
image is reduced. Thus the greatest blurring is seen in
tne periphery while the sharpest image is seen at Ihe
central area near' ihe fulcrum of rotation.
The principles of tomography can be
mechanically implemented in two ways : 1 .The X-ray
tube ond film can move synchronously in opposite
directions in parallel planes. 2.The X-ray tube and film
can move synchronously and in opposite directions in
parallel p anes but with motions other than straight line
ie circular, spiral, etc.,.
Competed Tomograph/; It is also called C.T. or CAT
(computed axial tomography). C.T. systems are mainly
complex imaging systems which use thin beams of X
ray that move in a synchronous manner with an array
of detectors which calculate and attenuate the X ray
beams at different cngles and in different planes. This
data is fed into a computer which performs numerous
calculations as per the program and constructs
accurate images in the coronal and oxial planes.
The advantages of C.T. scan are :
1. Accurate visualisation of an area of interest is
-eeth may draw the examiners vision away from —e 1. Storage of study model images.
diagnostic information thereby making detection of 2. Measurement of incisor intrusions.
pathologic changes difficult. The advancement of Orthodontic Diagnosis 141
caries from an incipient lesion "rough the 3. Study the effects of high oull heodgeor traction in
dentino-enamel function is often f fficult to detect. children s skulls.
Likewise the assessment of a -ealing or expanding 4. Tooth position measurements on dental casts.
lesion after root canal therapy is a challenge because 5. To study the effect of maxillary expansion on
of the subtle —anges in the density of the lesion that facial skeletons.
may not detectable with the unaided eye. 6. To study the effect of Class II elastics on bone
The detection of initial saucering or .'fbrmotion of displacement.
angular defects around implants is difficultto visualize 7. To study the effect of cervical pull headgear on
on radiographs. Moreover the spread of bone loss maxilla.
along the thread of the -re4 form implant is often 8. To determine Ihe centres of rotation produced by
obscured by the sharp rest between the bone and orthodontic forces.
imp'ant surfoce. 9. Lower incisor space analysis.
ction radiography addresses many of the 'ations in the
10. To assess the facial and dentol arch symmetiy.
detection of these radiograohic nges by decreasing
the amount of distracting ground information and by Photocephalometry
allowing the eye ocus on the actual change that has Although the standard lateral and antero-posterior
occured n two images. By subtracting all anatomic cephalogram s reveal some aspects of soft tissue, they
ures that have not changed between raphic nevertheless do not give adequate soft tissue details.
examinations, changes in diagnostic ation are easier In a lateral cephalogram only the profile is seen while in
for the reader to see. Technically this is an imoae
an antero-posterior cephalogram
enhancement od that removes the structured noise
from mages. The result is Ihe area of change clearly d
either against a neutral grey background c s
superimposed on the original radiograph *. The
subtraction of original two radiographs termed an
image rather than a radiograph use it does not directly
result from exposure c radiographic film.
The digital subtraction technique ively enhances the
differences between two s. Image registration however
is found to o technical problem. It is impossible to
achieve t registration of images during digitization use
of imperfections in the radiograohic and
alignment procedures. The larger the differences in
registration, the more the visual noise present in the
subtracted image.

Laser Holography
Holography is a photographic technique for recording
and reconstructing images in such a way that the 3
dimensional aspect of an object can be obtained. The
recorded imcge is called a hologram. Loser is light
amplification by stimulated emission of radiation.
Holography is a wave front reconstruction
process in which two coherent beams converge to
produce a constructive and destructive interference
patte-n which is recorded on film. Orthodontic
applications of loser holography include:
1601?" Orthodontics - The Art and Science

the lateral soft tissue margins are seen.

Thomas in 1978 developed photo-
cep'nalometry to better visualize the soft tissues of the
Three radio-opaque metalic markers with
holes are placed on tho patient's skin with cdhesives
and standard lateral ond antero-posterior
cepholograms are taken. Using the same position
lateral and frontal photographs are taken. The
photographs are printed to the some size as the
radiographs and are superimposed over the
radiographic tracing taking the metalic markers as the

This is basically a radiographic motion picture.The
subject is oriented properly and stabilized in a modified
cepholostat. An X ray motion picture is obtained using
a cine camera which runs at 240 frames per second.
This diagnostic aid is used to visualize the swallowing
pattern OT the patient. The X ray motion picture is
studied using a movie projector.

1. Downs VVB : Analysis of -.KB dentofadol profi U . Angle Orthod
1956 ;26 .191
2. Hous:onWj& : Ortnodontic Diagnoses, Wright, Bristol, 1982
3. Jocobson : Introduction to Radiographic Cepnabmetry, Lea
ard Febiger, Philadelphia, 1985
4. P'cdcep CS, Vcl ctlian Ashi-na : Digital sub-radion
rcdiograpny: KDJ 1998. 20: 51-55
5. Profrtt WR: Contemporary Orthodontics. St Louis, Of Mosby,
6. Rcber 5 Mayers : Hand boo'< of Orthedon'ics, Year boo<
nedical oublishers, inc,19B8.
7. Romeo A : Ho ograms in Orthodontics : Arn J Orlhod
8. 5neholata, Vo liana n Ash i mo : Laser holography: KDJ 199b.
18: 1169-1171
9. Thomas M Graber, Robert L Vanarsdail : Onhodor-
tics.current principles and technictus, Mosby year book Inc ,
10. Yen P : IdentificaHon of landmarks in osphalanelric
rcdiograpna. Angle Orthod I960 ;30-36
L^jS^SSttij 41 ol ' jL^l i U^wli Vj

he assessment of cranio-facial structures Cephalograms can be of two types:
forms a part of orthodontic diagnosis. The Lateral cephalogram : This provides a lateral view
earliest method used to assess facial of the skull (fig 1 .a). It is taken with the head in a
coportions was by artistic standards with -crmony, standardized reproducible position at a specified
symmetry ard beauty as key points. Craniometry can distance from the source of the X ray.
be said to be the forerunner of cephalometry. Frontal cephalogram : This provides an
Craniometry involved -easurements of cranio-fccicl antero-posteriorview of the skull (fig 1.b).
dimensions of skulls of dead persons. This method
was' not practical in living individuals due to the soft
tissue envelop which made direct measurements
difficult end far iess reliable.
The discovery of X-rays in 1 895 by
•oentgen revolutionized dentistry. It provided a -ethod
of obtaining the inner cranio-facial ~easurements with
quite a bit of accuracy and •^oroducibility. In 1922
Paccini standardized the 'adiographic head images
by positioning the rjbjects against a film cassette at a
distance of 2
meters from the X - ray tube. In 1931 Boardbent in
U.S.A. and Hofrath in Germany simultaneously
oresented a standardized cephalometric technique
using a high powered X-ray machine ond a head holder
called Cephalostat. The term cepha I o metrics is used
to describe the analysis ond measurements made on
the cephalometric rodiogrophs.

USES OF e. Cephalometrics helps in
CEPHALOGRAM -'g 1 ;A) .cte.'cl CepMogrom (B! Frontal Cephalogram
predicting the growth related
changes and changes associated with surgical
Cephalometrics has established itself as one of Ihe treatment.
pillcrs of comprehensive orthodontic diagnosis. It is f. Cephalometrics is c valuable o id in research work
also a s'oluable fool irt treatment planning and follow involving the cranio- dento facial region.
up of patients undergoing orthodontic treatment. Tne
following are some of the applications of
c:ephotometries in orthodontics. The cephalometric radiographs are taken using an
a. Cephalometrics helps iri ortnodonticdiagnosis apparatus that consists of an X-ray source and a head
by enabling tne study of skeletal, dental and soft holding device called ccphaloslal. The cephalostat (fig
tissue structures of Ihe cranio-facial region. 2.b)consists of two ear rods that prevent the movement
b. It helps in classification of the skeletal arid dentol of the heed in the horizontal plane. Vertical stabilization
abnormalities and olso helps in establishing facial of the head is brought oboul by an orbital pointer thot
type. contacts
c. Cephalometrics helps in planning treatment for an
d. It helps in evaluation of the treatment results
by quantifying the changes brought about by
Cephalometrics 145

WM „

Fig 2 (A) Source- rrid sagircl plane distance o: 5 tee*. (BJ Cemdos-at used to stabilize the head and be p ii s-cndcrdizirg the teoc

rhe lower border of the left orbit. The upper port of the
Anatomic landmarks

face is supported by the forehead clamp cositioned These landmarks represent actual aratomic structures
above the region of the nasal bridge, "he distance of the skull.
between the X-ray source and the mid-sagittal plane of
Derived landmarks
the patient (fig 2.o) is fixed at 5 feet (152.4 cm). Thus
the equipment helps in randardizing the radiographs These are landmarks that have been obto'ned

by use of constant Head position and source film secondorily from anatomic structures in a

distance so that serial radiographs can be compared. cephalogram.

The landmarks that are used in
CEPHALOMETRIC LANDMARKS cephalometrics should fulfill certain requirements.
a. II should be easily seen in a radiograph.
Cephalometrics makes use of certain landmarks or
b. It should be uniform in outline and should be
points on the skull which are used for quantitative
analysis and meosurements. The cephalometric
landmarks (fig 3) can be of
two types:

146 f Orthodontics - The Art and Science

Fig 3 (A) Impotent lateral cepha oneiric landmarks identit ed an the lateral ccuna ogrom

fig 3(B) Important laterol cephalometric landmarks : N - Nas:or, S - Sel!c, O - Orbitale, ANS - Anterior nasal spine, ^S - Posterior nosal spine, A - Point A, B - Point B, Pog
- Pogor-ion, Gn - Gnathicn, We • Men'on, Go - Gonion, Ba - 9a$ior, 3o - Bolton's poinl, A r - Articolare, P - Porion, PTM - Ptm point.

c. The landmarb should permit vclid quantitative Sella : The point representing the midpoint of the
measurements of lines and angles projected from pituitary fossa or sella turcica. It is a constructed point
them. in the mid-sagittal plane. .
The landmarks used in cepholometrics can Point A : It is the deepest point in the midline between
be classified as hard tissue and soft tissue landmarks. the anterior nosal spine and alveolar crest between the
The following are some of the mportant cephalometric two central incisors. It is also called subspinale.
Point B : It is the deepest point in the midline between
Vosion : The most anterior point midway between the ihe alveolar crest of mandible ond the mental process.
frontal ond nasal bones on the fronto-nasal suture. It is also called supramentale.
Orbitale : The lowest point on the inferior bony margin Bas/on : It is the median point of the anterior margin of
of the orbit. the foramen magnum.
Porion : The highest bony point on the upper r-.argin of Bo/fon point : The highest point at the post condylar
external auditory meatus. notch of the occipital bone.
Anterior rvasai1 spine : It :s the anterior tip of the shorp
bony process of the mcxilla in the midline of the lower
margin of anterior nasal opening. Cephlometrics makes use of certain lines or planes

Gonio.n : It is a constructed point arthe junction of (;'ig 4). These I'nes are obtained by connecting two

ramal plone and tne mandibular plane. landmarks. Based on their orientation the lines or
planes can be classified into horizontal and vertical
Pogonion : It is the most anterior ooint of rhe bony chin
in the median plane.

iVienton : It is the rrost inferior midline point on the Horizontal planes

mandibulor symphysis. S.N. plane : It is the cranial line between the center of
Gnathior? : It is the most antero-inferior ooint on the sella tursica (sella) and the anterior point of rhe
symphysis o the chin. It is constructed by intersecting fronto-nasal suture (nasion). It represents the anterior
a line drawn perpendicularrothe fine connecting crcnial base.
menton ond pogonion. Frankfort horizontal plane : This plane connects the
Articulate : It is a point at the junction of the posterior lowest point of tne orbit (orbitale) and the superior
border of ramus and the inferior border of the basilar point of the external auditory meatus (porion).
part of the occipital bone. Occlusal plane : It is a denture plone bisecting the
CondyJ'ion : The most superior point on Ihe head of posterior occlusion of the permanent molars and
the condyle. premolars (or deciduous molars in mixed dentition)

Prosfbion : The lowest and most anterior point on the ond extends anteriorly. Pa/ato/ plane : It is a line

alveolar bone in the midline, be:ween tne upper central linking the anterior nasal spine of the maxilla and Ihe

incisors. It is also called supradenla'e. posterior nasal spine of the palatine bone.

/nf'rac/emoi'e : The highest end most anterior point on Mondiku/ar plane : Several mandibular planes are

the alveolcr process, in the median plane between the used in cephalometrics, based on the analysis

mandibular central incisors.

The key ridge : Tne lower most point on the contour of

the anterior wall of the infra-remporal fossa.

Posterior nasai spine : The intersection of a

continuation of Ihe anterior wall of the pterygopalatine
fossa and the floor of the nose, marking the distal limit
of the rnoxilla.

Broodbent registration point : It is the midpoint of the

perpendicular from Ihe center of sella tursica to the
Bolton plane.

Ptm point : It is the intersection of the inferior border of

the foraman rotunduni with the posterior wall of Ihe
plerygo-maxillcry fissure.

G.'abe/.'o : It is the most orominent point of the

forehead in Ihe mid-sagittal plane.

CbeJjon ; It is the lateral terminus of the oral slit on the

outer corner of the mouth.

Sufcncsa'e : The point where the lowest border of the

nose meets the outer contour of the upper lip.
^ 4 Cephalometric planes. (A) Sella • Nosion plane IB) Frankfort Horzonta plane (Q Pclaxl plcne {D] Occlusal plane

being done. The most commonly used ones are Facial axis : A line from Ptm point to cephalometric

a. Tangent to the lower borer of the mandible E. Plane : or the esthetic plane is a line between the
(Tweed). most anterior point of the soft tissue nose and soft
b. A line connecting gonion ond gnathion (Steiner). tissue chin.
c. A line connecting gonion and menton (Downs).
Boston - Nosion plane : It is a line connecting the
basion and nosion. It represents the cranial base.
Solton's plane : This is a plane that connects the
Bolton's points posterior to the occipital condyles and
Vertical plane

A - Pog Line : It is a line from point A on the maxilla to

pogonion on the mandible.

Facial plane : It is a line from the anterior point of the

fronto-nasal suture (nasion) to the most anterior point
of the mondible (pogonion).
Fig 4 Ccplido-iiolric planes continued. • E; Mandibu ar plane (F) Basioo - Nosior plane (G) Estnetic plane (H) A - Pogonion plane |l| Fccia plane
(JJFaciol cxis
Cephalometrics 151

DOWNS ANALYSIS A'1andiu/ar plane angle : The m and i u la r o lane

angle is formed by the intersection of the mandibu'ar
One of the most frequently used cephalorvetric
plone with the F.H.plane (fig The mean value is
analysis is the Downs anclysis. Downs had based his
21.9* while the range is 1 7 to 28°. An increased
findings on 20 Caucasian individuc is of 12 - 17 years
mandibular plane angle is suggestive of a vertical
age group belonging to both tne sexes. Downs
grower with hyperdivergent facial oattem.
analysis consists of 10 parameters of which five are
Y - ax.;s fgrowJ.h axis) : This angle is obtained by
skeletal and five ore dental.
joining the sol la-gnathion line with the F.H. plane (fig
Ske/eta/ Parameters 5.e). The mean value is 59° with a range of 53 to 66 s .

racial angle : It is the inside inferior angle formed by The angle is larger in Clcss

the intersection of nasion- oogonion plane and the II facial oa-terns ihon "n patients exnibiting Class

F.H. plane (fig 5.a). The average value is 87.8" while III pattern. In addition, the Y oxis indicates the growth

the range is 82 to 95°. This angle gives us an pattern of the individual. If the angle is grecterthan

indication of the antero- oosterior positioning of the normal, it indicates greater vertical growth o*

mandible in relation *o the upper fcce. The magnitude mandible. If the angle is smaller than no-mal, it
of this value increases in cases of skeletol Class III indicctes greater horizontal growth of mandible.
with orominentchin while it decreases in skeletal Class
Dentai Parameters
II cases.
Cent of occtasa' pi one ; This angle is formed between
Angle of convexity : This angle is formed by rhe
the occlusal plane and the F.H. plane (fig S.f). Downs
intersection of a line from nasion to point A and a line
constructed the occlusal plane by bisecting the
from point A to pogonion (fig 5.b). This angle reveals
occlusion of the 1 st permanent molars and the incisal
the convexity or concavity of the skeletal profile.
overbite. The mean value is 9.3" while the range is 1.5
The average value is 0° while the range is
between - 8.5 to 10°. A positive angle or an "ncreased to 14'"'. This angle gives us a measure of the slope of

angle suggests a prominent maxillary denture base the occlusal plane relative to *he F.H. plane.

relative lo mandible. A decreased cngle of convexity or /nter-mc.'sa/ ongle : This angle is formed belween Ihe

a negative angle is indicative of a prognathic profile. long axes of the upper and lower incisors (fig 5.g). The
average reading is 135.4" while the range is between
A-B plane angle : This angle is formed between c line
130 to 150.5°. The angle is decreased in Class I
connecting point A and point B ond a line joining
bimaxillan/ protrusion and Class II, division 1
nasion to pogonion (facial plane)(fig 5.c). The mean
malocclusion whereas it is increased in a Class II,
value is -4.6'' while Ihe range is -9 to 0\ This angle is
division 2 case.
indicative of the maxillo- mandibular relationship in
J.ocisor ocdusaJ pione ongle : This is the inside
relotion to the fecial plane. It is usually negative in
inferior angle formed by the intersection
value since point B is positioned behind point A. In
case of Class
III malocclusions a positive angle may be found.
Rg 5 Downs analysis (A) Facial angle (BJ Angle of convexity JC) A-B plane angle (D) Mandibular alone angle [EJ Y • ax's (growth cxisl |F| Cart of occusal plare
^g 5 Downs analysis continued ; (G! Inler-incisa cnQle (HJ Incisor occlusal plane cngle (lj Incisor mandibular plcno r^gle (JJ Upper ir.cisor to A - pcg ine

retween the long axis of lower central incisor and occlusal 5-j). This distance is on an average 2.7 mm (range : -1
plane and is read as a plus or minus deviation from a right to 5 mm). The measurement is more in patients
angle (fig 5.h). The average olue is 14.5f' while the ronge presenting with upper incisor proclination.
is between 3.5 to 20°. An increase in this angle is
suggestive of rcreased lower incisor proclination.

Incisor mandibular plane angle : This ongle s formed Cecil. C. Sleiner in the yeor 1930 developed this
by intersection of the long axis of the lower incisor ond the analysis with the idea of providing maximal clinical
mandibular plane (fig f i).The mean angulation is 1.4° information with the least number of
while the range •s between - 8.5 to 7°. An increase in
this angle is "dicafive of lower incisor proclination.
Upper j.ncrsor fo A - Pog /ine : This is a linear
measurement between the incisal edge of the maxillary
central incisor and the line joining point A to pogonion(fig
1601?" Orthodontics - The Art and Science

prognathic (Class II) while a smaller value is

suggestive of c retrognathic maxilla (Class III).
S.iV.8. ongle : It is the angle between the S.N plane
Variable Mean value Range
and a line joining nasion ro point B(fic 6.b). This angle

Skeletal indicates the antero-posterior positioning of the

mandible in relation to the cranial base. Its average
Facial angle 8?.0{degi 52 - So',ceo;
value is 80". An increase in this ang.'e indicates a
A".gle of.convexity '.Oideg; • ' -S.5-ipidegj prognathic mandibie (Class III) whereas a 'ess ?hon

.A-g';piana angle. . -4.6(degV -9 - Oideg) normal angle suggests a retrusive mandible (Class II).

Mandibula' plane angle?... 2l;.9(dcg) .17-28i;d©g;<

A.N.8. angle : Tnis angle is formed by the
intersection of lines ioining nasion to point A and
Y axis 5$.4(desJ S3-S6(dec;
nasion to point B (fig 6.c). 11 denotes the relative
posrion of the maxilioand mandible to each other. The
mean value is 2C. An increase in this angle is indicative

Cant ot dcdusal plan-e 5.3(deg'/ t .5 - I 4{degj of a Clcss II skeletal tendency while ari angle that is
less than normal or c negative angle is suggestive of a
\ Lower inciscr to occlusal piano i4.5(deg) 3.5 :20
skeletal Class III relationship.
/vlorcdfbui'ar p'one angfe : It is the angle formed incisor. to. ma"dibula< plana 1..4[deg;- 4J '•;' between S.N. plane and fhe mandibular plane (fig 6.d}.

7(dag) :'•. The mandibular-plane used in this analysis is a line

connecting gonion and gnathion. The average value is
. InterincisBl angle .'.'.
32°. This angle gives an indication of the growth
130-i5G.o!d$ pattern of on individual. A lower angle is indicative of a
gj horizontal growing foce while an increased cngle
suggests a vertical growing individual.
Upper Incisor to A - pog 2.7 nn -1 • 5 mm
Occtusa/ p'one angic : The occlusal plane angle is
formed between the occlusal plane end the S.N. plane
(fig 6.e). In this analysis 'he occlusal plane represents
a line passing through the overlapping cusps of first
premolars and first molars. It has a mean value of
The Steiner analysis in divided into three
14.5°. This angle indicates tne relation of the occlusal
parts. They ore Ihe skeletal analysis, dental analysis
plane to tne cranium and face. It also indicates the
and the soft tissue a n lysis
growth pattern of an individual.
Ske/etaf analysis
Den fa/ Analysis
S.N.A. angle : It is the angle formed by the
Upper incisor fo N'-A (angle) : It is the angle
intersection of S.N. Plone and a line joining nasion
formed by Ihe intersection of the .!ong axis of the
and point A (fig 6.a). This angle indicates the relative
anlero-posterior positioning of the maxilla in relation
to the cranial base. The mean value is 82". A
largort.nan normal value indicates that the maxilla is
.oper central incisors and the line joining nasion •o incisor inclination. An increase in this measure-ment
point A (fig 6.f). The normal angle is 22°. Thisangle indicates proclined lower incisors. The normal value is

inter-incisor angle : Tnis is the angle formed between

the long axis of the upper and lower central incisors

Variabl (fig 6.j). A reduced inler-incisor angle is associated

e with a Class II, division 1 malocclusion or a Closs I
Skeleta bimax. A larger than normal angle is seen in Class II,
division 2 malocclusion. The mean value is 130 to 131

Soft t/ssue ana/ys/s

) S line : According to Steiner the lips in a well balanced
Occlusal plane angle face should touch aline extending from soft tissue

Mandibular plane contour of the chin lo the middle of an 'S' formed by the
lower border of the nose (fig 6. k). If the lips are located
angle Dental
beyond this line then the lips are believed to be
Upper incisor to NA (angle} 22{deg) upper
protrusive and is interpreted as a convex profile. If the
Irxisor to NA (linear) 4{mm)- lips arc

Lower incisor to NB (angle} 25{deg) Lower

incisor to NB (linear) 4{mm) Interincisal

angfc 131


indicates the relative inclination of the .oper incisors.

An increased angle is seen in catients who have
proclined upper incisors as in Cass II, Division 1

Upper incisor f o N-A (linear) : It is a linear Fig 7 Tweed analysis

—-easurement between the labial surface of the .oper
central incisor ond the line joining nasion ib point A (fig
6.g). This measurement also helps r determining the
upper incisor position. Normal clue is 4mm. It
increases in cases with proclined .•pper incisors.

lower incisor to N-B (angle) : This angle is ^med

between the N-B plane ond the long axis c^the lower
incisor (fig 6.h). This angle indicates —e inclination of
the lower central incisor and -es a mean value of 25°.
An increased value indicates proclamation of lower
incisors whereas a decreased value indicates upright
or retroc!ined lower incisors.

Lower incisor to N-B (linear) : It is the lineor

distance between the labial surface of lower central
incisor and the line joining nasion to point B (fig
6.i).This measurement helps In assessing the lower
c. Long axis of lower incisor
The objectives of the analysis include the
determination of the position of the lower incisor] and

Frankfort mandibular 25{deg)i6-35(<teg) plane angle (FMPA)

evaluation of prognosis of o cose. The angles formed

Incisor mandibular 90(<teg)85-95(d<?g) plane angle (IMPAJ by these three planes are :
Franktort mandibular 65(deg)60-75(deg) Incisor angle (FMIA)
Frankfort mandibular plane angle

It is the angle formed by the intersection

behind this line they are said to be retrusive and the of the Frankfort horizontal plane with the mandibular
patient may have a concave profile. plane. The meon value is 25=.

TWEED ANALYStS Incisor mandibular plane angie (IMPA)

It is the angle formed by the intersection of the long
The Tweed analysis makes use of three planes (fig 7)
axis of the lower incisor with the mandibular plane. It
that form a diagnostic triangle. The planes used are:
indicates the inclination of the lower incisor. The mean
a. Frankfort horizontal plane
volue is 90°.
b. Mandibular plone
Frankfort mandibular incisor angle

It is the angle formed by the

intersection of the long axis of the lower incisor with the
F.H.plane. The mean value is 65c.

The Wits appraisal

The wits appraisal is a measure of the extent to which
the maxilla and the mandible are related to each other
in the antero-posterior or sagittal plane. The wits
approisal is used in cases where the ANB angle is
considered not so reliable due to factors such as
position of nasion and rotation of the jaws.
A functional occlusal plane is drawn through
the overlapping cusps of first premolars and first
molars (fig 8). Perpendiculars are drawn to the
occlusal plane from points A and B. The points of
contact of these perpendiculars on the occlusal plane
are termed AO and BO. The distance between points
AO and BO gives the anteroposterior relation between
Fig 8 Wits Apprise I the two jaws. In
1601?" Orthodontics - The Art and Science



Brror mmm
Causes of
1. Radiographic projection errors
f-Aagrilcation enors are because By us;rg a long tocus- ob.eci distance
A. Magnfcaiion i a certa.n tho X ray beams are not parallel w th all points of and a start ohect • film distance By
amounlofertanjemeni s seen t"e ob;ect use ot a-gUar ratierSiar. rear
in cephalorretr'c rad'cgraohs. measurement.
B. Distorters : tie head being Th's enx>r may be overcome by
3 dimensions' causes Lardmaiks arid stwctires /Jbt s i„ated in the record tte nucpo -t cf die vx
dlfarerf. magnifications at d mdsagitlal olana are usually bilateral ard Images.
flerent depths c t lie'd. This nay cajse CuaJ -mages in radiograph
may rest>1 in distortions.

Rolaic n of the pafenfs tesd in ary plane of space By stardard<2ed head orerrtaicn
in the cephaiostot may prcduce linear a-d i&jjng ear rods, orbits oointe- and
angular distoricre. forehead rest

2. Errors within the measuring system

Emors may occir in tie

measu^ment of the va-iois
lines' and Tie angular
neasu-ements. Human enor may creep in during tt-e iraclng and The use of computerized olotters and
measurements. digitizers to digitize ne Isndma-ks a^d
to carry ou- 1"e various linear and
angular measurements tas proved to
1 Errors in landmark fdenlifitalion
Blurring of the radiograph may occur as a ^sult be more accurate and consistent
A. Quafffy cf ot scattered radiate n frat togs the ilm Good quality f&jiog'aphy ard use of
radiog, r apttc image Poor contest of flm may make differentiation avetage values from mUfple
between adjacent structures difficult. identification of tho same landma-k
I i3 advisable tor tte same person to
Identify and trace in patens who are
Errors may occur if Bie landmark is not defined subject« serisi cephafometic
accurately. This causes confusion in studies
identificalcn ol a tandma-k. Ws can be overcome by randomizing
the recorded measurements and by
In general certain lardmaiks are drtfcult to adopting a double blind study pattern.
identify such as porior.

Variation f-^/e been observed in landman

identification between operators.

"Pie operators oipectafors can result <n bias of

B. Precision of landman the values
Recomended t'ms snotld be used to avoid ooo r
deinltion and reproducibility Of
deinition radiographs
landmark location

Tris can be avoided oy stabilization of Ite object,

tube and tte film. By increasing tie currern, ine
exposure time is reduced, tius minimizing tiifi
possibility of motlo,-- blu',
C. Operator Bias This can be 'educed by jse of g ids.
Poor detrison of radiographs may
occu' tiw to use ot test iims and Good contrast is obtained by using; good films
intensive screens alhojgr the and use of sc'eqvate Kv level. Too Hgh Kv .-esulR
raJiaton dose is reduced, in poor contrast
Movement of the object tube or lardmaiks have to be accurately, defined.
the Sim may CETJSe a motion Certain lartimafts may require special condrtohs
blur, to identfy wfrich should be stricty toitowp.c.
case of males point BO is ahead of AO by 1 mm, while
in case of females Ihe points AO and BO coincide. In
case of skeletal Class II tendency BO is usually behird
AO {read as a oositive reading) while in skeletal Class
III pattern the point BO is located aneod of AO {reed as
a negative reading}


A number o* possible errors may creep in during

cephalometry as it involves a number of steps such as
obtaining a good radiograph, use of geometric
constructions and analysis and interpolation of the
values obrained without any observer bios. Table 4
gives o summary of the sources of error in
cephalometry. Although conventional cephalomctry
may be associated with a number of sources of errors,
il slill offers vital information fortne orthodontist in
diagnosis and treatment planning.


1. Downs WB - Analysis of the denlofac c I profile.

Angle Ortnod 1956 ;26 :191
2. Downs WB : The no e o: cephalometry in Orhocon- tic casfl
analysis onr. diagnosos. Am .1 OrtnocJ 1952

3 Grcber T.V1 : Orthodontics : Principles and practice. W3

Saunders, 198B
4. Jacobscn : introduction to Radiographic Cepnolomelry, Leo
and Fcbigcr, Pniladclphia, 1985
5. Profitt WR: Contemporan^ Orthocoilics. St Louis, CV Mosby,
6. Robsrl t Moyers : Hand boo< of Orthodontics, Yea' book
medical publishers, 'nc,1988.
7. Sazman JA : P'octice ot Orthodontics, JB Lippincott com
pony. -966
8. S'einer CC : Cephalometrics for you ond me.Am J Orthod
1953:39; 729
9. Stc nor CC : C'Bphclomet'y in clinical prcdice. Angle Orthod
1959:29; 8
10. Sleiner CC : The use o: Cepha om«try us an aid in planning
and asscssinc ortnodontic treatment. Am J Orthod 1960:46;
11. Thomas M Grobc, Robert L Vanarsdoll : Orthodonlics current
principles and technicues, Mosby year book Inc , 1994
12. Yen P : identification of landmark in cephalometric
radiographs. Angle Orthod 1960 ;30-3S
1601?" Orthodontics - The Art and Science


A n understanding of growth events is of primary

importance in the practice of
orthodontics. Biologic age, skeletal age, bone
age, and skeletal maturotion ore -early synonymous
A number o; methods are available to
assess the skeletal maturity of an individual. These
A. Use of hand-wrist radiographs.
terms used to describe the stages of moturalion of a B. Evaluation of skeletal maturation using cervical
person. Due to indi- «xiual variations in timing, duration vertebrae.
and velocity cf growth, skeletol age assessment is C. Assessment of maturity by clinical and radio-
essential in ^-rmulating vioble orthodontic treatment graphic examination of different stages of
plans, '•'oturationol status can have considerable
influence on diagnosis, treatment goals, treatment
cfanning, and the eventual outcome of orthodon- -c
treatment. Clinical decisions regarding use of extraoral
traction forces, functional appliances, extraction
versus non-extraction treatment or orthognathic
surgery are, at least partially, based co growth
considerations. Prediction of both the -me and the
amount of active growth, especially n the craniofacial
complex, would be useful to —e orthodontist.
In view of the importance of growth in
orthodontic treatment, objective assessment of
moturalion is important. The chronological age based
on the date of birth o^ers little insight in determining the
developmental stage or somatic maturity of a person.
Thus the maturity indicators provide an objective
diagnostic evaluction of stage o: maturity in an
The basis for skeletal age assessment by
radiographs is thot the different ossificction centres
apoear ond mature ot different times.The order, rate,
time of appearance and progress o: ossification in the
various ossification centres occurs in a predictable
sequence. 161
tooth development. the distal aspect. The radius and tne ulna give rise to o
Althougn a number of metnods of skeletal distol projection on their respective sides. These are
met jrity determination have been described, the use called the ulna styloid ond the radial styloid.
of hend-wrist radiographs has been the most widely
The carpals
accep'ed method.
They consist of eight small, irregularly snapec bones
HAND-WRIST RADIOGRAPHS arranged in two rows, a proximol row and a distal row.
The bones of the proximol row are scophoid, lunote,
Tne hand - wrist region is made up of numerous small
triquetral and pisiform. The distal row of bones include
bones. These bones show a predictable and
trapezium, trapezoid, capitate, and hamate. Each of
scheduled pattern of appearance, ossification and
these eight carpc bones ossifies from one primary
union from birth to maturity. Thus by mere y comparing
center, which appears in a predictable pattern.
a patient's hand-wrist radiograph with standard
radiographs that represent different skeletcl ages, we TVre metacarpals
will be able to determine rhe skeletal maturation status They are 5 miniature long bones forming the skeletal
ot that individual. framework of the pa I m of the hand. They are
A number o: methods have been described numbered I - 5 from the thumb to the little finger. Each
TO assess the skeletal maturity using hand- wrist metacarpal ossifies from one primary center (in its
rcdiograpns. The following are the most commonly shaft) and a secondary center on the distal end (except
used methods: for the first rnetacarpol where it appeors at the
A. Atlas Method by G'eulich and Pyle proximal end).
B. Bjork, Grave and Brown Method
C. Fishmon's Skeletal Maturity Indicators The phalanges
D. Hag g and Ta ranger Met nod. They are small bones forming the fingers. They are
three in number in each finger, except the thumb which
has only two pholanges.

The hand-wrist region is made up of I he following four The three bones are referred to as the
oroximal, middle (absent in thumb) ond the distal
groups of bones (lig 1}.
phalanges. The phalanges ossify in 3 stages
1. Distal ends of long bones of forearm
(fig 2).
2. Corpals
3. Metacarpals STAGE 1 : The epiphysis and
4. Phalanges diaphysis are equal. STAGE 2 : The
epiphysis caps the diaphysis by
Dfsts/ ends of tong bones of forearm
surrounding it like a cap. STAGE 3:
The distal ends of radius and ulna, which are long
Fusion occurs between the
bones of the forearm, form the first group of bones. In
epiphysis and diaphysis.
the anatomical position with the palm focing the front
the ulna is on the mediol aspect while the radius is on

1601?" Orthodontics - The Art and Science

Skeletal Maturity

Indicators 163
1. Radius
2. Ulna
3. Distal Epiphysis of Rodius
4. Distal Epiphysis of Ulna
5. Trapezium
6. Trapezoid
7. Capitate
8. Hdmular process of Hamate
9. Hamate
10. Triquetral 11 .Pisiform 12. =
ig 1 Ana'Oftiy of hand and wrisl
] 3. Scaphoid 14 ^Sesamoid . M =
Metacarpal P ''§ Phalanx

|g4 Orthodontics - The Art and Science

in the atlas is representative o*' c particular skeletal

age. The patient's radiograph is matched on an overcll
In patiems who exhibit napr discrepancy between dental and
basis with one of the photographs in the atlas.
chronologic a$s.

2. Determination of skeletal maturity status prior to treat-

men: of skeletal malocclusion s*ch as a skelelal Class
II or Class III malocclusion. They have divided skeletal development into 9 stoges.
3. To assess the skeletal age •:> a patient whose growth is Each of these stages represents a level of skeletal
ajfeaed by rnfecton3. aplastic or fa--mate oy- cftons maturity (fig 3). Appropriate chronological age for ecch
4. Serial assessment cl skeletal age using hard-wrist of the stages was given by Schopf in 1978.
radiographs helps not only in assessing ihs growth of Stage I (mates 10.6 y , fema/es 8. Iy): The epiphysis
a-, individual, but also helps predicl future skeletal and diophysis of the proximal phalanx of index finger
maturation rate and status.
are equal. It occurs approximately three years before
5. To predicl the pubertal growth spurt.
the peak of pubertal growth spurt.
6. II is a valuable aid $ research airr.ed at stuoying 1he role
of heredity, environment, nulrt.on etc., on the Stage 2 (mafes J 2.0 y, femoJes 8. J y): The epiphysis

maturation pattern. and diaphysis of the middle pho- lanx of the middle
f, It is indicated in patients wdh skeletal malocc^uson nesting finger are equal.
onhognathic surgery, if undertaken between :6 - 20 Stage 3 fma/es /2.6 y, f em ales 9.6 y): This stage is
years so as to-assess thegrowh status.
characterized by presence of 3 areas of ossification:
The hamular process of the hamote exhibits
The sesamoid bone
The sesamoid bone is a small nodular bone mosT
Ossification of pisiform.
often present embedded in tendons in the region of
The epiphysis and diaphysis of radius are
the thumb.

Stage 4 (moles 13.0 y , fema/es f 0.6 y): This stage

marks the beginning of the pubertal growth spurt. It is
characterized by :
a. Initial mineralizotion of the ulnar
sesamoid of the thumb.
b. Increased ossification of the hamular

Fig 2 5lages in ossificot on of plia'crigcs |A)Ihu epiphysis and d
ephysis'are equal |B)The epiphysis caps -he c'iaphysis
(C)Fusion butween epiphysis and diaphysis.

Greulich and Pyle published an alias containing ideal

skeletal age pictures of the hand-wrist for different
cnronobgiccl ages pnd for each sex. Each photograph

Fig 3 (A) S'age one - Epiphysis and diaphysis of -ne croxirrol Fig 3 (B1 Stage -wo - The epiahysis and biaohysis of 'he rriddle
pha'anx o1' index finger a'e equcl. phalonx cf the ~iidd e finger are equcl.

Fig 3 (C) Stage "hree • The homula' process of ihe homa'e exhibits os$i ication |Oj Ossification at pisiform (E) The epiohysis end diaphysis of

radius ere equal.

Fig 3 (F) Stage four - Initial rrheralizafion of Ihe ulnar sesamoid cf the thumb |G) Increased ossification of -he hamular process of the narrate bone.
1601?" Orthodontics - The Art and Science

iiilli Fig 3 (H) Stage Five -

Capping of diophysis by the epioiysis is seen in middle pholar* of the third f nger (I) Proximol phaloru of
ha tnumb (J; Rod us

end diophysis of the distal phalanx of ihe middle f nger.

Fig 3 (I) S' O G E seven • Union of epiphysis and diophysis of the

O'oximal phalanx of the little finger
Fig 3 K) Stage Six - Un or- betweencpiohysis

Fig 3 (W) Srcge Eight • Fusion between the epiphysis end diophysis
of the middle phalanx of the rriddle finger,
Fig 3 (N; Stage Nine • Fusion of epiphysis and diaphysis of the
process of the hamate bone. Stage three (Pubertal onset)
Stage 5 (ma/es 14.0y, females ?.0 y): This stage This stage is characterized by
heralds the pea'< of the pubertal growth spurt.
Skeletal Maturity Indicators beginning of calci-
Capping of diaphysis by the epiphysis is seen in : fication of ulnar
a. Middle phalanx of the third "finger sesamoid, increased width of epiphysis of proximal
b. Proximal phalanx of the thumb phalanx of Ihe second finger and increcsed
c. Radius calcification of hook of hamate and pisiform.
Stage 6 fma/es /5.0 y , femafes J 3.0 y): This stage
Stage four (Puberal)
signifies the end of the pubertal growth spurt. It is
characterized by union between epiphysis and Stage four is characterized by calcified ulnar sesamoid

diaphysis of the distal phalanx of the middle finger. and capping of the diaphysis of the middle phalanx of
third finger by its epiphysis.
Stage 7 fma/es / 5.9 y,'/emo/es /3.3 y): Union of
epiphysis and diaphysis of the proximal phalanx of the Stage five (Puberal deceleration)
little finger occurs.
This stage is characterized by fully calcified ulnar
Stage 8 (males /5.9 y , females J 3.9 y This stage sesomoid, fusion of eoiphysis of distal phalanx of third
shows fusion between the epiphysis and diaphysis of finger with its shaft, and epiphyses of radius ond ulna
the middle phalanx of the middle finger. not fully fused with respective shafts. Stage 5
Stage 9 (ma/es /8.5 y , females 16.0 yj: This is the last represents that period of growth when orthodontic
stage ond it signifies the end of skeletal growth. It is treatment might be completed ond the patient is in
characterized by fusion of epiphysis and diaphysis of retention therapy.
the radius.
Stage s/x fGrowtft completion)
SINGER'S METHOD OF ASSESSMENT No removing growth sites seen.

Julian Singer in 1980 proposed a system of hand- wrist

radiograph assessment that would enable the clinician
to rapidly and with some degree of reliability help
determine the maturational status of the patient. Six
stages of hand-wrist development ore described. The
stages and their characteristics are :

Stage one (Early)

This stage is characterized by absence of the pisiform,

obsence of hook of the hamate and epiphysis of
proximal phalanx of second finger being narrowerthan
its dioohysis.

Stage two (Prepubertal)

Stage two is characterized by initial ossification of hook

of the hamate, initial ossification of the pisiform and
proximo' ohalanx of second finger being eaual to its
epiphysis. Stage 2 represents that period prior to the
adolescent growth spurt during which significant
amounts of mandibular growth are possible. Maxillary
orthodontic tneropy in conduction with mondibular
growth might aid correction of a Class II relationship
with considerable speed and ease.
1601?" Orthodontics - The Art and Science Fishmon s system of interpretation uses four stages of
bone maturation. They are:

1) Epiphysis equal in width to diaphysis.

S.M.I. 1 : The third lingef proximal
2) Appearance of adductor sesamoid of the thumb.
phalanx-.shows equal w.dth of
3} Capping of ephiphysis 4} Fusion of epiphysis
epiphysis and diaphysis.
Table 2 gives tne eleven skeletal maturity in-
S.M.I. 2 : V^idih of epiphysis equal to lhal of
diaphysis in Ihe middle phalanx of dicator (fig 4). Table 3 gives us the approximate

third finger. chronological age and percentage of growth that is

S.M.I. 3 : Width of epiphysis ecual to thai of completed corresponding to each of the eleven
diaphysis in the micdle phalanx of skeletal maturity indicators.
fifth finger.
S .M. 1 . 4 ; Appearance ot adductor sesmod
of the thumb.
S.M.I. 5 : Capping of epiphysis seen in distal
Skeletal development in the hand and wrist is analyzed
phalanx of third finger.
from annual radiographs, taken between the oges of 6
S.M.I. 6 ; Capprvg of epiphysis seen in micdle
and 18 years, by assessment of Ihe ossification of the
phalanx of third finger.
ulnar sesamoid of the metacarpophalangeal joint of the
S.M.I. 7 : Capping of epiphysis seen in middle
first finger (S) and certain specified stages of three
phalanx of lifth finger.
epiphyseal bones: the middle and distal phalanges of
S.M.I. 8; . Fusion of epiphysis and diaphysis in
the third finger (MP3 and DP3) and the distal epiphysis
the distal phalanx of third finger.
of the radius (R) (fig 5).
S.M.L 9 : Fusion of epiphysis and diaphysis in
proximal phalanx of third finger. Sesamoid
S.M.L 10 : Fusion of epiphyss and diaphysis
Sesamoid is usually attained during the acceleration
in the middle phalanx of third
period of the pubertal growth spurt (onset of Peak
height velocity).
S.M.I. 11 ; Fusion of epiphysis and diaphysis
seen in the radius.
Third finger middle phalanx
MP3-F : The epiphysis is os wide as the meta-
physis. This stage is attained before onset of RH.V. by
about 40 percent of the subjects and at RH.V. by many
A system for evaluation of skeletal maturation was /VIP3-FG : The epiphysis is as wide as the meta-
proposed by Leonord S. Fishman in 1982. This system physis and there is distinct medial and/or lateral border
of evaluating hand-wrist radiographs makes use of of the epiphysis forming a line of demarcation at right
anatomical sites located on the thumb, third finger, fifth angles to the distal border. This stage is attoined 1
finger and radius. Eleven discrete adolescent skeletal year before or at RH.V
maturity indicators (S.M.I.'s) covering the entire period
of adolescent development have been described. The
v Approximate chronological age and percentage of growth completed corresponding to the

1601?" Orthodontics - The Art and Science

SMI No. Age in Years

Percentage of Adolescent growth % of Max Growth % of Mand.
completed Completed Growth
1 9.94 ±0.96

2 10.58 =0.88 12.2 16.7 14.7

3 10.88 ±0.99 22.5 18.5 25.0

4 11.22 =1.11 32.7 20.3 33.1

5 11.64 ±0.90 39.8 28.6 38.3

6* 12.06 ±0.96 51.7 49.7 47.0

7 12.34 »0.90 73.6 69.0 58.0

8 13.10 ±0.87 86.6 83.0 72.7

9 13.90 ±0.99 91.9 89.6 84.0

10 14.77 ±0.96 96.1 92.7 90.0

11 16.07 ±1.25 100% 100% 100%

SMI No. Age in Years
Percentage of Adolescent growth % of Max Growth % of Mand.
completed Completed Growth
1 11.01 ±1.22

2 11.68 ±1.06 15 16.7 15.9

3 12.12 ±1.00 21.6 18.5 19.5

4 12.33 ±1.09 28.9 20.3 26.7

5 12.98 ±1.12 34.0 28.6 30.8

6* 13.75 ±1.06 52.6 49.7 48.5

7 14.38 ±1.08 74.3 69.0 66.7

8 15.11 ±1.03 87.3 83.0 77.7

9 15.50 ±1.07 92.0 89.6 84.6

10 16.40 ±1.00 95.3 92.7 91.5

11 17.37 ±1.26 100% 100% 100%

i si
fig 4. fisnnian's skeletal maturity indicators
Skeletal Maturity Indicators 171

MP3-G : The sides of the epiphysis h.ave thickened distally at one or both sides. This stage is attained at or
ond also cap its metaphysis, forming a sharp edge 1 year after RH.V MP3-H : Fusion of the epiphysis
and metaphy- r"s has begun and is attained after PHV rectangular, followed by square shape.In addition
but be- ^re end of growth spurt by practically all boys They became taller os skeletal maturity progressed.
end about 90 percent of the girls. WP3-J: Is attained The inferior vertebral borders were flat when
before or at end of growth ssurt in all subjects except a immature, and they were concave when mature. The
few girls. curvatures of the inferior vertebral borders were seen
to appear sequentially from C2 to C3 to C4 as the
Third finger dlstat phalanx
skeleton matured. The concavities became more
3 D 3-I ; Fusion of the epiphysis and metaphysis s distinct as the person matured.
completed. This stage signifies the fusion of the Hassel and Forma n have put toward the
•oiphysis and metaphysis and is attained during ■he following six stages in vetribral development:
deceleration period of the pubertal growth spurt e. end
of RH.V.) by all subjects.
Stage I
This stage called initiation, corresponds to beginning
Radius of adolescent growth with 80% to 100% of adolescent
8J: Fusion of the epiphysis ond metaphysis has regun. growth expected. Inferior borders of C2, C3, and C4
This stage is attained 1 year before or at 1-« end of were flat at this stage. The vertebrae were wedge
growth spurt by about 80% of the girls rrd about 90% shaped, and the superior vertebral borders were
of the boys. t-U : Fusion is almost completed but there tapered from posterior to anterior.
is r II a small gap at one or both margins. <-J : is
characterized by fusion of the epiphysis rrd Stage 2
metaphysis. The second stage is called acceleration. Growth
These stages were not attained before end of H.V. by acceleration begins at this stage, with 65% to 85% of
any subject. adolescent growth expected. Concavities were
developing in the inferior borders of C2 ond C3. The
inferior border of C4 was flat. The bodies of C3 and C4
USING CERVICAL VERTEBRAE were nearly rectangular in shape.

-ossel and Farman developed a system of skeletal Stage 3

maturation determination using the cervical «ertebrae.
The third stage colled transition, corresponded to
The shapes of the cervical vertebrae -ere seen to differ
acceleration of growth towards peak height velocity
at each level of skeletal devel- rcment (fig 6}. This
with 25% lo 65% of adolescent growth expected.
provided a means to deter- —fne the skeletal maturity
Distinct concavities were seen in the inferior borders of
of a person and thereby :-exermine whether the
C2 and C3. A concavity was beginning lo develop in
possibility of potential growth existed.
the inferior border of C4. The bodies of C3 and C4
The shapes of the vertebral bodies of C3 and C4
were rectangular in
changed from somewhat wedge shaped, to

Orthodontics - The Art and Science



D Fig 5. Hond-wrist rodiogroph assessment by Hagg end Toranger
Skeletal Maturity Indicators fj

Initiation Acceleration Transition

Completion Maturation Deceleration

Fig 6. Assessment of skeletal motu'etien using the verebral coljmr.

borders of C2, C3, and C4. The bodies of C3 and C4

were nearly souare to square in shape.

Stage 4
Stage 6
This stege colled deceleration, corresponds to
This stage called completion corresponds to
deceleration of adolescent growth spurt with 10% •o
completion of growth. Little or no adolescent growth
25% of adolescent growth expected. Distinct
could be expected. Deep concavities were seen in the
concavities were seen in Ihe inferior borders of C2, C3,
inferior borders of C2, C3, and C4. The bodies of C3
and C4. The vertebral bodies of C3 and Z4 were
and C4 were sauare or were greater in vertical
becoming more square in shape.
dimension than in horizontal dimension.

Stage 5
The fifth stage is called maturation. Final malu- trtion of INDICATOR OF SKELETAL MATURITY
the vertebrae took place during this stage, *:th 5% to
10% of odolescent growth expected. More The calcification patterns and stage of mineralization
accentuated concavities were seen in the inferior of the teeth is believed to have a close

relationship with the s<eletal maturation of an
individual. Seymour Chertkow has described a method
of determining -he skeletal maturity based on Ihe
mineralization of the lower canine. Demirjcln,
Goldstein and Tanner have described a similar

1. Chctkow : loolli minerol2a'ion as on indica-o' of the pubertal
growth spurt. Am j Orhoc 19SO; vol : 79-91.
I. Coutinbo, Buscnarc and Miranda: Mcndibulor ca- rine
calcifica-icn stages end s<clcla ma urity, Am „
Orthod 1993 ; vol :?6? 968 3. Demirjiar, Buscha-ig, languoy,
arc Poters: Intsrre- Iclionshios cr-iong mp.asi.res of somatic, skc
clul, den-cl, arc saxjal malumy. Am J Onhod 1985; vol: 433-138
Grave end Brown: Skeletal oss'tication arc ccolcs- cen- crcwih
spur. Am J Orhoo 1976; vol: 69-80. I>. (■•egg ard Tamnger :
Metjrotor nd LCIOIS end Ihe pubc-ta g'owlh Spur Am j Onbodl9&2; vol
: 299- 309
6. rasscl and Fair-ai : 5<s etcl maturat'en o value- •icn. Am J
O.-tiodl 995; vol : 68-66
7. Julian Siraer : Phys'olagic timing o; O'lfodorvic •reel-Men'.
Argle Orhocont 1980; vol: 322-333
8. Leite, O'Rei ly, end Close : Skols'cl age assess me n- wrh
first, second, and tliirc tinges. Am J Orthod " 987 ; vol :
9. (.eonorc S.Fisiman: Radiog'aphic cvaljJlio-i o; Skc c'al
matufity. Angle Ortnodcm 1982; vol: 83 - 112
10. Moore, Mover ord DuBois : Skele-al netu-etor a id crcniotccia
growth. Am J Oinod 1990; vol : 33-
II. Rcve o arc P'sircr : Evaluation of ossification of mid pa lota I
suxre. Am J Or boei 1 99*- ; vol : 283- 292.
12. Rcssouw. Lomberu, aid I laris: Frortcl sinus a id mandibii.fir
growth predict on. Am J Orthod 1991; vol: 5<12-5'-6.
(Jj Model Analysis

Determination of the discrepancy

tudy casts are essential diagnostic aids. The
study models provide a three dimensional The discrepancy refers to the difference between the
view of the maxillary and mandibular dental a'ch length and tooth material.
arches. Model analysis involves the study of the
^axillary and mandibular dental arches in all the three
planes of space (sagittal, vertical and ^nsverse planes}
and is a valuable tool in cfthodontic diagnosis and
treatment planning.


Many malocclusions occur as o result of discrepancy

between arch length and tooth material. Carey's
analysis helps in determining -he extent of the
discrepancy. It is performed on -he lower cast. The
same anolysis on the upper cast is called Arch
Perimeter Analysis.

Determination of arch length

"he arch length anterior to the first permanent -solar is
measured using a soft brass wire. The wire is placed
contacting the mesial surace of the first permanent
molar of one side and is passed over the bucccl cusps
of the premolars and along the anteriors and is
continued on Ihe opposite side in the same way upto
the mesial surface of Ihe opposite first permanent
molar. In case of proclined anteriors, the wire is passed
along the cingulum of anterior teeth. If the anterior
teeth are retroclined, the bross wire in the anterior
segment passes labial to the teeth. If the anterior teeth
are well aligned the wire passes over the incisoi edge
of anteriors.

Detez-m In a 11 on of tooth material

The mesio-distal width of the teeth anterior to the first

molcrs (second premolar lo second premolar) is
measured and summed up.

iv r
• Carey's analysis inference

Discrepancy Inference
0 - 2.5 mm Proximal stripping
2.5 • 5 mm Ext'aclicr, of seconc premolars
> 5 mm Extract on of firsi premolars

a. If the discrepancy is 0 to 2.5 mm, il indicates
minimal loom mcrenal cxccss. In such cases,
proximal stripoing can be carried ouf to reduce the
tooth material.
b. If the discrepancy is between 2.5 to 5 mm, il
indicates the need to extract the second
c. A discrepancy of more than 5 mm indicates the
need to extract the first premolars.


Ashley Howe corsidered loolh crowding to be due to

deficiency in arch width rather then arch lenglh. He
round a relationship between tnc total width of the 12
teeth anterior to tnc second molars and the width OT
the dental arch in the first premolor region.

Determination of total tooth

material (T.T.M.)

The mesio-distal width of cil the feefh mesial to the

second permanent molars is mecsureci with the hclo
of dividers (fig 1 .a) and al t'ne values are summed up.
This vclue is called the total loolh material.

Determination of premolar
diameter (P.M.D.)

The premolar diameter refers to the arch width from

the t'p of the bucccl cusp of one first premolar to ?he tip
o: bucca cusp of the opposite first premolar(fig 1 .bj.
h g I Ash1 ey Howe's analysis (A; Measurement cf -ne mesio-msta
width of tie ioctn cf ihe a ca o; maximum contour (3) Meosjrement of
premolar diameter (C) rreasjrerrent of premolar uasa ard 1 widlh.
esc- shows t ic oca'icn distal to tie canine prominence
Model Analysis 177

PMBAW Inference
% Need for exfadon
37 c l$S9 44 Trealmeni by
cr more 37 nc--extraction
to 44 Borderline cases
Determination of premolar basal arch
width (P.M.B.A.W.)
The canine fossa is found dista1 to carine eminence.
Tne measurement of the width from canine fossa of
one side to the other gives us Ihe width of the dental
Determ/naf/on of sum of
arch at the coical base or the junction between the incisors (S.i.)
basal bone and o'veolc process. If Ihe canine fossa is
The mes io-d istal widtn of 4 maxillary incisors is
not clearly distirguishcble the measurement is mede
measured ond the values summed up. This value is
from a ooint that is 8 mm below the crest of the irter-
called sum of incisors (S.I.).
dental papilla distal to 'he canineifig 1 .c)

The RM.B.A.W. and the RiV,.D. are compared. If the
RM.B.A.W. is greater than the PM.D., then it is an
indication that arch expansion is possible. If on the
other hand the RM.B.A.W. is less than RM.D., then
arch expansion is not oossible.
According lo Ashley Howe, to achieve normal
occlusion with o full complement of teeth the basal
arch width ot the premolar region should be 44% the
sum of mesio-distal widths o" all the teeth mesial to the
second permanent molar (tolol tooth material). This
ratio (expressed as %) between the apical base width
at the premolar region and the total tooth material is
called the prenolor 'oosal arch width percentage. It is
determined using the formulc :

RM.B.A.W. % - PM.B.A.W. x 100

a. If RM.B.A.W. % is 37% or less, it indicates a
Fig 2 ?orts analysis (A) Inte'-premolar width (B; rver-
mcla' w cfh

need for extraction.

b. If RM.B.A.W. % is 44% or more, Ihe case can
possibly be treated without extracting any teeth.
c. If RIVI.B.A.W. % is 37 - 44%, the case is referred
to as a borderline case.


Ponts in 1909 presented a system whereby the

measurement of the four maxillary incisors
automatically established the width of the arch in the
premolar and molar regions. Ponts analyst helps in :
a. Determining whether the denial orch is narrow or
is normal.
b. Determining the need for lateral arch expansion.
c. Determining how much expension is possible at
the oremolar and molar regions.
Determination of measured between the mesio-distal widths of maxillary and
premolar value (M.P.V.) mandibular teeth. Many malocclusions occur as a
The width of the arch in the premolar region from the result ot abnormalities in tooth size. The Bolton's
distal pit of ore upper -first premolar to the distal pit of analysis helps in determining disproportion in size
the oppos'te first premolar is measured. It "s called the between maxillary and mandibular teeth.
measured premolar value.
Sum of mandibular 12
Determination of measured
The mesio-distal widln of all the teeth mesial to the
molar value (M.M.V.)
mandibular second permanent molars is measured
Tne width of the arch in the mo or region from the and summed up.
mesial pit of one upper first molar to the mesial pi-of
the opposite first molar is measured. This value is Sum of maxillary 12
called the measured molar volue.

Deterro/nat/on of calculated
premolar value (C.P.V.)

Calculated premolar value or tne expected arch width

in the premolar region is determined by the formula :
S.I. x 100/80

Determination of calculated
molar value (C.M.V.)
Calculated molar value or the expected arch width in
the molar region is cetermined by the formula: S.I.x

If measured value is less than calculated value, it
indicates the need for expansion. Thus it is possible to
determine flow much expansion is needed in the molar
and the premolar regions.


This analysis is very similar to Pont'sanolysis except

that a new formula has been proposed to determine
the calculated premolar and molar value.
The calculated premolar value is determined
using tho formula : S.I. x 100 / 85
The calculated molar value is determined
using the formula : S.I. x 100 / 64


This analysis is also similar to Pon^s analysis. It makes

use of the Under Horth's formu la to determine the
ideal prph width in the premolar and mo'ar region. In
addition, this analysis utilizes a measurement made
from the midpoint of the inter-premolar line to a point in
between the two maxillary incisors. According to
Korkhaus, fora given width of upper incisors a specific
value of the distance between the midpoint of inrer-
premolor line to the point between the two maxillary
incisors should exist. An increase in this measurement
denotes proclined upper anterior teeth while a
decrease in this value denotes retroc I i ned u pper a
nte ri o rs.


Tooth size is ari important factor to be taken into

consideration in orthodontic diagnosis and treotment
planning. According to 8olton, there exists a ratio
The mesio-distal width of all the teeth mesial to the The sum of mesio-distal width of the mandibular
maxillary second permanent molars is measured ond Model
onteriors should be 77.2 Analysis
% o;tne T179
mesio-distal width of
summed uo. the maxillary anten'ors. The anterior rcrio is
determined using 'he following formula :

Sum of mandibular 6
sum of nand:bular 6 x 100 sum of maxillc-y 6
The mesio-distal width of all the teelh mesial to the
mondibulor first premolars is measured and summed If the anterior rat'o is less t nan 77.2% it
up. iridicctes n axil la ry anterior excess. r he
amount of maxillary anterior excess is
Sum of maxillary 6
Anterior ratio = determined by the following way:
The mesio-dista! width of all the teeth mesial to •he Mandibular 6 x 100
maxillary first premolars is measured and summed up. Maxillary6 -

l~ the anterior ratio is more than 77.2 %, it

Determination of overall ratio
indicates mandibular onterio- excess. The amount of
According to Bolton, the sum of mesio-distal widths of mandibular anterior exccss is determined usinc the
the mandibular leelh anterior to the second permanent formula :
molars is 91.3% the mesio- disfal width of the maxillary
teeth mesial to Ihe second molars. The overcll ratio is 77.2
determined using the formula :
Determination of anterior ratio

Mandibular 6 -
Over all ratio = sum of mandibular 12 x 100 sum of
maxillary 12


The ouraose of a mixed dentition analysis is to

evaluate the amount cf space available in the arch for
the erupting permanent canines and orernolars. In this
analysis the size of the
Maxillary 6 x 77.2 100
unerupted permanent
cuspids and premolars
are predicted from the knowledge of the sizes of

If overall ratio is less than 91.3%, it ndicates certain permanent teeth already erupted in the mouth.

maxillary tooth material excess. The amount of The Moyer's mixed dentition analysis predicts Ihe

maxillary excess is determined using "he formula combined mesio-dislal width of 3, 4 and 5 based on the
sum of the widths o* Ihe four lower permanent incisors.
The mesio-distal width of Ihe four lower
Mandibular 12 12
Maxillary x 100 91.3
x91.3 incisors are measured and summed up. The amount of
Maxillary 12 -12 -
Too space available for the 3, 4 and 5 crter incisor
alignment is determined by measuring

If the overall ratio is more than 91.3%. ft

indicates mandibular tooth materia! excess. The
amount of mandibular excess can be determined by
the formula :


«v it/ . e>- . Vr3
192 Orthodontics - The Art and Science unerupted
•'. teeth. Radiographic measurements c-
- .a. M'- !
• .
v\ J iii iii' jtt'- nfi ■'■ •lit' '. J. .-o to ■ unerupted teeth ore by themselves unreliable due to
U at. J-. ''■M
i'- Ihe distortion that can occur. It is possible to determine
xi m ■ ><~ !■<•: m m: '.
JNO 1yl 3.1
. HS.
.-.V the measurementsofthe unerupted teer by studying
•5 »> XI :</
:u . }if i: JiJ a» tne teeth that have already eruptec in a radiograph
.i SI
and on a cast. The following formula is used: Y1 = XI x
<5 .3! :iv M'. y>. ■ ii.' .11 '..u -4i ■'' :• ii Y2
<- JI: J i. >. IL*. •.
' X2
si 'M H? iV. >1 s< >1 JI 'l ii i .>). JO ' iU- a »
- S 9. >• .
."t- . •»> : !>i •\0 a» SM •
' U' widlh of unerupted tooth whose measurement is
M' II > IM Y!A Iff. m 5>- •a . iu JIJ 4 to be determined, width of unerupted tooth on
:' ■ l -
II JU . 11 u: H. IH ••■>/ ■
a:. U'. >u iii
the radiograph.
1- S width of a tooth that has erupted, measured on
i M n? . m II? u ii i . v> • .
iy> |IA • .1) the cast, width of a toolh that has
tl'MM «
o )> »■)
HA .•l .l' nt ]■•■
»y. . erupted, measured on the radiograph.
' 'i'/..'
>» : Y1 = References

u •.*».
JI ■'. SU c/ J)! Y2 =

1! )»» :xr. iCt ii». i.) r s r. . Cl •'U;
3K V.
XI =
l< . M . f a i-'. iii J» JI. •'t» SI 3l>
uv ' >'•' * -
» i»'. .i». :JJ i»« 3V . >:)
31 ;I.I ju . ill- • X2 =
'/. . > » ' 31
v.- u; ■W Mi ' ■
11 i» :i i ll>'.
/ y>j
X n UI 'M I<I 'n/' ■'• ■■ •'.»»•
,.T.> •'•-. .'.JI
j.' '. J- ■.v .- . T.» .')'.
m •■l' :
i> i • IV S IX ' yr 31*
lt. ' n> HA . ."
• IM ■■ 1- .V Kl >J 1« •..I . lO ;
'J'- .1 5 f ■ >- H i»-
: 1. »

• •
Si'i UI i'/ A'! :i f,; 1M
l -''
« 3. •! S jn n't: iiii a 4 131 a» Kl'
1 M' •'»' •
E it i M- m. ai • ' W- ILL . '.Ii .i. .
JI» >-t
u. M JJ iu Hi: ■:::+ Ii.' •3) . -
V- .i>>
M .
v m . Ji i-». * a) i;» .
J. 3-> -15
x .ii". ■ . JO .JJ
i.1 i JU' - v.'
■ .
n i«; m 1»t 5M
s:> . .''L-l- J.V
5 954
J? i» ■ M r 40: 811. -• Ji •U ji.r i'. ;..>.'. " '-■>. '.ii'"
4. i',Hunter
M S >. of arc lysis
H-: Application v * ■
of crowding and SpOC'ng-.
1 - North Am 1978; 563-578.
cf Ihe teeth. Derf Clin
19 IH n.J n». XV J M .i. - :>>J i--'. ".
5. Jaondeph . DR, ftiedei RA, Moore V: AW : Pcnrs .:'index-: Cl'nical
UT. Orrhod '•
1 /i* IH Angle
y u:
evaluation. '.It- 1970J>l ; 40W'.
: 12 «.«.;
6. Profil! WR:
. Contemporary Orthodontics, . '."'.V :
'. OJ'S. CV 5" L
Mosby,1986. irkitri
1- v'i c MoyersJI:. Hand book■ittof ■'o
7.«i Robert Orthcdon-ics, Year book Vi'v
I u- < .inc, 1988. -
publishers, ■
V j; 'i.« lu • ■ !7.l ' a<
8. "anaka MM, I.Johnston Jit
l£:J.The prediction of tho sizeof Ihe
. 3H
uneiupted Cannes : ar-d O'premolars in a contemporary
p M •i» v > • ll? iij- :i> W.': v -
COr'hadontic Population. .1 Am Den" Assoc 1974 ; 88 •.:«.: 798
'A >1 x; :»>■ M I'l ■JI v; .'-v
1 /-. ></■
H i<» . ■J •'. i •-■>
>u... M.'
11 j '. .
)» ■ • ■yt 15 • : >«. '
IH. JO 1 W' v 35"
U K • "'y r.t LLI -M' >0 - JIL ■
m.; A 'S; •'. • .-
'•' >•

IS -■ . )««'.
•'y/ • > . I' V M' •' -V' -J
J. i») -'- r/. 11.
. 1.
.-.» IV !>I II • !>-. ILL >I 1«/. IM .III »1
the distance between the distal surface of lateral
incisor arid Ihe mesial surface of first permanent molar.
Based on the mesio-distal width of the four
mandibular incisors, the expected width of the canines,
first and second premolars are predicted by referring
the probabilily cnart (Tcble 3). While doing so, the 75%
level of probability is considered reliable.
The predicted tooth size of 3,4 and 5 is
cornpored with the arch length available for them so as
to determine the discrepancy. If the predicted value is
greater than the ovailable orch length, crowding of
teeth can be expected.



This technique makes use of a radiograph as well os a

study cast to determine Ihe width of Ihe

rthodontic treatment is made possible by the c. Changes in tooth position during mastication

O 194 Orthodontics - The Art and Science


fact that teeth can be moved through the alveolar bone

by opplying appropriate forces. Orthodontic tooth
movement is o unique process where a solid object
(tooth) is made to move through a solid medium
(bor.e). The ability of independent movement of the
teeth is unique to humans in particular and mammals in
general. The earlier primitive animals such as reptiles
had teeth that were ankylosed or fused to the bone.
This did not allow independent movement of the teeth.
During the process of evolution, the periodontal
ligoment appeared between the tooth and the alveolar
socket. The appearance of this periodontal tissue
enabled independent tooth movement.
Orthodontic treatment is possible due to the
fact that whenever a pfolonged force is applied on a
tooth, bone remodeling occcurs around the toolh
resulting in its movement. As a rule of thumb it can be
said that bone subject to pressure as a result of
compression of periodontal ligament resorbs while
bone forms under tensile force asa result of stretching
of the periodontal ligament. The aim of the present
chapter is to study the various biological tissue
changes that occur during tooth movement.


Physiologic tooth movements are naturally occurring

tooth movements that take place during and after tooth
eruption. Physiologic tooth movements include :
a. Tooth eruption
b. Migration or drift of teeth
Tooth erupt/on which occur in cycles of one second or less and may
Tooth eruption is the axial movement of the tooth from range from 1 - 50 kilograms based on the typo of food
its developmental position in the jaw to its final position being masticated. Atootn subjected to these heavy
in the oral cavity. A number of theories have been put forces, exhibits slight movement within its socket and
forward to explain how the eruption process takes subsequently returns to its original position as soon as
place. The following are some of the theories : the load is removed.
When a tooth is subjected to such heavy
A) Blood pressure theory : According to this
forces, the tissue fluid present in the periodontal space,
theory, the tissue around the developing end of the root
being incompressable, prevents major displacement of
is highly vascular. This vascular pressure is believed to
the loolh within the socket. Therefore the forces arc
cause the axial movement of the teeth.
transmitted through the tissue fluids to the adjacent
B) Root growth ; According to the proponents of
alveolar bone. Recent studies hove shown that the
this theory, the apical growth of roots results in an
alveolar bone can bend in response to heavy
axially directed force that brings about the eruption of
masticatory forces.
the teeth. This theory has not been accepted for a
Whenever the forces of mastication are
number of reosons. Teeth move a greater distance
sustained and are more than the usual one second
during eruption than the increase in root length. In
cycle, the periodontal fluid is squeezed out ond a pain
oddition, the onset of root growth ond eruption do not
is felt as the the tooth is displaced into the periodontal
seem to coincide. Teeth that are malformed and lack
ligament space.
roots also erupt in a number of cases. HISTOLOGY OF TOOTH MOVEMENT
Q Hammock ligament: According to Sicher, a band
When force is applied on a tooth to bring about
of fibrous tissue exists below the root apex spanning
orthodontic movement, it results ir -ornrat'on of areas
from one side of the alveolar wall to the other. This
of pressure ond "ension around the tooth. Areas of
fibrous tissue appears to form o network below the
pressure are formed in 'he direction of the tooth
developing root and is rich in fluid droplets. The
movement, while ceas of tension form in the ooposi'e
developing root forces itself against this band of tissue,
which in turn opplies an occlusally directed force on the
Bone is a living tissue which rcacts to
oressure and tens'en in a certain denned manner.
D) Periodontal ligament traction : This theory
Bone surface subjected to pressure reacts by bone
states that the periodontal ligament is rich in fibroblasts
'esorption while bone subjected to -ension exhibits
that contain contractile tissue. The contraction of these deposition.
periodontal fibers (mainly the oblique group of fibers) When a tooth is moved due to application of
results in axial movement of the tooth. an orthodontic force, there is bone resorption on the
Migration or drift of teeth
oressure sice and new bone -'ormation on the s'de of
Migration refers to the minor changes in tooth position tension.
observed after eruption of teeth. It is generally beleived The hYologic chcrgesseen during tooth
that the direction of tooth migration vanes from species movement (fig 1) vary according to tho amount and
to species. The human dentition shows a natural duration of fo-ce appl:ed. The histologic changes seen
tendency to move in a mesial and occlusal direction. during tooth movement can be studied under two
This is largely true in case of the maxillary dentition. neadings as :
However the lower jaw could show certain variations. 1) Changes following cpplico'ion of mild force.
Tooth migration is usually a result of proximal anc 2) Charges following application of extreme force.
occlusal wear of teeth. As the teeth undergo occlusal Changes following application of
and proximol wear, they move in a mesial and occlusal mild force
direction to maintain inter-proximal ond occlusal When a force is applied to a tooth, areas cf pressure
contact. and tension are produced.

Tooth movement during mastication Changes on pressure side : The periodcrlol ligament in
the direction of the tooth movement gets compressed
During mastication, the teeth and periodontal
to almost l/3rd of its original thickness. A marked
structures are subjected to intermittent heavy forces
increase in the vascularity of periodontal ligament on Changes on tension s.:a'e : The arec of the tooth
Biology of Tooth Movement 183 ,
this side is cbsen/ed due to increase in capillary blood opposite to tne direction of force is colled -he tension
supply. This increase in blood supply helps in side. On application of orthocomic orce, the
mobilization of cells such as fibroblasts and periodontal membrane on the tension side gets
osteoclasts. stretched. Thus the distance between the o veolar
Osteoclasts are bone resorbing cells that process and the toctn is widened.
line up along the socket wall on the pressure side. In addition to stretching of the periodontal
They lie within shallow depressions ir bone ca 'ed fibers, a raised vascularity is seen on the tens:on sice
Howship's lacunae. A change in orientation of the bor y just as on Ihe pressure side. Tne raised vascularity
trabeculae is seen several weeks after continued causes mobilization of cells such as fibrobias-s and
orthodontic force application. Tne trabeculae which osteoblasts in this area. In response lo th's traction,
are usually oarallel to Ihe long axis of the teeth become osteoid is laid down by osteoblasts in the periodontal
norizontc; y oriented i.e. pcrallel 'o the direction of ligoment immediately odjacent to the lamino dura, "his

orthodontic force. The trabecular oattern revers bock lightly calcified bone in cue course of time matures to

to rcrmal pattern during re'ention phase of the form woven bone.

treatment. Secondary rcmode.'irjg changes ; Whenever a force is

The osteoclcsts that lie within Howship's applied to move teeth, the bone immediately adjacent
locunce start resorb'ng bone. When the forces applied shows osteoclastic ond osteoblastic activity on tne
are within physio ogic limits, the 'esorp^on is seen in pressure and tension side respect'vely. Ir addi*ior,
the alveolar plate immediately aciacent to the bony changes also take place elsewhere to-mc'ntcin
ligament. This kind o resoration is cal ed fror.'al the width or thickness of the alveolar bone. These
resorotion. changes are called secondary remodeling changes (fig
2). For example, if a tooth is being moved in a abial
184 Orthodontics - The Art and Science


ation of
Tension Pressure
Side Side

Application of
forces Periodontal Ligament Dentin

z •; Bone resorption

Pulp ; Cementum

Bone deposition

Fig I Histology oi looti -novemert

Biology of Tooth Movement 185 ,

5 2 (A Secondary rcmode ing changes seen following the application of a bodily fo'ce in o lirguol direction r Secondary remodeling cHangos
seen following fhe application o; o lipo'ng ?orce in o linguol direction

direction there is compensatory deposition of new resorption occurs in the adjacent marrow spoces and
bone on the outer side of the labial olveolar bony pfate in the alveolar plate below, behind and above the
and also a compensator/ resorption on the ngual side hyalinized zones. This kind of resorption is called
of the lingual alveolar bone (fig 2). "«nese undermining or rearword resorption.
compensatory structural alterations maintain •^e On the tension side, the periodontal ligament
thickness of the supporting alveolar process »ren gets over-stretched leading to tearing of the blood
though the tooth may be moved over a r stance vessels and ischemia.
several times greater than the thickness :f the alveolar Thus when extreme force is applied there is
bony plates. a net increase in osteoclastic activity os compared to
bone formation with the result that the tooth becomes
Changes following application of
loosened in its socket.
extreme forces
In addition, pain and hyperemia of the
Whenever extreme forces are applied to teeth, it Its in
gingiva may occur due to application of extreme forces
crushing or totol compression of the Jontal ligament.
during orthodontic tooth movement.
On the pressure side, the "cot closely approximates
the lamina dura, compresses the periodontal ligament OPTIMUM ORTHODONTIC FORCE
and leads t> occlusion of the blood vessels. The
ligament s hence deprived of its nutritional supply Optimum orthodontic force is one which moves teeth

leading ■o regressive changes called hyolinizalion. most rapidly in the desired direction, with the least

In this case, the bone cannot resorb in ■Se possible damage to tissue and with minimum patient

fronlol portion adjacent to the teeth. Rather bone discomfort.

186 Orthodontics - The Art and Science

Oppenheim and Schvvarz following 3] The compressed collagenous fibers graduc f j

extensive studies slate that the optimum force is unite into a more or less cell free mass.
equivalent to the capillary pulse pressure which is 4] In addition certain changes olso occur in the
20-26 cm/ sq. cm of root surface areo. From a clinical ground substance.
point of view, optimum orthodontic force has the 5) There is a breakdown of the blood vessel v.'Ci
following characteristics : leading to spilling of their contents.
a. Produces rapid tooth movement 6) Osteoclasts are formed in marrow spaces arc

b. Minimal patient discomfort adjccenl areas of Ihe inner bone surface afre- a

c. The iag phase of tooth movement is minimal period of 20>30 hours.

d. No marked mobility of the teem being moved The presence of a hyalinized zone indicates

From a histologic point of view Ihe use of that the ligament is non-functional ar.0 therefore bone
resorption cannot occur The tooth is hence not
optimum orthodontic force has the following
capable of further movement until the local damaged
characteristics ;
tissue has been removed and tne adjacent alveolar
a. The vitality of the tootn and supporting periodontal
bone wall resorbs.
ligament is maintained
The elimination of hyalinized tissue occurs
b. Initiates maximum cellular response
by two mechanisms.
c. Produces direct or frontal resorption
1) Resorption of the alveolar bone by osteoclasts
HYALlNiZATlON differentiating in the peripheral intact periodontal
rnembronc and in odjocent marrow spaces.
Hyalinization is a form of tissue degeneration 2) Invosion of cells and blood vessels from the
characterized byformationofa clear, eosinophilic periphery of the compressed zone by which the
homogenous substance. This hyalinization can occur necrotic tissue is removed. The invoding cells
in organs such as kidneys, lungs, etc.,. Hyalinization of penetrate the hyalinized tissue and eliminote the
the periodontal ligament denotes a comoressed and unwonted fibrous tissue by enzymatic action and
locally degenerated periodontal ligoment. phagocytosis.
The conventional pathologic process of Greater the forces, the wider is Ihe area of
hyalinization is on irreversible one, however, hyalinization. Thus larger areas of the ligament
hyalinization of the periodontal ligament is a reversible become functionlcss, thereby showing large areos of
process. reorvard resorption. If lighter forces ore used, the
Experimental evidences show that hyalinized zones are smaller and a larger area of
hyalinization of the periodontal ligament on the functioning ligament is available. This frontal
pressure side occurs in some areas during almost all resorption predominates in case lighter forces are
forms of orthodontic tooth movement. But the areas used.
are wider when the force applied is extreme. The location and the extent of the hyclinized
The changes observed during formation of tissue largly depends upon the nature of tooth
hyalinized zones are as follows : movement (fig 3). In case of tipping tooth
1) There is a gradual shrinkage of periodontal
ligament fibers.
2) The cellular structures become indistinct.
Some nuclei become srnoller (pycnotic) whie
some nuclei disappear.

c 3 Areas of hycl:nizaHon during foo>h movemert.fA) Tipping tooth move me n- causes hyalinizalion close -o -he alveolor I Tbyirg v.rh excessive
forces 'esult in two areas of hyol'nization. one in the cpical region arc tnc ot'ner in the jincl ores. |C) Bodily foolh movement results in
hyaliniza'ion closer 'o the middle portion of "he rod

/ement, the hyalinization would be close to t-e alveolar the same extent during this initial phase of tooth
crest while in case of bodily tooth jment it would be movement.
closer to the middle portion r-he root. Whenever The tooth movement in the initial phase is
excessive forces are cppl'ed ing tipping tooth between 0.4 to 0.9 mm and usually occurs in a week's
movement, it can result in 8wo areas of hyalinizalion, time.
one in the apical region the other in the marginal area.
Lag Phase
The form and outline of the adjacent [areolar bone
also plays a role in location of :!inized areas. Areas of During this phase, little or no tooth movement occurs.

bony prominences or jles usually result in areas of This phase is characlerized by formation of hyalinized

hyalinizalion. tissue in the periodontal ligament which has to be

resorbed before further tooth

lies have shown thot tooth movement jesses

through three stages (fig 4). Burstone jories the sieges
as : Initial phase r Lag phose i 3ost lag phase
initial phase
During the initial phase, very rapid tooth movement is
observed over a short distance which then stops. This
movement represents displacement of the tooth in the
periodontal membrane space and'probably bending of
alveolar bone to a certain extent. Studies have shown
thct both light and heavy forces displace the tooth lo
movement can occur. The duration of the lag phase
Pressure tension theory

depends on the amount of force used to move the Oppenheim in 1911 was the first person lo study the
188 are
tooth. If light forces Orthodontics - The
used, the area of Art and Science
hyalinization tissue changes in the bone incident to orthodontic tooth
is small and frontal resorption occurs. If heavy forces movement. Schwarz (1932} is so id to be the author of
are used, the area of hyalinization is large. Resorption this theory. According to

2mm Undermining Frontal

Resorption Resorption

1 mm

f Initial phasa Lag phase

Fig 4 Graph showing phoses of tooth movement.

in this case is rearward and a longer lag period occurs

to eliminate Ihe hyalinized tissue.
Post lag phase

The lag phase usually extends for 2-3 weeks

but may at times be as long as 10 weeks. The duration
of the lag phase depends upon a varied number of
factors including the density of alveolar bone, age of
the patient and the extent of the hyalinized tissue.

Post tag phase

After the lag phase, tooth movement progresses
rapidly as the hyalinized zone is removed and bone
undergoes resorption. During this post lag period,
osteoclasts are found over a large surface area
resulting in direct resorption of bony surface facing the
periodontal ligament.


The mechanism of movement of a tooth by an

orthodontic force is a subject of ongoing research for
decades. Numerous theories have been put forward to
explain the same. The theories thot are accepted and
have stood the test of time are

1} Pressure tension theory by Schwarz 2}

Blood flow theory by Bien 3) Bone bending
Schwarz, whenever a tooth is subjected to an Bone bending and pehroe/ectr/c f/teo- rles of
orthodontic force, it results in areas of pressure end tooth movement
tension. The area of the periodontium in the Erection of A century ago, Farrar (1876) first noted deformation or
Biology of Tooth Movement 189
tooth movement is under pressure -hile the area of bending of interseptal alveolar walls. He was the first to
periodontium opposite the tooth -ovement is under suggest that bone bending maybe o possible
tension. According to him, —e areas of pressure show mechanism for bringing about tooth movement.
bone resorption while rr'eas of tension show bone Piezoelectricity is a phenomenon observed
deposition. in many crystalline materials in which a deformation of
the crystal structure produces a flow of electric current
Fluid dynamic theory
as a result of displacement of electrons from one part
~-'s theory is also called the blood flow theory as of the crystal lattice to the other. A small electric current
coposed by Bien. According to this theory, tooth is generated when bone is mechanically deformed.
-ovement occurs os a result of alterations in fluid The possible sources of the electric current are :
rynamics in the periodontal ligament. The iodontol
a. Co/fagen : In bone, collagen exists in a crystallized
ligament occupies the periodontal ircce which is
state ond can thus be a source of piezoelectricity
confined between two hard tissues -amely the toolh
when deformed.
ond Ihe alveolar socket. The :eriodontal space
contains a fluid system made JO of interstitial fluid, b. Hydroxy apa tr'te : It also is crystalline in form and

cellular elements, blood vessels and viscous ground therefore can produce electricity when deformed.
substance in addition -c *he periodontal fibers. If is a
confined space r~d the passage of fluid in and out of c. Coliagcn-hydroxyapottte interface : The

this space s 'imifed. The contents of the periodontal junction between the collagen and hydroxyapatite

icament thus creates a unique hydrodynamic lition crystals when bent can be o

resembling a hydraulic mechanism and r shock

absorber. When the force is removed, -"•e fluid is
replenished by diffusion from capillary •c'ls and
recirculation of the interstitial fluid. Aren the force
apolied is of short duration such s during mastication,
the fluid in the periodontal rrcce is replenished as soon
as Ihe force is -=snoved. But when a force of greater
magnitude md duration is applied such as during
orthodontic ■roth movement, the interstitial fluid in the
r-eriodontal space gets squeezed out and moves
"chords the apex and cervical margins and results r
decreased tooth movement. This is called Ihe scueeze
film effect' by Bien.
When an orthodonticforce is applied, it i?sults
in compression of the periodontal ligament.
Blood vessels of the periodontal ligament get trapped
between the principal fibers and this results in their
stenosis. The vessel above the stenosis then balloons
resulting in formation of an aneurysm'. These
aneurysms are minute flexible walled sacs of fluid.
Bien suggest that there is an alteration in the
chemical environment at the site of the vascular
stenosis due to a decreased oxygen level in the
compressed areas as compared to the tension side.
The formation of these aneurysms and vasculor
stenosis causes blood gases to escope into the
interstitial fluid thereby creating a favorable local
environment for resorption.
source of piezoelectricity.
190 f d. The mucopolysaccharide fraction of the ground
commited osteoprogenitor cells. Whenever there is a
stress or strain due to orthodontic force, these
substance Orthodontics
although - The
not crystalline may Art
alsoand Science
osteoprogenitor cells undergo increase in nuclear
possess the ability to generate electric current volume and form the G1 stage preosteobiasts. With
when deformed. further DNA synthesis the G1 stage preosteobiasts
When a crystal structure is deformed, transform into G2 stage preosteobiasts. As a final step
electrons migrate from one location to another the G2 stage preosleoblasts undergo mitosis and form
resulting in an electric charge. As long as the force is the osteoblasts or bone forming cells.
maintained, the crystal structure is stable and no The bone formed posses through three
further electric effect is observed. When the force is stoges. They are the osteoid, bundle bone and the
released the crystals return to their original shape and lamellated bone. The new bone formed by the
a reverse flow of electrons is observed. This rhythmic osteoblasts is the osteoid which is lightly calcified. As
activity produces a constant interplay of electric more and more osteoid is formed the deeper layers
signals whereas occasional application and release of undergo more calcification and form the bundle bone.
force produces occasional electric signals. The fibers of tne periodontal apparatus also get
Piezoelectric signals have two unusual characteristics attached to the bundle bone. When the bunndle bone
: reaches a certain maturity, parts of it get reorganized
into moture lamellated bone.
a. Quick decay rate: When a force is applied, a
piezoelectric signal is produced. This electric charge Osteoid tissue, deposited on the tension side,

quickly dies away to zero even though the force is gels calcified resulting in the formation of

b. When the force is releosed, electron flow in the
opposite direction is seen.
On application of a force on a tooth, the
adjacent alveolar bone bends. Areas of concavity in
bone are associated witn negative charges and evoke
bone deposition. Areas of convexity are associated
with positive charges and evoke bone resorption.
When a force is opplied, compression of the
alveolar wall occurs resulting in the alveolar and
medullary cortical plates of bone being moved closer
together. In this manner, the bone becomes less
concove ond an electric signal associated with
resorption is established.

Bone formative cnanges are observed on t tension

side. As a forerunner to the process bone deposition,
there seems to be on increa in tne number of
osteoblasts which are the bo forming cells. They are
ovoid cells with basophil" cytoplasm and have an oval
nucleus. They lie against the bone surface where
active bone formation is in progress i.e. periosteum .
endosteum and help in the formation of Ihe organic
matrix and also control Ihe deposition o* mineral soils.
Osteoblasts increase in number by proliferation of their
precursor cells (fig 5).
The osteoblasts are derived from
paravascular connective tissue cells, closely
associated with the blood vessels. These precursor
cells undergo mitosis and DNA synthesis and form the
of Tooth

precursor cells

Gt Stage


G2 Sage



Fig 5 Summary o osteoblast nistogenesis.

182 /' Orthodontics ■ The Art and Science

bone lamellae. The and resorption. However, tnecha that occur at the
periodontal fibers readapt to the new position of the cellular level in response to force arc not totally
tooth by proliferation of the intermediate zone. understood.
When a force is applied onto a tooth, results
BONE RESORPTION in a number of biophysical events such compression
of periodontal ligament, bone deformation and tissue
Bone resorption is brought about by cells called
injury. These biophysicc events in turn lead to certain
osteoclasts. They are multi-nucleated giant cells and
biochemicc reactions at o cellular level which bring
may have 12 or more nuclei. Osteoclasts are
abc bone remodeling. Tnus a process of transductio-
irregularly oval or club shaped with branching
occurs where mechanical energy (orthodontic force) is
processes. They occur in bay like depressions in bone
converted into a cellular response.
called Howship's lacunae and have prominent
Bone deformation and compression & the
mitochondria, lysosomes and vacuoles. Each of their
periodontal ligament leads to the release a- some
nucloi has a single nucleolus. The port of the
extra-cellular signaling molecules called tirr
osteoclast in contact with the resorbing bone has a
messengers. They include hormones such as PTH,
ruffled border. The osteoclasts are derived from :
local chemical mediators such as prostaglandins and
a. Activation of previously present inactive neurotransmitters such as substance P one
osteoclasts. vasoactive intestinal polypeptide (VIP).
b. Migration from adjacent bone. The first messengers bind to receptors
c. Formation of new osteoclasts from local present on the cell surface of target cells and initiate a
macrophages of periodontal ligament. process of intra-cellular signaling. The intra-cellular
d. Influx of monocytes from blood vessels. signalling results in formation of second messengers,

During bone resorption three processes which include cyclic amp, cyclic gmp and calcium.
The formation of second messengers inside
occur in more or less rapid succession. They are:
the cclls is believed to initiate formation of bone cells
1) Decalcification
namely osteoclasts and osteoblasts which are
2) Degradation of matrix
responsible lor bone remodeling.
3) Transport of soluble products to the extracellular
An alternative biologic pathway for
fluid or blood vascular system.
orthodontic tooth movement has been suggested by
Organic acids such as citric acid, ond lactic
some workers. According lo them, orlhodonlic force
acid and hydrogen ions are secreted by Ihe ruffled
results in certain amount of tissue injury.
border of the osteoclasts which increases the solubility
Subsequently, hydrolytic enzymes are released
of hydroxyapatite leading to decalcification.
The degradation of the matrix is brought about by the
activity of Cothepsin B-l (lysosomal acid protease).
Finally, the breakdown products of bone are
transported to the extracellular fluid and blood
vascular system.

It is known that bone cells i.e. osteoclasts

osteoblasts respond to an orthodontic force
proliferation in order to bring about b deposition

Biology of Tooth Movement 193

Summary of Biochemical Reactions

Orthodontic Force

194 Orthodontics - The Art and Science

Orthodontic Tooth Movement

which activote enzyme collagenose that contributes to
bone resorption.

of Tboth


E Mecnamcs

very body continues in its state of rest or of uniform motion

in a straight line, unless it is compelled to change that state
by forces mpressed upon it (Sir Isaac Newton) - and teeth
are no exception.
Physics, Mathematics and Engineering ere 3
importantdisciplines thotcan effectively be applied to the
study of orthodontic tooth movement.
Mechanics is defined as that branch of
engineering science that describes the effect of force on a
body. A cleor understanding of the •heories of mechanics
have potential applications in 3 areas:
1. Precise application of forces.
2. A better understanding of clinical and histological
response to various magnitudes of force.
3. Improving the design of orthodontic appliances.
The response of a tooth to an applied force can
be at 3 levels i.e. clinical, cellular and stress-stroin level of
activity within the investing tissues which is the least
understood. There exist no stress-strain gauges, at
present, which can be placed within the periodontium to
evaluate the stress-strain activity. Therefore, the
importance of the study of mechanics cannot be over-
emphasized as olmost all the assumptions made about the
stress-strain activity in the periodontium are based on
several mathematical formulations and conclusions.
Fora better understanding of mechanics one
should be familiar with the terminology used.
Force can be delined as an act upon a body that calculation, this point can ae taken cs the point where
changes or tends to change the state of rest or of the whole body weigh* is concentrated and can be
uniform motion Orthodontics
of that - Theforce
body. Being a vector, Art has
anda Science
termec centre of gravity.
definite magnitude, a specific direction and o point of However, teeth cannot move in a free
application. In clinical practice it is eithor a 'pusn' or a 'Pjll. manner within the jaws. They are restricted by the
In •he metric system Ihe unit of force is expressed in investing tissues around rheir roots. In such a situation,
'grams. a point analogous to the centre of gravity is mace use
Orthodontic correction is based on application of of and is called the centre of resistance.
aopropriate force on the teeth .Tne forces are generated Centre of resistance of a tooth can be
by a variety of ortnodontic cppliances. denned as that point on the tootn when a single forcc is
passed through it, would bring about its translation
alone the line of action cf the force.
Generally the centre of resistance of a tooth
Stress is tne force applied per unit area while strain can be
is constant. In a single-rooted tooth it lies between one
defined as the internal distortion per unit area.
third and one half of the roo*, cpical to Ihe alveolar
Stress and strain are inre'-related terms as
crest while in a multi-rooted tooth the centre of
stress is an externcl fcrcc acring upon a booy while strain
resistance lies between the roots, 1 - 7 mm apical to
is the resultant of stress on that body. Strain can be
rhe furcation {fig 2). The centre of resistance exis's for
expressed in tne form of a change in either the external
single tooth, units of tooth, the entire dentoi arch and
dimension or internal energy of the body.
the jaws. Knowing the Ideation of the centre of
50 Grams
resistance is thus very important in planning
appropriate mechanotherapy.
Two factors which can change the position
"of Ihe centre of resistance are the root length and
alveolar bone neighl. Longer the root, the centre of
10 mm resistance will be placed more

Couple is c pair of concentrated forces havin; equal

magnitude and opposite direction wi parallel but
non-collinear line of action (fig 1).
A couple when ccting upon a body bring; a bot t
pure rotation.


A Every body or tree objec:

Fig 1 »A) Couple two forces of same magnitude, parallel to each

otnc and acting h opposite direction. |3) Clinicol aaplica'ion or a
C C U J B in treatment of rotators

behaves as if its mass is concentrated a* a single point on

which it ccn be perfectly balanced. For physical
h 2 Certre o- 'esistcncc cf
magnitude o*' force and the distance from the centre of
resistance (fig 4). Eithe' one of these two variables can
be manipulated to produce the desired force systems.
Mechanics of Tooth Movement

mu'tirooted end sirg'e -cotec teeth

Fig 4 Moment is calculated by ruhiplying lie mogiitjde of
Rg 3 Certre o; resistance force by tie psrperdicula' distance of the lire cf action to ihe
rfluenced by the alveola' rone cen ire of resistance
height and the rool length. (A)
Normal clvsola' sone (B) Alveo cr
bone loss resu'fs in oplccl shift of CENTRE OF ROTATION
cen're r* ' (Q -oot 'csorption and shorening results in —ore
corona centre of
Centre of rolotion is a point, obout which o body
appears to hove rotated, as determined from its initial
and final positions.
apically. Likewise if
The centre of rotation is a voriable point and
the olveolor crest is
changes according to the type of tooth movement. It
higher, -he centre of
can be at any position on or off
resistance will be
placed rrore
coronally (fig 3)
Similarly the
morphology and ■he
number of roots also influence Ihe location of •fie centre of


Moment can be defined as the measure of rotational

potential of a force with respect to a specific axis.
Orthodontic forces are most commonly applied at the level
of the crowns of the teeth. Therefore the forces are
seldom applied through the centre of resis'ance of the
crowns. Thus these forces not only produce a lineor
motion, they also produce a rotation. Tne moment of the
force is therefore the tendency for a force to produce
Moment = Magnitude of force xdistorice
(perpendiculor distonce from *he centre o resis'ance of the
body *o *he line of action of Ihe force). The unit of
measurement of moment is gram millimeters. The two
variables that determine Ihe moment of force ore the
Fig 5 Centre o* ro-ction (AJ A' ihe incisat edge
during torqung \B) At tne rcot acex dur'ng
controlled tipping (Cj Away from the root epcx
curing jncort'olled tpping (D) Outside the roorh
djriny intrusion o' extrusion

the tooth (fig 5).

E.g. In case of controlled crown tipping, the
centre of rotation will be at the root apex while in case
of a perfect translation it will be at infinity.
In clinical practice, the tooth usually follows
an irregular path to reach its final position, thus
changing the centre of rotation several times.


Tipping is a simple type of tooth movement where a
single force is applied to the crown which results in
The prime motive of orthodontic treatment is to move
movement of Ihe crown in the direction of tne force and
the teeth into more favorable and corrected positions.
the root in the opposite direction. Tipping is considered
In the process of achieving this goal, the teeth undergo
to be the simplest among the tooth movements. It can
a variety of movements in all the 3 planes of space i.e.
be of two types :
sagittal, coronal and transverse. Tooth movements
within the oral cavity can be listed as follows :
1. Tipping
2. Bodily movement
3. Intrusion
4. Extrusion
5. Torquing
6. U prig h ting

Controlled Tipping : Controlled tipping of o tooth centre of resistance of a tooth. Pure translation con be
occurs when o tooth tios about a centre of rotation at its of three types:
apex. Here there is a lingual movement of the crown with Mechamcs of Tooth Movement 189
minimal movement of the root in labial direction. 1. Intrusion
Uncontrolled tipping : Uncontrolled tipping of a tooth 2. Extrusion
describes the movement of a tooth that occurs about o 3. Bodily movement (mesio-distal, labio- lingual)
centre of rotation apical to ond very close to the centre of
Pure rotation
resistance. It is characterized by the crown moving in one
direction while the root moves in the opposite direction. A displacement of the body, produced by a couple,
characterized by the centre of rotation coinciding with
Bodily movement the centre of resistance i.e. the movement of points of
the line of action of an applied force passes trough the the tooth along the area of a circle, with the centre of
centre of resistance of a tooth, all the coints on the tooth resistance being the centre of fhe circle. Pure rotations
will move an equal distance in the same direction con be divided into 2 types :
signifying a bodily displacement. This is called translation. Transverse Rotation : Those tooth displacements
during which the long-axis orientation changes. E.g.
Tipping and torouing. Long-axis rotation : Here the
Intrusion is the bodily displacement of a tooth along its angulation of the long-axis is not altered. E.g. Rotation
long axis in an apical direction. of a tooth around its long axis.

Extrusion Generalized rotation

Extrusion is the bodily displacement of o tooth clong its
Any movement thai is not pure translation or rotation
long axis in an occlusal direction.
can be described os a combination of

'otations ore labial or lingual movements of o tooth around
its long axis.

lorquing can be considered os a reverse tipping
characterized by lingual movement of the root.

During orthodontic treatment, the crowns of certain teeth
will be tipped in a mesio-distal direction with -He roots
tipped in the opposite way. Tipping these roots back *o get
a parallel orientation is termed uprighting.
Although these are the commonly encountered
movements within the oral cavity, in a more scientific
approach the tooth movements can be classified basically
into three :
1. Pure translation
2. Pure Rotation
3. Generalized Rotation

Pure translation
It occurs when all points on tne tooth move an equal
distance in the same direction. This is brought about when
the line of action of an applied force passes through the

Fig 6 Types
of loolh move men- (A} Uncontrolled tipping S3) Controlled tipping <C| Trans ot on (D; Torqjing i[) Upiighing (G) Intrusion (H) fx-rusian
[F! Rota I or
Interrupted Force


Fig 7 Grooh showing tne d fferent types force

roth translation and rotation end can be termed the activation must be done to a relatively low force level.
:eneralized rotation. This type of movement can re This is because continuous forces are expected to bring
seen during routine clinical practice. about direct resorption of the root socket. They should
hence not occludc more than a small percentage of blood
vessels within the periodontal ligament and not

As is well-stated by the pioneers in Ihe subjecr, if substantially interfere with their nutritional supply.

-olocclusion is the disease in orthodontics, force s Moreover, Ihe continuous force cycle includes no 'rest

definitely its medicine. It is therefore very '-loortant for period'ond little interference with normal biologic

the clinician to use his knowledge r-d experience in functioning within the soft tissue can be tolerated.

determining the type, amount rid direction of force

/ntorm/ttent force
required to bring about ■efficient treatment results.
8ased on the d u roti on of application, It is an active orthodontic force that decays to zero

-orce con be divided into : '. Continuous force magnitude or nearly so prior to the next appointment. E.g.

2. Intermittent force Removable active plates.

3. Interrupted force For an appliance to deliver intermittent force,

the appliance components should have high stiffness and
Continuous force the initio I activation should be twice
- is an active orthodontic force that decreases
- e in magnitude between appointment periods.
E.g. Light wire appliance.
For an appliance to deliver continuous force,
the appliance components should be highly flexible and

the expected corresponding soft-tissue deformation.
Due to a relatively high activation, a greater force is
exerted on the Orthodontics
This leads to- The Art and
undermining Science
resorption and corresponding tooth movement. Once
the tooth has moved, the force will decay considerably
so that repair of the necrosed soft tissue and
resumption of blood supply occurs within the

Interrupted force
Il is on orthodontic or orthooeadic force that is inactive
for intervals of time between appointments. It often
exhibits, cyclic, long-term magnitude-time pattern, e.g.
Force exerted by an exlra-oral appliance worn only at
For an interrupted force lo be delivered, the
pro-requisites include:
a. It should deliver heavy forces.
b. There should not be any force decay.
c. There should be a specific magnitude-time pattern
for example, 200 - 300 gms of force 10-14 hours a
d. The inactive period of each day must be sufficient
to keep the periodontal ligament healthy over the
total period of time of use of the appliance.
Thinking in tne normal way, it might occur to
us that a continuous forcc may bring about a
continuous movement or an increased force may lead
to an increased tooth movement. But, tnese
assumptions ore far from reality both in the clinical and
cellular context. The rate of tooth movement is highly
dependent upon the complex biologic responses to the
various types of forces which are yet to be clearly

.More ; The terms interrupted ond jntermrffent

forces are interpreted in different ways by
different authors. The above menf/oried description
is based on Robert J. Nikolai's description of the
ooth movement during orthodontic therapy is

T brought about by forces generated by the

active components of an
ropliance. The force used to move teeth is derived

~om certain anatomic areas which act as cnchors.

According to Newton's third law of r-otion, for every
action there is an equal and coposite reaction. In
accordance with this law, forces used to move teeth
may induce an equal and opposite force on the
anchorage units -«ending to cause their movement
which is not Desirable. The resistance that the
anchorage areas r*er to these unwanted tooth
movements is called ' cnchorage.
Graber has defined anchorage in r'thodontics as
the nature and degree of ••sistance to displacement
offered by an anatomic .nit for Ihe purpose of effecting
tooth movement. According to White and Gardiner,
'Anchorage is —e site of delivery from which a force is

Anchorage during orthodontic therapy is mainly

obtained from two sources.
1] Intra-orol sources
2] Extra-oral sources

tntra-oral sources
The intraoral sources of onchoroge include the teeth,
alveolar bone, the basal jaw bone, and the

The teeth : Whenever some teeth are moved

orthodonlically, the remaining teeth of the oral cavity
can act as anchorage or resistance units. This is due lo
the fact that the teeth themselves can resist movement.

2?3 The anchorage potential of teeth depends on a number

of factors such as root form, root size, number of roots,
root length ond root inclination.
J. Roof iorm : The anchorage potential of a tooth Extraorat sources
depends largely on its root form. Cross sections of Certain extraoral areas can be utilized as sources of
roots can be of threeOrthodontics
types; round, flat -and
The Art and Science
triangular. anchoroge TO bring about orthodontic or orthopaedic
Round roots as seen in bicuspids and palatal root of changes. They are mainly used when adequate
maxillary molars can resist horizontally directed forces resistance cannot be obtained from intraoral sources for
in any direction. Flat roots, for example those of the purpose of anchorage. The extraoral sources of
mandibular incisors and molars and the buccal roots of anchorage include the cranium, the back of the neck and
maxillary molars, can resist movements in the the facial bones.
mesio-distal direction but have little resistance to Cranium (occipital or parietal anchorage):
movement on Ihe thin edges found on thoir buccal and Extrooral anchorage can be obtained by using head
lingual sides. Triangular roots of canines ond maxillory gears that derive anchorcge from the occipital or parietal
control and lateral incisors offer the maximum region of the cranium. These devices are used along with
resistance to displacement compared to round or flat o face bow to restrict maxillary growth or to move the
root forms.
dentition or maxillary bone distally.
2. Size and number of roote : Multirooted teeth with
Back of the neck (cervical anchoroge) : Extraoral
large roots have a greater ability to withstand stress
anchorage can alternatively be obtained from the neck or
than single rooled teeth.
cervical region. Such a type of head gear is called
3. Root length : In physiologic conditions, the root
cervical head gear.
length indicates the depth to which the tooth is
embedded in bone. The longer the root, the deeper it is
embedded in bone and the greoleris its resistance to
4. inclination of tooth : The axial inclination of a
tooth is important in assessing its value os a source of
anchorage. A greater resistance to displacement is
offered when the force exerted to move teeth is
opposite lo that of their axial inclination.
5. Anfcyfosed teeth : Ankylosed teeth are directly fixed
to the alveolar bone and hence lack a periodontal
ligament. Orthodontic movement of such teeth is not
possible and they can therefore serve as excellent
anchors whenever possible.

Atveolor bone : The alveolar bone that surrounds a

tooth offers resistance to tooth movement upto a
certain amount of force. When the force applied
exceeds a certain limit, the alveolar bone permits tooth
movement by bone
Basa/ bone : Certain areas of the baso I j bones are
available intraorally as sources anchorage. These
areas include the hard palcre and the lingual surface of
the mandible in the region of the roots. These intraoral
hard areas basal bone can be used to augment
intramaxillcr. or inter-maxillary anchorage.

Muscu/oture : The normal tonus of the fade and

masticatory muscles plays an important ro!e in the
normal development of dental arches Abnormal
hypotonic musculoture causes florinc ana spacing of
teeth while hypertonic muscles exert restrictive forces
in a lingual direction. Dentc anchorage may be
increased by making use o: hypertonic lobiol
musculature as in the case of c lip bumper.
According lo the manner of force application : are to be moved within the
1) Sirrple anchorage same dental arch (fig 1).
2) Stationary anchorage
The combined root surface
3) Reciprocal a^orage According to
area of the teeth forming the anchorage unit must be
|aws Involved :
double that of the leelh lo be moved. Thus the
1) htramaxillary
2) Intermaxillary resistance offered by the qgchorage unit is greater
According to the site of anchorage: than that offered by the tooth or te$j> being moved. An
1) Intraoral example of simple anchorage -is given in fig 5, ' where
2} Extraoral : a pa lata I ly placed premolar is pushed bucally with
A. Cervical
the rest of the leelh in Ihe dental arch' as Ihe anchor
B. Occipital
C. Cranial
D. Facial
Stationary anchorage
3) Muscular
According to the number of anchorage unils : II is defined as dental anchorage in which the manner
t) Single or primary anchorage & application of force lends to disploce the anchorage
Compound anchorage unit bodily in the plane of space in which the force is
Multiple or reinforced anchorage
being applied. The anchorage provided by a tooth
resisting bodily movement is considerably greater than
ocia/ bones : The frontal bone and the -randibular one resisting tipping force.
symphysis offer anchorage during face -^ask therapy
in order to protract the maxillo. Head gears that makes Reciprocal anchorage
use of anchorage from •he foreheod and chin are The term generally refers to the resistance offered by
colled reverse -!eadgears. two malposed units when the dissipation of equal and
Simple anchorage
opposite forces tends to move each Unit towards a
It is defined as dental anchorage in which the more normol occlusion. Here two teeth or two groups
manner & application of force is such that it tends to of teeth of equal anchorage value are made to move in
change the axial inclination of the tooth or teeth that opposite directions. Examples of reciprocal anchorage
include closure

Fig 1 Simple onchorage - removable cppliance incorpomting n screw

for buccal movement of a pala fa II y placed premolar

if form the anchorage unit in the plane of space in

which the force is being applied. Thus the resistance
of the anchorage unit to tipping is utilized to move
another tooth or teeth.
Simple anchorage is obtained by engaging
with the appliance a greater number of teeth than
Fig 2 Reciprocal anchorage : (A) Correction o: midline diastema elastics. \B) Finger springs used to close c midline
diastema (C) Cioss bi'e elastics to' correction of single tooth posterior cross brc. (D) Arch expansion using a
removable app'.iance incorporating a Coffin spring

of a midline diastema by moving the two central incisors towards each otner. The use of crossbite elastics and
dental arch expansion ore other examples of reciprocal anchorage (fig 2).

Intraoral anchorage
Anchorage in which all the resistance units are situated within the oral cavity is termed intraoral anchorage. The
teeth to be moved ond the anatomic areas that offer anchorage are all within the oral cavity. Various intraoral
anatomic units that maybe employed are the teeth, palate and lingual alveolar bone of mandible.

Extraoral anchorage
Anchoroge in which the resistance units are situated outside the oral cavity is termed extraoral anchorage. Various
extraoral anatomic units

Fig 3 Examples of extruoral anchoroge |A) Face mask ;or prolraciion

of maxilla - anchorage fromfare head and chin \8J Occipital head
geor - oncnoroge from the cranium

Anchorage in which the resistance units

Fig A Lip bumper utilizing musculor onchorgc

used as sites of resistance are occiput, back of *he

neck, cranium and face. Examples of extraoral
anchorage include the use of head gears that derive
anchorage from the cervical or cranial regions and
face mask that derives anchorage from the facial
bones (fig 3}.

Muscular anchorage
certain cases the perioral musculature is employed as
Fig 5 Bakers anchorage : (AJ Class 51 i-item-iax i J a ry anchorage.
resistance units. Muscular anchorage makes use of |B) Closs III intermaxi'lary anchorage.

forces generated by muscles to aid in the movement of situated in one jaw are used to effect tooth movement
teeth. An example of muscular anchorage is the use of in the opposing jaw is called intermaxillary anchorage.
a p bumper to distalize molars (fig 4). It is also termed Bakers anchorage. Class II elastic
fraction (fig 5.a) applied between the lower molar and
Intramaxlllary anchorage
upper anteriors as well as Class III elastic traction
'•'/hen all the units offering resistance are situated
applied between the upper molar and lower anteriors
within the same jaw the anchorage is described cs
(fig 5.b) are types of intermaxillary anchorage.
intra maxillary. In this type of anchorage the teeth to be
moved and the anchorage units are ell situated either
entirely in the maxillary or the •mandibular arches.
Intermaxillary anchorage
Reinforced or multiple anchorage

Anchorage in which more rhan one type c: j resistance

unir is utilized is termed reinforced anchorage.
Reinforced anchorage refers "o the . augmentation of
anchorage by various means sucn as extraoral
appliances, upper anrerior i inclined plane or a
rranspatotal arch connecting the two mo xi I lory
A. tx.Vcrorai forces TO augmen.'
anchoroge: Forces generated from extraoral areas
such c= cranium, back of the neck and face can be
used to reinforce one nonage.

B. Upper anterior inclined p.'one ;

A removable appliance incorporating an upper anterior
inclined plane resu'ts in forward glide of the mondible
during closure of the jaw (fig 6.a). This results in
stretching of the retractor muscles of Ihe mordib e
which subsequently contracts and forces the mandible
against Ihe upper inclined plane. Thus a distal force is
applied on the maxillary teeth thereby reinforcing
maxillary anchorage. A modification of the anterior
inclined plane is the 5ved appliance the* hos on
additional upper inciso capping Jfig 6.b).

Single or primary Banchorage C. Trarcspa/ofcri arch : This is a wire that spans Ihe
pciale in a transverse direction loss'.
Fig 6 Examples of reinforces anchorage (A) Uppsr a irerior ind nad
pla-ic (B) Svcd appliance

Cases wnerein the resistcnce provided by o single

tooth with greateralveo ar support's used lo move
another tooth with lesser sue port is refered to as single
or primary ancnoraae.

Compound anchorage

Anchoroge where the resistance provided by more

than one tooth with greater support is used to move
leelh with lesse.' support is called compound
Fin 7 Traispa rra' arc n
connecting the first permanent mo ars of either side
(fig 7).They are used in fixed mechanotherapy to
ougmenl onchorace.


Anchorage planning is of utmost i m po ranee •he

success of orthodontic treatment. Prior to initiation of
orthodontic therapy, it is essentia! to carefu'ly assess
the anchorage demands o: an individual case so that
appropriate treatment modalities car be executed. The
anchorage -equirement deoends on a number of
factors which are listed below :

1. Number of *eot.h being moved : The create' the

number of teeth oeing moved, the crecte' is the
demand on the anchorage.

2. Typo of feefh be.'.na moved : The movement of

slender anterior teeth offers lesser strain on the
anchorage than robust multirooted teeth.

2. Type of ,'ooffc movement ■' Whenever bodily tooth

movement is required, there is a greater, strain on tho
anchorage. In contrast, -pping tooth movements offer
a relatively 'cssor rrain on the anchorage units.

Duration of tooth movement ; Treatment cx a

prolonged duration oloces an undue strain on the

Based on the above mentioned factors, the

anchorage demand of a particular patient is
determined. Cases that have a high anchorage
-equirement need reinforcement of the anchorage by
one or more of Ihe various means mentioned earlier. In
spite of the precaution ta'<en in p annirg anchoroge, a
certain amount of unwanted movement of the
ancho'teetn invariably occurs during orthodontic
treatment. Such unwanted movements of anchor teeth
is called 'anchorage
H g 6 Classification o; andiccgc demand : (A) Maximum cncho'agc
(B) .NAode'a'fi ancnorcge (C) Mln mum anchorage

Based on the anchorage loss that is permissible,
the anchorage demand of an extraction case can be of
three types i.e. maximum anchorage, moderate
anchorage and minimum anchorage case (fig 9).

Maximum anchorage cases

In cases where the anchorage demand is very
high, not more than 1 /4 tn of the extraction space
should be lost by forward movement of the anchor
teelh. The anchorage in those patients should be
augmented to avoid unwanted movement of the
anchor teeth.

Moderate anchorage cases

In these cases, the anchor teeth can be permitted to
move forward into 1/4 th to 1/2 of the extraction space.

Minimum anchorage cases

In these cases, the anchorage demand is very low.
More than hoff the extraction space can be lost by the
anchor teeth moving mesially.

^uaUw 4JS
U^^I^iSiliJ J^JI J^j^
P—C Iff-J U^Wtli V j

Age Factor in

n important consideration in Orthodontic The chronological age of the patient may

A diagnosis and treatment planning is the age of

the patient. In addition age factors influence
the treatment mechanics and prognosis.
sometimes be misleading and may not reflect the exact
growth status. Thus skeletal and dental ages of the
patient should be ascertained for a more accurate
diagnosis. The skeletal age or bone age as it is
DIAGNOSIS AND AGE sometimes called is determined by studying a
hand-wrist radiograph. The hand- wrist region has a
Diagnosis forms a vital part of successful rrthodontic
number of carpal bones. The ossification and union of
therapy. In order to diagnose abnormalities of the
these skeletal centers follow a definite time table and
dento-facial complex, the orthodontist should know
pottem. Thus by ascertaining the status of these
what constitutes -ormalcy. Normalcy in the dento-facial
ossificotion centers ond comparing them with
region r^ers from age to age. There are certain
standards for different skeletal ages, one can
features rrthe developing dento-facial complex which
determine the exoct skeletal
are "ormal in a child, however if present in an adult
*ould constitute malocclusion. These are referred 'o as
self-correcting malocclusions or transient
-alocclusions. Some of the transient
clocclusions are : a. Open bite seen in
the gum pads o Spacing in deciduous
c. First deep bite
d. Flush terminal plane
e. Ugly duckling stage
f. Second deep bite
These malocclusions are considered normal
for that age and need no treatment as they get
corrected automatically as the age advances.
maturity status o* an individual. The dentci age ot an armamentarium that include growth modulation,
individual is determined by assessing -he stage of guidance of eruption, use of notura'. ^orces etc.,.
calcification andOrthodontics
root develooment. - The Art and Science
However, in an adult patient the treatment options are
limited to moving teeth and surgery.
Considering the fact that orthodontic and
Compromise on treatment objectives : In an adult
dento-facial orthopcedic oopl'ances are most effective
patient in whom growth has ceased, it may not be
during growtn, the assessment of skeletal maturation
possible to achieve all the objectives of function,
in young patients is of utmost importance for the
esthetics and stability tnat represent ideal dentition
success of tne therapy.
and occlusion. In many adult patients compromises
TREATMENT AND AGE might have to be made in the treatment. While sealing
trectmenl objectives for cduit patients the orrnodontist
Early treatment
should set goals that are realistic, attainable and which
Most orthodon-'s-s believe in the concept of 'ca'ch strike the best possible balance in function, esthetics
them young'. Treating a patient at cn early cge when and treatment stability.
derto-focial growth is act've has numerous benefits.
Scope for growth modification : Skeletal
malocclusion that occurs as a resut o* altered growth
direction and amount ccn be intercepted by modulating
further growth. These procedures that modify growth
should be in'tiated at an earfy age before cranio-facial
growth ceases.

Scope for prevention ond m Perception ; One of the

advantages that early treatment offcs is the possibility
of preventing or intercepting a malocclusion. Even if
tne malocclusion ccnnot be totally eliminated, its
severity can be reduced so that complex orthodontic
trealment involving extraction and surges can oe

Harnessing natural growth forces : The humon

dentition has a natural tendency lo move in a mesial
and occlusal direction. These natural tendencies con
be used to guide the erupting teeth to more favorable

Minimize psycho/ogrcai distress : Trealment carried

out at an early age avoids psychological disturbances
as a result of coping with a full- fledged malocclusion.
Late treatment
Roie of growth : Orthodontic treatment car r out
during adolescence or still later in adu~ cannot make
use of the growth potenticl. Altho working with growth
potential has numero advantages as enlisted earlier,
certc malocclusions are best treated offer growr-
completion. Most skeletal malocclusion indicated fo'
orthognatnic surgery arc to be treatec aftergrowth
completion so as to avoid recurre~ growth changes
associated with continuation o: abnormal growth

Limited treatment options : In a growing patient, the

orthodontist has a numbe' of options in his
Vitality of tissue ; orthodoritis1 merely relics on tooth movement o"
Orthodontic tooth surgery.
movement is Diagnosis : Most of the routine diagnostic aids can be
Age Factor in Orthodontics 213
used in both young as well as adult patients. An adult
most effectively
ccrried out in young patients. Young patients ex'nibir patient shows greater possibility of dormant octhosis,
increased vascularity and cellularity of the periodontal impaction, periodontal problems, wear of dentition,
membrane and bone as compared to older patients. faulty restoration, bone ioss, loss of teeth due to
Patients of younger age ere nence more responsive to decay, etc.,. The diagnostic exercise in an cdult
ortnodontic ;orces which makes is possible to move should hence consider these factors as some of them
Teeth faster. may homoerthe success of the orthodontic therapy.

App.'ionce se'ech'oft ; Younger patients who, are

Role of growth : Most orthodontic and orthooaedic
growing can benefit from orthooaedic and
corrections are effectively carried out during the growth
myofund'onal appliances that nelp modulate growth in
period. This is due to tne fact that younger growing
case of abnormal growth amount and direction. In or
patients reoct more favorably to orthodontic and
adult paliert the options are restricted to orthodontic
orthopaedic forces.
too'h movement and surgery.
Although it is desircble to carry out
It is a fact that younge' patients tolerate most
orthodontic treatment at a younger age, it is
appliances ard are not botnered by the appearance of
nevertheless possible to move teeth in older oatients
he appliance. Incase of adults, the appliance
by altering 'he force magnitude and duration.
tolerance is much lesser than a child. Adults are often
Sole of op i co / foramen : In an adult patient the
bothered by tne looks of the cppliance. Ir such
apical foramen is narrow. Force application during
patients, removable aoplrances ard fixed appliances
treatment may pose a greater chance of non-vitality,
that are more esthetic or inconspicuous are advoccted
root resorpt:on and ankylosis of teeth occuring. In a
whenever feasible.
young patient, the apical foramen s wider thus there is
Per/odo.oto/ problems ; Presence of periodontal
lesser cnance o6" ptipcl damage.
involvement and bone loss is mora common in an
Density of bone : As adults exhibit greater density of adult patient. Periodontally involved teeth move more
bore, orthodontic tooth movement is much slower. readily and offer poor anchorage.

YOUNG VERSUS ADULT PATIENTS Patient motivation and cooperation : Most

adult patients seeking orthodontic therapy are well
in recent times there has been an ircrease in the motivated as compared to children. Thus the
number of adult patients who desire orthodontic orthodontist can expect more co-ooeration in an adult
correction of their malocclusion. Numerous differences patient.
exist between adult orthodontics and orthodontics for
Tissue vitality : The tissue vitality and
the young child. The following ore some of the
responsiveness to force is much greater in a child than
important areas where the difference is seen :
in on adult patient. This is because of
Growth to work wi.'h ; One of vhe important differences
in treating a child and on adult is the fact that in a child
the orhodontist has growth to work with. Most
orthodontic and orthopcedic treatment is efficiently
carried out using the growth potential of the pctient. In
comparison, an adult lacks growth. Thus the

6 1. Special Considerations for Adult Orthodontics : : J.clinical

orthod : 535-545,1976
12. Tayer : Adults' at-itudes toward orthodontic therapy :
A.J.0:305-315, 1981
13. Thomas M. Graber ond Robert L VanansdaJ: Mosby , 199S'
14. Vare o ond Ga'cia-Camaa: Impact of orthodontics or ad jit
patients ; A.J.O: 142-148, 1995
15. Warren Harnjla : Orthodontic Office Design Designing Ad u t
.Areas : J.clinical ortnod 1992 : 355-360
reduced vascularity and cellulahty in an adult patient.

Treatment objectives ; In an adult patient, many

Orthodontics - The Art and Science

compromises might hove to be made. The 3 objectives
of function, esthetics and stability may not be achieved
in an adult patient and the orthodontist should thus
strike the best possible balance between the various

Treatment appreciation : Adult patients ore more

appreciative of tne treatment results than a child




Preventive Orthodontics

reventive orthodontics is that part of 1. Parent education

P orthodontic practice which is concerned with

the patient's ond parents' education, •
supervision of the growth and development of the
Caries control
Care of deciduous dentition
Management of ankylosed tooth
dentition and the cranio-facial structures, the d 5. Maintenance of quadrant wise tooth shedding time
agnostic procedures undertaken to predict the table
ropearance of malocclusion and the treatment 6. Checkup for oral habits and habit breaking
s-ocedures instituted to prevent the onset of appliance if necessary
Talocclusion. 7. Occlusol equilibriation if there are any occlusal
Preventive orthodontics is a long range prematurities
roprooch and it is largely a responsibility of the 8. Prevention of damage to occlusion e.g. Milwaukee
general dentist. Many of the procedures ore common
in preventive and interceptive orthodontics but the
9. Extraction of supernumerary teeth
timings are different. -eventive procedures are
10. Space maintenance
undertaken in znticipation of development of a
11. Management of deeply locked first permanent
problem, 'rterceptive procedures are undertaken
when the :'oblem has already manifested. For e.g.
12. Management of abnormal frenol attachments
extraction of supernumerary teeth before they cause
r splacement of other teeth is a preventive cocedure,
while their extraction ofter the signs of
malocclusion have appeared is an interceptive
The following are some of the procedures
undertaken in preventive orthodontics :

Fig' (A) Ihres'orec caries in dseciducjs oertition can ead to less o; arch length Note how ihe cones in deciduous molor has resU'ed in ihe
ceciducjs second molar mo'/irg mesiolty into -ha spoce". (B| pi- and fssure sealants

Preventive dentistry should ideally begin much before material when the bigger permanent teern erupt into
the b'rtn of the child. The expecting mother should be the oral cavity. Caries should be detected by clinical
educated on matters such as nutrition to provide an and radiographic examination. Bitewing radiographs
ideal environment for the developing fetus. Soon after are a valuable aid in detection of caries. Once caries is
birth, the mother should be educated on proper nursing de~ectec. proper restoration of the affected teeth
and care of the child. In case tne child is being bottle should be undertaken immediately to prevent loss of
fed the mother is advised on the use of physiologic arch length.

nipple and not the conventional nipple. The

conventional nipples are non-physiologic and do not
permit suckling by movement of tne tongue and the Preventive orthodontics includes care of the dcciduous
lower jaw. They rather cause sucking of the milk which dentition by way of prevention and timely restoration of
moy lead to various orthodontic problems of the teeth. carious teeth. The deciduous teelh are excellent
The physiologic nipples on the other hand are designed natural space maintained until tne developing
to permit suckling of the milk which more or less oermanentteetn ere reedy to erupt into the oral cavity.
resembles the normal functional activity as in breast Thus all efforts should be taken to prevent early loss of
feeding. The mother is also adviced against the the deciduous teeth. Simple preventive procedures
prolonged use of pacifiers which car have a detrimental such as application of topical fluoride and pit and
effect on the denrition. The young mothers arc o I so fissure scalcnts (fig l .b} help in preventing caries.
adviced on matters pertaining to prevention of nursing
bottle syndrome.
The parents should oiso be educated on the
need for maintaining good oral hygiene. The parents
should be taught the correct method of brushing the
child s teeth.
Ccries involving the proximal surface of deciduc teeth if
not restored leads to loss ot arch length I movement of
adjacent leetn into that space l .A} Such loss of arch
lengrn by mesial movement of teeth can result 'n
discrepencies between the arch length and tooth
Preventive Orthodontics 217

G 2 ;A) And (B) Presence c>f supernumerary leelh has restl'ed in delay ii erjption OF the rncxillary incisors |C| and (D) Mesiodons causing rrcculari'-Y o :

the developing dcnlrion. JE; end \z\ Supplemerlo la'e'cl incsors


-Vesence of supernumerary arid supplemental •®eth

can interfere with the eruption of nearby -ormal leelh (:ig
2). They can deflect adjacent teeth lo erupt in abnormal
positions. Presence o* an unerupted mesiodens
prevents the two maxillary central incisors from
approximating each other. Thus supernumerary teeth
snould be identified and extracted before they cause
disolacement of o'he' tee'h.
Fig 3 (A) Ankylosed primary second molar in int'raocdusion (submerged! (BjRodiog-cph of 'he same patent

All functional prematurities should be eliminated as they

can lead to deviations in the mandibular path of closure
and also predispose to bruxism. Using articulating
paper, the premature contact area is detected and
selective grinding is carried out. Sometimes abnormal
anatomical features like enamel pearls, may couse
Fig 4 (A) Midline diastema due to thick maxillary frcntm (B)
premature contact. They should be eliminated by Radiographs s h o w i n g interdental bono nolching


There should not be more than 3 months difference in

shedding of deciduous teeth and eruption of permanent
teeth in one quadrant as compared to other quadrants.
Delay in eruption may be due to one of the following
factors :
a. Presence of over-retained deciduous teeth roots
b. Presence of unresorbed deciduous root fragments.
c. Supernumerary tooth (fig 2)
d. Cysts and tumors
e. Over-hanging restoration in deciduous teeth
f. Fibrosis of gingiva
g. Ankylosed primary teeth

Ankylosis is a codition characterized by absence of the

periodontal membrane, in a small area or
and possible deformities. Whenever such an appliance
is used, occlusion should be protected using functional
appliances or positioners made of soft materials.
Preventive Orthodontics 219

The deciduous second molars occasionally have a

prominent distal bulge which prevents the eruption of the
first permanent molars. Slicing the distal surface of the
ig 5 Arkylcglossio or tongue tie
second deciduous molar helps in guiding the eruption of
the first permanent molars.
•he whole of the root surfcce. Ankylosed deciduous
^eth do not get rcsorbcd and therefore either SPACE MAINTENANCE
creventthe permanent teeth from erupting (fig 3} or
deflect them to erupt in obnormol locations. These Premature loss of deciduous teeth can cause drifting of

ankylosed teeth should be diagnosed and surgically the adjacent teeth into the space. It can result in

removed at on appropriate time to permit 'he abnormal axial inclination of teeth, spocing between
permanent teeth to erupt". teeth ond shift in the dental midline. Premature loss of
deciduous anteriors leads to very little orthodontic
MANAGEMENT OF ABNORMAL F RENAL changes. If the deciduous first molars ore lost
ATTACHMENTS prematurely, lateral

The presence of a thick and fleshy maxillary labial

^enum that is attached relatively low prevents the
maxillary control incisors from approximating each
other producing a midline diastema. This kind of
cbnormal fronol ottachment in most patients is caused
due lo hereditary factors. They should Hence be
diagnosed and treated at an early age. A blanch test
helps in diagnosing a thick frenum. h addition notching
of interdental bene in a ceriapical radiograph confirms
a thick frenal attachment
Presence of ankyloglossia or tongue tie (fig
4.b) prevents normal functional development due to
lowered position of the tongue and cbnormalities in
speech and swallowing. This condition should be
surgically treated to prevent full-fledged

Habits such as finger and thumb sucking, nail biting,

tongue thrusting and lip biting should be identified and
stopped. Prevention starts with proper nursing and use
of a physiologically designed nursing nipple and pacifier
to enhance normal functional and deglutational activity.


Milwaukee brace is an orthopaedic appliance used for

the correction of scoliosis. This appliance exerts
tremendous force on the mandible and the developing
occlusion leading to retardation of mandibular growth
According lo Hilchcock
Advantages of removable space
Removable or fixed cr s?irifwed VVIh ma/ntainers
bands ot without bands Rational or non 1. They are easy to clean arid permit mointoinance of
Lrcrional Active ot pass v? C^rla n
prooero'al hygiene.
CQTibinaiions ot the above
2. They maintain or restore the vertical dimension.

According to Raymond C. Thurov;

3. They can be worn part time allowing circulation o:
Ihe olood lo the solt tissues.
Removable Complex a-ch .
A. They serve other important functions I ke
rgu3l arch cx'ra-oral ar.corag
ndivdual toot- masticat on, esthetics and p.noretics. 5. Dental
check-up for caries detection can be undertaken
Acccrdng to Hinrlchsen easily.

rixed spa:* maintains: Class I

aj Nor. f.naicnal types i| 2ar lype i I iwp type O) F
n ""ic nal lypes i; Pontc type i) lingual arch lype Class I
• C^riileve' :yp«s (distal shoe. ba'C & ■OOP)
Ra-ncvaolo spacc nain:airers : Ao-y-'C pan si dentu'$s

shift of anteriors takes ploce. In case of oremalune loss

of deciduous second molars, the first permanent molars
migrate mes "ally "hereby leaving insufficient space for
the erupting second premolors wh'ch can get impacted
within Ihe jew or get ceflected and erupt in on abnormal
ocalicn. Soacc mainta ne' is a device used -o maintain
the space created by the OSS of a deciduous tooth.
A space mainto'ner should fulfil! the following
reouirements: I. It shou d mc'ntain tne entire mesio-distal
scoce created by a lost tooth.
2. t must restore the function as far as pos and
prevent over-eruption of opposirg te«
3. :t should be simple in construction.
4. It should be strong enough *o withstand v
functional forces.
5. I* shouid not exert excessive stress adjoining
6. It mus* oermit maintenance of ore1 hygier
7. I* must not restrict normal growth ar development
and natural adjustments whic take ploce during
the transition fro* decid jous to permanent
8. The space rnaintainer should not come id Ihe woy
of other functions.


They are spcce maintained which can be removes and

reinserted into the oral cavity by the patient Removable
soace maintained can be classifiec as funct:onal and
non-functional space maintainers. Funct space
maintainers :ncorporale -eeth lo aia in masticat or,
speech and esthetics whereas non-functional space
maintainers hove only an acrylic extension over the
edentulous area to prevent space closure.
Jc 6 Arcyl'c poriol cen'tro used as spare martoinc
1. Lack of patient co-opera r ion.
|c Room con be mode for permanent teeth to erupt 2. In patien's who are allergic to acrylic matericls.
without changing the appliance. 3. Epilept'c patients wno have uncontrolled seizures.
| ~ They stimulate eruption of permanent teeth.
5. Some commonly used removable space
tS. Band construction is not necessary.
11 They help in preventing development of tongue
thrust habit into the extraction space. Acrylic Partial Denture s .' Acrylic pcrtial dentures
have been used success*'ully in patients who have
Disadvantages of removable space 6.
undergone multiple extractions (fig 5). Tnis apoliance
con be readily adjusted to allow the eruption of teerh.
f T h e y may be lost or broken by the patient. The inclusion of artificial 4eeth in ihe denture restores
12. Unco-operative patients may not wear the mas*:catory function. Clasps can be -abricated on
apoliance. deciduous canines and molars for retention.
B. Lateral jaw growth maybe restricted, if clasps are
i^. They mcy cause irritation of the underlying so^

id/cations of removable space nalntalners

i'T. Removable dentures are indicated when aesthetics
is cf importance.
BZ. In case the abutment teeth connot suppori a fixed
appliance it is recommended to use a removab'e space
maintained 1 In cleft palate patients who require
of the palatal defect. 4. In ccse the rodiograph
reveals thot the unerupted permanent tooth is no* going
erupt in loss than five montns time, a removable
space maintainer can be given. If the permanent teetn
have not fully erupted it rncybe difficult to adapt bands.
Thus it ;s advisable to 'use removable space maintained.
Multiple loss of deciduous teeth which may require
functional replacement in the form cf either partial or
comp'ete dentures.

Contra/jjd/cat/ons of removable type of space

Space mainlainers which are fixed or fitted ontc the
Fig 6 Band and loop space maintainer toeth are called fixed space maintainers.
Full or Complete dentures : Sometimes all the
primary teeth of a pre-school child may require
extraction due to rampant caries of teeth that cannot be
restored. Although this procedure was more common in
the pre-fluoridation era, even today some children may
require complete extraction of their deciduous teeth.
These cases are managed by the use of a complete
denture. These dentures not only restore masticatory
function and esthetics, but also guide the first permanent
molars into their correct position. The posterior border of
the denture should be placed over the area
Fig 7 Band and loop spaco moimainer •
approximating the mesial surfoce of the unerupted first
permanent molar. The denture will hove to be adjusted
and a portion of it cut away as the permanent incisors
erupt, and the posterior border contoured to guide the
first permanent molars into position. When the
permanent incisors ond first permanent molars hove
erupted, a partial denture space maintainer can be used
until the remaining permanent teeth erupt.
Removab/e Dfsia^ Shoe space Maintainor: An
'immediate acrylic partial denture with an acrylic distal
shoe extension has been used successfully to guide the
first permanent molar
into position when the deciduous second mc is lost
shortly before the eruption of the fir permanent molar.
The tooth to be extracted is < away from the stone
model and a depression i cut into the stone model to
allow the fabricatic of the acrylic extension. The acrylic
will i into the alveolus after the removal of the prime»
tooth. The extension maybe removed after the | eruption
of the permanent tooth.


Advantages of
Fig S (A Uinguol arch space maintaire' (B- Nance held rg arch Crown and foop appliance :
fixed space
malntalners Crown and loop apoliances are similar to band end loop

1. Bands and crowns are used which require minimum space maintainers in all respects except that a stainless

or no tooth preparation. steel crown is used for the abutment tooth. The crown is

2. They do not interfere with passive eruption of used in preference to the band when the abutment tooth

abutment teeth. is highly carious, exhibits marked hypoplasio or is

3. Jaw g rowth is n ot ha m pered. pulpotomized.

The succedaneous permanent teeth are free to Trie fongua/ arch space maintainer : The lingual arch is
erupt into the oral cavity. the most effective appliance for space maintenance in
5. They can be used in unco-operative patients. Ihe lower arch. The classical mandibular lingual arch
5. Masticatory function is restored if pontics are placed. consists of two bands cemented on the first permanent
molars or on the second deciduous molars, which are
Disadvantages of fixed space joined
1. Elaborate instrumentation with expert skill is
2. They may result in decalcification of tooth material
under the bands.
3. Supra-eruption of opposing teeth can take place if
pontics are not used.
4. If pontics are used it can interfere with vertical
eruption of the abutment tooth and may prevent
eruption of replacing permanent teeth if the patient
fails to report.
Examples of fixed space malntalners
Bond and loop space /naintorner : Bond and loop
space mointainers are one of the most common spoce
controlling oopliances used in dental practice. The tooth
distal to the extraction space is banded and a loop of
thick stainless steel wire is soldered to it with its mesial
end touching the tooth mesic! to tnc extraction space (fig
6 & 7). It is a unilateral fixed appliance indicated for
space maintenance in the posterior segments when a
single toolh is lost.
Fig 9 Transpalatal arch anterior palate (fig 8.b). h incorporates an ocrylic
by a stainless steel wire contacting the lingual
button in the anterior region that contacts the
surface of the four mandibular incisors (fig 8.a). The
polatal tissue.
appliance is usually indicated to preserve tne spaces
Transpa/otai1 arch : More recently, the transpalatol
created by multiple loss of primary molcrs. If helps in
arch has been recommended for stabilizing the maxillary
maintaining the arch perimeter by preventing borh
first permanent molars when the primary molars require
mesial drifting of tne molars and also lingual collapse of
extraction (fig 9}.The transpalatal arch consists of a thick
the anterior teeth.
stainless steel wire that spans the palate connecting the
Pa/cfa. 7 arch oppfionces : They are similar to the
first permanent molar of one side with the other. The
lingual arch described above. Palatal arches are
best indication for transpalotcl arch is when one side of
designed to prevent mesial migration of the maxillary
the arch is intact, and several primary teeth on the other
molars. They are constructed using
side are missing.

0.036 inch diameter hard stainless steel wire. The

F g 10 Disfcl shoe space r-ia rtniner

Nance nolding arch is a maxillary lingual arcn that does

not contact the anterior teeth, but approximates the

7 Time elapsed since loss of tooth : It is usually

advisable to place a space maintainer as
Fig 1 1 |AJ Band and bar space maintainer (BJ Crown and be r spacic ncintoiner

Distoi shoe space maintainer : Distal shoe appliance fabricate the appliance prior to extraction of the primary
is otherwise known as the intra-alveolor appliance (fig toolh and insert the appliance soon after Ihe extraction.
10). The distal surface of the second primary molar 2. Dental age of fne patient : The dental age of the
guides the unerupted first permanent molar. When the patient should always be considered ralherthon the
second primary molar is removed prior to the eruption of chronological age. This is because too much variation in
the first permanent molar, the infra-alveolar appliance eruption of teeth is observed. It is usucily observed that
provides greater control of the path of eruption of the the permanent teeth erupt once 3/4th of their root
unerupted tooth ond prevents undesirable mesial development is complete. This criteria can be used lo
migration. The applionce which is used in practice now is predict the age of eruption of the permanent teeth.
Roche's distal shoe or its modifications using crown and Early loss of teeth can cause a delay in
band applionces with a distal intra-gingival extension. eruption of the successor. For example early loss of the
rsf/iefrc anterior space mainioiners : It ■vas deciduous molars before 7 yecrs of age results in a
described by Steffen, Wilier and Johnson in 1971. Its delay in eruption of the oremolar.
method of construction is simple and clso provides on 3. Thickness ol bone covering the
esthetic component. The spoce maintainer consists of a unerupted teeth: The more the bone covering the
plastic toolh fixed onto a ' ngual arch which, in turn, is unerupted tooth, the more would be the time it would
attached to molar bands. take to erupt, and therefore space maintenance is ;
Bond ond Bar type spoce maintainer : This is a
indicated. Normally premolars take 4 - 5 months to erupt
fixed space maintainer in which the abutment teeth on
through a bone of 1 mm.
either side of the extraction space are banded and
connected to each other by a bar (fig 1 1. a).
Alternatively stainless steel crowns can be used on the
abutments. This type of space maintainer is called crown
and borspacc maintainer {fig 1 l.b).


The following factors should be considered when space

maintainer is planned following the early loss of primay
soon as the primary teeth are removed. Studies indicate
that the maximum loss of space occurs within 6 months
of exlraction of the teeth. It would be a good idea to

236 Orthodontics - The Art and Science

4. Sequence of eruption of teeth : Whenever a

space maintainer is planned, adequate consideration
should be given lo the adjacent deveioping and
erupting teeth. The neighbouring dentition can greatly
influence the closure of the extraction space. For exam
pie when the deciduous second molar is lost early, we
should study the d evelopm e nt of the perm anent
second mola rand the successor second premolar. In
case the second molar is ahead of the second
premolar in its eruption, it is likely to exert a mesiol
force on the first molar which can move mesially. This
may result in insufficient space for the second

5. Congenita/ absence of permanent tooth: If

permanent teeth are congenitally missing, ihe dentist
should decide if he is going to retain the space until a
replacement can be given or allow the other erupting
teeth lo drift and close the space.

f 1. Serial extraction

T here ore a
number of
2. Correction of developing crossbite
Control of abnormal habits I 4. Spoce regaining
; 5. Muscle exercises . 6. Interception of skeletal ma I re
lotion \7. Removal of soft tissue or bony borrier to
enable eruption of teeth

procedures that can be undertaken by the orthodontist,

so as to intercept a malocclusion that is developing.
Unlike preventive orthodontic orocedures that are
aimed at elimination of fcctors that may lead to
malocclusion, interceptive orthodontics is undertaken
at a time when the malocclusion has already
developed or is developing. Thus interceptive
orthodontics basically refers to measures undertaken
to prevent o potential malocclusion from progressing
into o more severe one.
The terms preventive and interceptive
orthodontics are sometimes used synonymously. But it
should be understood that preventive orthodontic
procedures are undertaken when Ihe dentition and
occlusion_are perfectly normal, while the interceptive
procedures are carried out when the signs and
symptoms of a malocclusion have
appeared. Some of the procedures carried out in
preventive orthodontics can also be carried out in
interceptive orthodontics but the timings are different.
Interceptive orthodontics has been defined
as that phase of the science and art of orthodontics
employed to recognize and eliminate potential
irregularities and malpositions of Ihe developing
dento-facial complex.
The procedures undertaken in interceptive
orthodontics include :
SERIAL EXTRACTION Malposilioned or impacted loterol incisors that erupt
palataily out of the crch
Serial extraction is an interceptive
228 Orthodontics - Theorthodontic
Art and Science
Markedly irregular or crowded upper anc lower
procedure usually initiated in the early mixed dentition
when ore can recognize end anticioate potential
Localized gingival recession in the lower anlerfor
irrecuarities in the dento-facial complex and is
region is a characteristic feature of arch .'ength
corrected by a procedure *hat includes the planned
extraction of certain deciduous teeth and later specific
Ectopic eruption of teeth
permanent teeth in an orderly sequence and
Mesial migration of buccal segment
pre-determined pattern to guide the e.'upting
n. Abnormal eruption pattern & sequence i. Lower
permanent teeth into a more favorable position.
anterior flaring j. Ankylosis of one or more teelh
3. Where growth is not enough to over come the
discrepancy between tooth material and basal bone
Kjellgren in i 929 used 'he term serial extraction to
4. Patients with straight profile and pleasing
describe a proced jre where some deciduous teeth
followed by permanent teelh were extracted to guide
the rest of tne teeth into normal occlusion. Nance Contra-/ndJcat/ons of serial extraction
during the 1940's popularized rhis technique in the
Serial extractions are contra-indicated in a number of
United States of America and termed it planned &
conditions which include :
progressive extraction'. Hotz in 1970 called suc.n c
Class II & III malocclusion with skeletal
procedure active supervision of teeth ay extraction'.
Spaced dentition
Serial extraction is based on two basic principles.

Arch length - teeth materia/ discrepancy: Whenever

there is an excess of toolh material as compared to Ihe
arch length, it is advisable -o reduce the tooth ma'erial
in order lo achieve stable results. This principle is
utilized in sericl extraction procedures where tooth
material is reduced by selective extraction of teeth so
that the rest of the leelh can be guided to norma!

Physiologic foofb movement : Human dentition shows

a physiologic tendency to move towards an extraction
space. Thus by selective removal of some teeth the
rest of the teeth which are in the process of eruption
are guided by the

natural forces into the extraction spaces.

Serial extraction is indicated in the following cases
1. Class'I malocclusion snowing harmo between
skeletal and muscular system.
2. Arch length deficiency as compared to the tooth
material is the most important indicator for serial
extraction. Arch length deficienc. is indicated by
the presence of one or more of the following
Abserceof physiologic spacing
Unilateral or biiatercl premature loss o* deciduous
canines with midline shift
Open bite ond deep bite h. Tneaxia' inclination of leeth at *he termination of Ihe
Midline diastemo serial extraction procedure may require correction.
Class I malocclusions with minimal space This necessitates short *erm fixed aopliance
Interceptive Orthodontics
Unerupled malformed teeth e.g. dilaceration
Extensive caries or heavily filled first permanent Dtognost/c procedure
molars The diagnostic exercise orior to treatment snould involve
Mild disproportion between arch length and tooth comprehensive assessment of the dental, skeletal and
maten'al thot con be treated by proximal stripping soft tissues. A tooth material - arch length discrepancy
mus4- ideally exist. According to most authors, an arch
Advantages of serial extraction
length deficiency of not less than 5 - 7 mm should exist to
Serial extraction carried out during the mixed dentition undertake this procedure. Study model analysis should
and early permanent dentition periods has 0 number of be carried out to determine the arch length discrepancy.
advantages : 0. Treatment is more physiologic as it Carey's analysis in the lower arch and orch perimeter
involves guidance of teeth into normal positions analysis in the uppe' arch should be carried out. Mixed
making use of the physiologic forces. deration analysis helps in determining Ihe spoce required
b. Psychological trauma associated with for the erupting buccal teeth. The eruption status of ihe
malocclusion con be avoided by treatment of Ihe dentition is evaluated from an O.RG.
malocclusion ot an early age. The skeletal tissue assessment should involve
c. It eliminotes or reduces the duration of comprehensive cephalometric examination to study the
multibonded fixed treatment. underlying skeletal relation. Serial extraction produces
d. Better oral hygiene is possible thereby reducing the best results in a Class I skeletal pattern. Presence of
the risk of caries. 0 Class II or a Class III skeletal pattern are
e_ Health of investing tissues is preserved. - Lesser contraindicationsforseriol extraction procedure.
retention period is indicated at the
completion of treatment, g. More stable results
are achieved as the tooth material and arch length are
in harmony.

Disadvantages of serial extraction

a. Serial extraction requires clinical judgement.
There is no single approach that can be
universally applied to all patients. Each patient
has to be ossessed and a suitable extraction time
table planned.
b. Treatment time is prolonged o s the treatment is
corned out in stages spreod over 2-3 years.
c. It requires the patient to visit the dentist often.
Thus patier+ co-operation is needed.
d. As extractior spaces are created that close
gradually, the patient has a tendency of
developing tongue thrust.
e. Extraction of Ihe buccal teeth can 'esult in
deepening of the bite.
f Ifthe p roced u res a re not earned out properly there
is a risk of arch length reducing by mesial
migrator, of the bjccal segment. Thus a poorly
executed serial extraction progremme can be
worse than rone at all.
g. Ditching o' spoce can exist between tne canine
and second premolar
F'g 1 Dewel's method o: sercl ex-radion (A) Step one • extroct'on of dcddcous canines to crecte space for the alignment of tho incisors.(B; S- ec
two ■ ex-radion of deciduous f rst molars to accelerate rhe eruction cf fi'st o'emolars.fO Step throe • extradion of 'lie erjptina *irs- prornola's to
permit tne pe'manenl canines 'o erup\ (D} Se'ial extraction completed

g 2 "weed's neihod of serial extraction (A) S'ep one • isoduaus
space for the alignment of the incisors. This step is
carine and first premolar
corried out at 8-9 years of oge. A year later, the
The soft tissue assessment by clinical deciduous first molars are extracted so that the
examination and cephalograms help in the ciagnosis. eruption of first premolars is accelerated. This is
Serial extraction is generally .-dertaken in patients followed by the extraction of the erupting first
exhibiting harmonious soft *ssue pattern. premolars to permitthe permanent canines to erupt in
their place.
Procecfure In some cases a modified Dewel's technioue
A number of methods or sequence of extraction -eve is followed wherein the first premolars are enucleacted
been described. Three of the popular —ethods are: at the time of extraction of the first deciduous molars.

c. Dewel's method b. This is frequently necessary in the mandibular arch

Tweed's method c Nance where the canines often erupt before the first

method premolars.

Tweed's mefhoaf ; This method involves the extraction

Oewe/'s method ; Dewel has proposed a 3 s'ep serial
of the deciduous first molars around 8 years of age.
extraction procedure (fig 1}. In the first rep the
This is followed by the extraction of the first premolars
deciduous canines are extracted to create
racrion o cec'duous first r^olar (Bj Slep two • extraction of
: and Ihe deciduous canines

simultaneously (fig 2).
posterior bite plate (Refer chapter 34).
Ma nee mefhod : This is similar to the Tweed's anterior crossbile: Some anterior cross bites are
echnique end involves the extrcction of the deciduous referred to as functional crossbites. This type of
first molors followed by the extraction of the first crossbite is the so called pseudo Class III
premolars and the deciduous canines. malocclusion where the mandible is compelled to
close in a oosition forward of its true centric relation.
Post serial extraction fixed therapy
Functional crossbites occur os a result of oculusal
Most cases o1 seria1 extraction need fixed appliance
prematurities that cause a deflection of the mandible
therapy for the correction of axiol ;nclination and
into a forward position during closure. These are to be
detailing of the occlusion.
treated by eliminating the occlusal prematurities.

DEVELOPING ANTERIOR CROSSBITE S.kefetof anterior crossbite ; Skeletal anterior

crossbites are usually a result of skeletal
Anterior crossbite is a condition characterized by
discrepencies in growth of maxilla orthe mandible.
reverse over jet where in one o- more maxillary anterior
Anterior crossbites can be a result of maxillary skeletal
teeth are in lingucl relation to the mandibular teeth.
retrognathism or hypoplasia or mandibular
Anterior crossbites should be intercepted ond
prognathism. These are best treated during growth by
treated at an early stage so as to prevent o minor
growth modification procedures by use of
orthodontic problem from progressing into o
myofunctional or orthopaedic appliances
majordento-facial anomaly. An o'd orthodon*-c maxim
states " The best time to treat c crossbite is the first INTERCEPTION OF HABITS
time it is seen."
Habits in the orthodontic sense refer to certain actions
Anterior crossbite should be treated eariy
involving the teeth and other oral or perioral structures
-'orthe following reasons :
which are repeated often enough by some patients to
a. This type of malocclusion is self-perpetuating i.e. if
have a profound and deleterious effect on the positions
the cross bite is present in the deciduous dentition,
it may manifest in the mixed and permanent of teeth and occlusion. Some of the habits that can

dentition as well. affect the

b. Simple anterior cross bites that are not treated

early have the potential of growing into skeletal
malocclusion thct later need complicated
orthodontic treatment combined, at times, with
surgical procedures.
Anterior cross bites can broadly be classified
a. Dento-alveolar anterior crossbites
b. Skeletal anterior crossbite
c. Functional anterior crossbites
Denfo - a/veo/ar anterior crossb/te : Anteriorcrossbite
in which one or more moxillary anterior teeth ore in
lingual relation to the mandibular anteriors is termed
dento-alvelolar anterior crossbite. This kind of anterior
crossbite is often manifested as single tooth crossbite
and usually occurs due to over-retained deciduous
teeth thot deflect the erupting permanent teeth into a
pa'atal position. These dento-alveolar crossbites can
be effectively treated using tongue blades,
Catalan'saoplianceand double conti lever spring s with
Thumb sucking

One of the habits that patients, the space lost

Fig 4Habit breakers (A) Removable hafctf o'eaker (6) F'.xed nabit breaker
is most frequently by mesial movement of

orol structures ore thumb sucking, tongue thrusting Mouth breathing

and mouth breothing. Mouth breathing habit has a profound effec on the
practiced by children and is capable of producing dento-facial region. It can be obstructive or habitual in
damaging effects on the dento-clveolar structures is noture. Obstructive mouth breathing is usually a result
the thumb sucking habit. The presence of this habit of nasal obstruction such as nasal polyps, nasal
upto 2 1/2 - 3 years of age is considered quite normal. tumors, chronic nasc; inflommotory conditions and
Persistence of this habit beyond 3 1/2 - 4 years of age deviated nasal septum. Habitual mouth breathing is
can have a damaging influence on the dento-alveolar one where oral breathing persists as a habit after the
structures and should hence be intercepted (Refer removal of the nasal obstruction.
choper 9). Thumb sucking is intercepted by use of habit Mouth breathing affects the oro-facial
breakers that could be of removable type or one that is equilibrium due to lowered mandibular and tongue
fixed (fig 4). posture and can therefore produce severe
Tongue thrust Interceptive procedures should involve
Tongue thrust is defined as o condition in which the identification and removal of the cause. Persistence of
tongue makes contact with any teeth anterior to the habitual oral breathing is an indication to use a
molars during swallowing. This is a deleterious habit vestibular screen to intercept the habit.
that can clinically present with open bite and anterior
the molar con be regained by distal movement of the
The tongue thrust habit should be
intercepted by using habit breakers. The potient should
be trained and educated on the correct technique of
If a primary molar is lost early and space maintainors
arc not used, a reduction in arch length by mesiol
movement of the first molar can be expected. In such
first molar.
Not oil patients who haveF'g 5 Gerber"s soaca regainer
lost arch length by mesial molar
movement are ideal candidates for space regaining.
The space regaining procedures are preferably
undertaken at on early age prior to the eruption of the


Fig 6 (A) Space re gainer using jack screw !3) Space regainer using anti eve' springs

second molar. The following are some of the commonly

used space regainers.
Gerber apace regainer b. Patients can be asked to stretch the upper lip in a
237 Orthodontics
A seamless orlhodontic band or a crown is-selected
The Art and
for the Science
downward direction towards the chin.
tooth to be distalized. This space regainer consists of o 'U c. Holding and pumping of water back and forrr behind
shaped hollow tubing and o 'U' shaped rod that enters the the lips.
tubing. The tube is soldered or welded on the mesial d. Massaging of the lips.
aspect of the first molar to be moved distally. The 'U' e. Button pull exorcise : A button of I 1/2 inch diameter
shaped wire or rod is fitted into the tube, in such a way that is taken and a thread passec through the button hole.
the base of the 'U' rod contacts the tooth mesial to the The patient is asked to place the button behind the
edentulous area. Open coil springs of adequate length are lips and pul the threod, while restricting it from being
placed around the free ends of the 'U' shaped rod and pulled out by using lip pressure.
inserted into the tubing assembly. The forces generated f. Tug of war exercise : This is similar to the button pull
by the compressed open coil springs bring about a distal exercise. This involves use of two buttons, with one
movement of the first molar. placed behind the lips while the other button is held
by another person to pull the thread.
Space regalners using jack screws
Exercise s for the tongue
Space regaining can be brought about using jack screws
One elastic s wo Mow : This exercise is used for
placed in such a way that an increase in arch length is
correction of improper positioning of tne tongue. A 5/16
obtained by distolizotion of the mojgr. The appliance
inch intra-oral elastic is placed on the tip of the tongue and
consists of a split acrylic plate with a jack screw in relation
the patient is asked to raise the tongue and hold the
to the edentulous space and is retained using Adam's
elastic against the rugae area and swallow. Tongue ho/d
exercise : A 5/16 inch elastic is positioned over the
Space regaining using cantilever spring tongue in o designated spot fora prescribed period of time

The molar can be distalized to regain space by using with the lips closed. The patient is then asked to swallow

removable appliances that incorporate simple finger with elastic



The dental tissues are blanketed from all directions by

muscles. Normal occlusal development depends upon the
presence of normal oro-facial muscle function. Muscle
exercises help in improving aberrant muscle function.

Exercise for the masseter muscie

An exercise to strengthen the masseter muscle involves
the clenching of teeth by the patient while counting to ten.
The patienr is asked to repecr tnis for some duration of

Exercise for the Hps (clrcum-oral


A number of exercises have been suggested far tne lip

and cheek muscles.
a. Stretching of the upper lip to maintain I p seal is an
important therapeutic measure in patients having
short hypotonic lips. To aic in the stretching, the
patient is asked to hold a piece of paper between the
Skeletal Class III Face mask therapy and
severity of the malocclusion thot may occur. These growth
238 ' f Orthodontics - The Art and Science modulation procedures are aimed at normalizing the
skeletal relationship.
Ske-elaJ Class Restrict m axil; ary growth
ma'oeclusion due to us'mg headgears
Interception of Class II malocclusions
malocclusion due to cttn cap to .restrict Class II skeletal malocclusion usually occurs as a result of
Skeletal Class II Myotu actional applances either excessive maxillary growth, deficiency in
ma'occtusion due to to promote rnardibular mandibular growth or a combination of both. Moxillary
mandibular grcvrfh retrogna'.hlsm
growth can be restricted by use of face bow with headgear.
maxillary retrc$nathisn mandibular growth Class II malocclusion due to deficient mandibular growth is
usually treated by myo-functfonal appliances.
Skeletal Class II Myofunctional appliances
malocclusion due tc to promote mandibular
mandfbular growth and iveadgear to Interception of Class III malocclusions
re'rognathlsm a-"d restrict maxillary g-owth
maxillary prognathism Class III malocclusion occurs as a result of mandibular
prognathism, maxillary retro- gnanthism or a combination
Skeletal- Class III
of both. Chin cup with head gear helps in restriction of
mandibular growth while FR III or face mask therapy is
Skeletal Ciass 111 Chin cup therapy to
used for cases of maxillary deficiency.
malocclusion due to restrict mandibular
mandibu'ar growlh prognathism
malocclusion due to
maxillary ; Whenever a permonenl tooth fai's to erupt at the
retrognathisn and SKELETAL
appropriate time, its eruption may be stimulated by
MALRELATIONS surgically exposing the crown. Over-retained primary
Myofunctional appliance
teeth, ankylosed primary teeth and supernumerary teeth
to promote maxillary Ske'etal malocclusion if
growth and face mask are other possible causes of non-eruption of
diagnosed at an early
therapy succedaneous teeth, which should be ruled out prior to this
age can be intercepted
so as to reduce the
The surgical procedure involves excision of the
soft tissue and removal of any bone overlying the crown of
the unerupted tooth. The extent of tissue removal should

n place and lips apart. be such that the greatest diameter of the crown of the tooth
"Wo e/astic swo/low r Two 5/16 inch elastics ere placed
over the tongue, one in the midline and the other on the
tip and the patient is asked 'o swallow with the elcslics in

Ihe hold pull exercise : The tip of the tongue end the
midpoint are made to contact the palate -nd the mandible
is gradually opened. This exercise helps in stretching the
lingual frenum.
exposed. In other words the surgically created opening in
the tissue is sligntly larger than the greatest dimension of
the tooth. The surgical wound is given a cement dressing
for a period of 2 weeks. References

thods of ing

he correction o: many

1. Proximal stripping is usuolly indicated when the
malocclusions requi'es space required is minimal i.e., 0 - 2.5 mm. In these
space in order to move coses, it is possible to avoid extraction of teeth by
teeth into more ideal locations. Space is required for performing reproximation.
rrection of crowding, 'etradfor of proclined ;th, leveling a 2. If the Bolton's analysis show mild tooth
steep curve o: Spee, derototion zt anterior teeth and for
correction of unstable Correlation.The orthodontist is
often faced with •be dilema of how to obtain space
required for -^ese corections. Planning space is an
important rsoect of treatment planning.
Some of the methods of gaining space nclude :
z. Proximal stripping c Expansion r.
Extraction r. Distalization r
Uprightinaof moles : Derogation of
posterior teeth z Proclfnation of

•Voximal stripping is a met nod by which the proximal

surfcces of tie teeth are sliced in order to reduce the
mesio-distol width of the teeth. It is also known by the
synonyms, rearoximation, slenderization, disking and
proximal slicing. Although this procedure is routinely
carried out on the lower ameriors it can olso be done on
the upper anteriors and buccal segments of the upper
ond lower arches.

Indications for proximal stripping

240 Orthodontics - The Art and Science

material excess in either o- the arches, it is Amount of proximal stripping

possible to reouce the tooth material by proximal Not more than 50% of the enamel thickness shou'c! be
stripping. 3. It can be underraken in the lower anterior reduced by proximal stripping. Whenei reproximation
region as an o:d -o retention. is undertaken in a segment of arch, it is advisable to
equally distribute them ove~ j all the teeth.
Contra • indications for proximal stripping
Disadvantages of proximal stripping
1. Proximal stripping is not carried out in young
patients as they possess large pulp chamber The procedure of proximol reduction has a number of

which increases the risk of pulpol exposure. drawbacks which include :

2. Patients are susceptible to caries or those a. The stripping procedure creates roughenec

who nave a high caries index. proximal surface that attracts ploque.
b. Caries susceptibility is increased-as part o* thc
Advantages of proximal stripping enamel Is removed, leaving behind c roughened
1. It is possible to avoid extraction in borderline area.
cases where space requirement is minimal. c. Patients may experience sensitivity of teeth.
2. A more favourable over b.'te and overjot relation d. Improper procedure at the hands of inexperienced
can be established by eliminating tooth material operators can result in alteration of morphology of
excess in c ther of the arches. the teeth, creating an unnatural appearance of the
3. More stable results can be established by teeth.
broadening the contact area thereby eliminating e. Loss of contact between adjacent teeth moy result
small contact points which can slip arid cause in food impaction.
rotation of teeth.
Procedure of proximal stripping
Diagnostic aids for proximal stripping Proximal stripping is carried out in one of the following
Arch perimeter cnc'ysfs : Arch perimeter or Careys ways (fig 1) :
analysis showing a tooth material excess of 0 - 2.5 mrn 1. Use of metallic abrasive strips
over the arch length is o diagnostic criteria favoring 2. Safe sided carborundum discs
reproximation. 3. Long thin topered fissure burs

BoJton's analysis : Bolton's an o lysis revealing an

Fluoride application
excess of tooth materia! in either of the arches is an
The increased caries susceptibility after slenderizalion
indication to reduce tooth material in that arch. Minimal
is managed by a comprehensive fluoride progromme
inter-arch tooth material discrepancies can also be
following the procedure.
corrected by proximal strip ping, (fig 2)
Intro - oral periapical radiographs : It is
advisable to carefully analyze an accurately taken
intra-oral periapical radiogroph of the region.
This would give an idea of tne enamel thick and a
rough estimate of the amount of ena that can be
removed from the proximal surfo without exposure of
the pulp chomber.
Fig I Proximal striap'ng usir g (A)
Lc-ig -Kin -cpered -Issure burs (BJ
Safe sided carborundum d'scs •Q
Metallic abrasive strips

Fig 2 (A) Pretreatmcnt pholograoh of a

patient having mandibular Bolton's
excess toolh mater'al. (B) P'oximal
stripping was oerormed to reduce the
mandibular anteriors end t'ea-cd with
fxed applicnce (C) Post- t'eafment
cno-ograph after a'ignmert of lower
;'.'v ' '-'Att

•;, v ' ' ^^


B %L

F<g 3 Arch expansion os o method of gaining spcce in patients presenting witn narrow constricted arches.



Exponsion is one of ihe non-invasive methods of

gaining space (fig 3). It is usually undertaken in
patients having constricted maxillary arch or in patients
with unilateral or bilateral cross bite. Expansion can be
skeletal or dento-alveolar. Skeletal expansion involves
splitting of the mid- palatal suture while dento-alveolar
exponsion produces a dental expansion with no
skeletal change. Expansion is brought obout by
various appliances that incorporate jack screws or by
use of springs. A more detailed account of various
expansion procedures and devices is given in the
ensuing chapter.
confronting problem (crowding or proclination) without
unduly hampering function and esthetics (fig 4).In cdoition,
the location of premolars in the arch is such that the space



One of the frequently resorted methods to gaining

space for orthodontic purposes is by extraction of one
or more teeth. Extraction that is undertaken as a part of
orthodontic treatment is called therapeutic extraction.
Premolars are the most frequently extracted
teeth as part of orthodonlic treatment. Extraction of one
premolar from eoch quadrant of the jaw provides Fig 4 (A! Extraction of some teeth is required >o goin space in
pc- errs having arch length cefficiency and crowding. |B)
sufficient space to correct the
P'oclination is also an indicclion for extractor o" some 'eetn
extraction can be utilized for correction in both ■fie In order to overcome the drawbacks of extra-oral
anterior as well as the posterior segments of the arch. appliances, various intra-oral appliances to distalize
It is not uncommon to extract molars or iower molars were introduced. These appliances are fixed on
incisors during orthodontic therapy, -iowever, to the teeth and therefore produce a continuous effect.
extraction of canines and upper incisors s usually The following are some of the intra-oral devices used.
Sagittal appliance : Molar distalization can be
The answerto the question of which teeth t>
brought about by removable appliances incorporating
extract for a patient should be based on a sound
jack screws. The appliance consists of a split acrylic
diagnosis. More details on therapeutic extractions zre
plate joined together by a jack screw.(fig 5) The acrylic
given in chapter 23.
plate is sectioned in such a way that the tooth that is to

DISTAUZATION be distalized is isolated, while the rest of the arch is

used for the purpose of anchorage.
One of the technioues that has gained popularity n These appliances are retained using Adam's
recent times is distolization of molars. Distalization clasps on the molars and premolars. The jack screws
procedures are aimed ct moving the molars in a distal are positioned in such a way that their long axis is
direction so as to gain space. This approach is parallel to the occlusal plane as well as the buccal
becoming popular due to the ■bet that extraction can surface of the molars. This
be avoided. Distalization cf maxillory molar assumes
significant value in -ne treatment of mild to moderate
Class II molar -=!ation associated with a norma!
mandible. Thus ry distalizina the maxillary molars in
these cases, fraction o* teeth can be avoided. The
ideal ^ming for d istal ization is during the mixed
dentition reriod prior to the eruption of the second
cermanent molar.
Distalization can be brought about by ~e
following methods
1. Extra - oral methods
2. Intra - oral methods

Extra - oral methods

Head gears deriving anchorage from the cervical c
cranial region can be used to distalize molars. The
head gear assembly consists of a face bow which is
made of an inner and an outer bow. The nner bow is
fixed to buccal tubes present on the —olars. The outer
bow is attached to the extra- oral head cap or neck
strap. The use of extra- oral forces for distalization has
the following disadvantages:
\. Patient coo peration is essentia I for ti mely wea r
of the appliance". 2. The appliances are usually not
worn continuously. Thus they ore intermittent in their
action resulting in prolonged treatment time.

Intra - oral methods

Fig 6 (A) ond ;3)Pre aid post distolizction (bilateral) occlusal photographs of a pat'ent ireoled using coil springs (Q (DJ Pre end uos! d'slol'/alicn (cniloteral)
occlusal photographs of o polen- healed using pendulum appliance

type of appliance can be used for distalization of only one tooth at a time to avoid undue strain on
th e a n chorag e. iTj^J^^^^^&V'i»
DistaJization using rnfra ■ ora/ magnets : Intra-oral repelling magnets con be used to
dislalize molars. These devices consist of repelling vT^ff* WP'Ty
magnets placed on the molar to be distalized ond
the tooth anterior to it. The anterior anchorage 'A |
can be reinforced using a Nance holding arch.

Use of open coif springs to a'isfafize /fV'lfc'S^^

motors: Mo lar distal izatio n ca n be b ro ught a bout p^"' _
using open coil nickel titanium spring compressed
bctween the rnolar and the anterior segment. The f ^IK ^^fs^v
anterior anchorage is reinforced by use of a Nance ^felsl ^^Sfli
button that rests against the anterior port of the S-iTVjBifc». •f

Pendulum appliance : It is an intraoral

Fig 7 Pencu-un appliance
^g 8 Open coil springs used (o dislolize mo ors. Shown nere's cn aoo iancc called Jones ig 'hot inccporxres a coen cc I soring ond a Nance buton for anterior

defalcation appliance that incorporates a modified r^f^^OlY^T^TT

Nance button for purpose of anchorage.In A J\- AA^A /\V
addition it consists of a stainless steel wire with a' f \ f ' \ \ \ ! \ ! \ i if;
rrelix, the distal end of which is inserted into o KWV"j
sleeve on the palatal aspect of the molars to be j \ J\
distalized (fig 7). Distalization is produced by I j ~~~~ -------- —|
opening the helix and forcefully engaging the ^ ---- J__________ ____________ —J
distal ends into the sleeves. ^ ____ ^


-remature loss of a second deciduous molar or extraction of a second

premolar can cause mesial tipping of the first permanent molor. A
mesially -oped molar occupies more space than an „oright molar (fig 9).
Thus by uprighting these -'oped molars, certain amount of space can be
-^covered. Molars can be uprighted using molar

Fig 9 A tilted too'h occjpies more arch space thai an upright one
5. Graaer Tfvi : Orthodontics : Princio es and era; WB
6. Hcas : Palatal exparsion: Just the beginning
dantofaciol orthopedics. A~i J Or hoc 1970 ;2' 255
7. Hass : Raa c exrans on ot 'he rcxillary dcivcl and "he
r.ascl cavity by opening the rnia pc! «ulure. A-i^lc
Orthod 1961; 31 : 73-90
8. Hciss • lone term cost trea-ment Bvcljatian ct rcc*: calatol
excansion. Angle orthod I960; 5C ; 189- 217.
• v'-.,- .V,'-.--..
9 Hass : Trca'rront of rraxi la'y deficiency by Open "he midna atel
Hg i D A footed posterio' tooth occupies r.ore scoce •ha n a suxre. Angle Crthcd 1965; c5 : 20C- 217.
norrral cne 10. "O'Z : Guidance of cructors versus serial extraction. Am J
Orhoc 1970 ; 1-20
11. Johr v. sheridor : Air-Rote Srpphg Ucda-e. Am j Orhoc 1987
uorighting springs or some fonrt of space regainer. ; 781-783
12. Julie n Phiiope : A Method of fcrcrriel Rodtctior fcr
Correction of Adj t Arcli-.ongth Discrepcrcy. Am J Orthod
1991 ; 484-^89
13. Profitt WR: Contemcorary Orthodontics, S' Louis,
14. Robert : Moysrs : Herd book of Crthodon-ics, Yeoi book
r-ed cnl publishers, inc. 1988.
15. Sazrran ..A : 3racrice o: Orthodort cs, JB Lpphcott company.


Rotated posterior teeth occupy more soace thon

normally p aced posterior teeth. Derotation of these
"eeth hence provides some amount of arch length (fig
10).Derotution is best achieved with fixed cpplianccs
incoroorating springs or elastics usinc a force couple.



1. Ackins, N anda, aid Curie : Arc n perimeter cha. on

'cpic pelalai expansion . An J Ortnod 1 ;194-19?
2. Bemsre n : Edv/orc H Angle vests Ca v'n S. Ex'roction
vc'sus nonextractior
3. Dev/ol : Prcrocuis tes in ser o I extraction Am J 1969;
4. Dewel : Se'ial ex-rac'ion iri o-friedcn-ics: hdic
objectives arc -roctmen- procedures . Air» J O 1954;

Procl i nation of a retruded anterior tooth results in gain

of arch length. This is usually indicated in cases where
the teeth are retrod ined or in those cases where
protracting tne anteriors will not affect the soft tissue
profile of the patient.

n appcrently complex yet relatively simple

procedure in orthodontics is palatcl expansion. Its

versatility s unique for respite the many con'roversies the first time in 1 860, used a jack screw *ype of device
surrounding it, desirable results are achieved when between the maxillary premolars in a 1A year old girl
used in the :oprooriate s'tuation by a skilled clinician. and achieved an increase in orch width by "/4 inch in 1 A
Expansion of the palate was first achieved ~f days (fig 1). Wolter Coffin in 1877 introduced a soring
Emerson C. Angell in 1860. Palatal expansion •ran be called Coffin spring rorthe purpose of expanding fhe
carried out in different ways which are broadly orch. These efforts however were not accepted by the
classified as rc o i o' & slow. orthodontic community at that time.


'coid mcxillan/ exponsion is also known by the ^s rap'd

palatal expansion or split palate. It is skeletal *ype of
expansion that involves the arotion of the mid - pcilotal
suture ond movement of the maxilla0/ shelves away
from each

Emerson C. Angell is considered the -ner of

rap'd maxillan,! expansion. Angell, for
It was the oral surgeons and E.N.T. narrow maxilla. Relative maxillary deficiency is
surgeons who pooularized this technique during characterized by norma maxilla but oversized
the early part of this century. E.N.T. surgeons mandible.
Orthodontics - The Art and Science
used this technique in treatment of nasal
insufficiency and constricted naso-maxillary complex
with great success.
Korhkaus and Andrew Hass during the 1950's
reintroduced raaid maxillary expansion to the
orthodontic community. They popularized the concept
with excellent reseorch publications on animals and
humans using a variety of techniques ond methods.


The maxilla together with the palatine bone forms the

hard palate, floor and greater part of the lateral walls of
the nasal cavity. The maxilla is c paired bone that
articulates with its opposite member and various other
bones including frontal, ethmoid, nasal, lacrimal, vomer,
zygomatic and the palatine bones. Most of the sutural
attachments of the maxilla to the adjoining bones are ot
its posterior and superior aspects leaving the anterior
and inferior aspects tree, which makes it vulnerable for
lateral displacement.
Fig 2 (AJPostcrior cross bite. (B| Occlusal view of narrow arcn
The inter-maxillary and the inter-palatine
sutures arc collectively called the mid-palatal suture.
Rapid maxillary expansion should be initiated prior to
the ossification of the mid - palatal suture. Various
studies nove been done to ascertain the age at which
the mid - palatal suture ossifies. Melsen reports that the
transverse growth of the mid - palatal suture continued
upto 16 years in girls and 18 years in boys. Most studies
report a broad range of ossification timetable i.e.
between 15-27 years. The clinician should hence
ascertain that the suture is not ossified by using
appropriate diagnostic aids to be described later in this
The sphenoid and the zygomatic bor,s |
nave c buttressing effect resisting mid - palctai suture


Rapid maxillary expansion hes been carried c-_r for

dental as well as medical purposes. The following are
some of the indications for rape maxillary expansion:
(1) Posterior crossbite (fig 2) associated with rez or
relative maxillary deficiencies. A rec maxillary
deficiency is associcted with cr undersized /
Fig 3 (AjTriangjIar spli' of the nc*il c in fcnsverse view (BlTriangiJar split of the moxi la in fronlal view

(2) Class III malocclusion of dental or skeletal cause. reciprocal force so as to open the mid - palatal suture.
Improvement is seen in both anterior as well as Since the force employed for the procedure is very high,
posterior crossbites. not much of orthodontic changes can be obsen/ed. The
(3) Cleft palate pationts with collapsed maxillary arch. appliance on activation comoresses the periodontal
(4) In cases requiring face mask therapy, R.M.E. is ligament and bends the alveolar process bucally and
used along with face mask to loosen the maxillary slowly opens the mid • palatal suture. The opening of
sutural attachments so as to facilitate protraction. the mid - palatal suture is fan-shaped or triangular with
(5) The medicol indications for ropid maxillary maximum opening at the incisor region and gradually
expansion include nasal stenosis, poor nasal diminishing towards the posterior part of polatc (fig 3 a).
airway, septal deformities, recurrent ear ond nasal This can be appreciated in a post R.M.E. occlusal
infection, allergic rhinitis, D.N.S., e.t.c.,. radiograoh. Similar fan - shaped or non-parallel opening
is also seen in the superio-inferior direction. The
maximum opening is towards the oral cavity with
progressively less opening towards the nasal aspect
The routine diagnostic aids such as case history,
(fig 3 b).
clinical examination and study models are useful in
According to Krebs, the two halves of the
diagnosis. The mid - palatol suture can be visualized in
a maxillary occlusal view radiograph. These maxilla rotate in the sagittal and coronal

radiographs are also useful during treatment to check

for mid - palatal split ond also to estimate the amount of
maxillary expansion achieved. RA. cephalogram is
another valuable diagnostic aid in rapid maxillary
expansion procedures to estimate the omount of
exponsion that has taken place.

Though R.M.E. is essentially a dento-facial orthopaedic

apoliance used by orthodontists, it finds application in
other fields such as oral surgery, E.N.T. ond plastic

Moxilhry skeletal effect : The maxillary posterior

teeth are used as handles to apply a transverse
planes. Inrne coronal plane the two nalves of the
maxilla 'otate away from each other. The point at wn'ch
the rotation takes place is abound the fronto- maxii an^
suture. In the scgittal plcne, the maxilla is found to
rotate in a downward and forward direction.

Amount of expa.os/on achieved : An increase in

mcxilary width OF J oto 10mm can be achieved by rapic
maxilla^ expansion. Tne rare of expans'on is ooout 0.2
to 0.5mm per day.

Effect on o/veo'or borre : The areolar bone in the area

adjacent to the anchor teeth bends slightly. This is due
to the resident nature of the alveolor bone.

Effect on morxiffaiy onferror fee?.1) ; The apoearanee

of a midline spacing between tne two maxillary central
incisors is the most reliable clinical evidence of tne B
maxillary separation. The incisor seoaration is about Fig 4 (A) Normal axiol inclination of the onchor molars (BJ
half of the distance the screw is opened. By tnree to five Buccol y tipped anchor molars

months, the midline diastema closes as a result of the

trans- septa I fibre traction.
structures. In addition to the effects on those bones
Effect on maxillary posterior teeth : The directly articulating with the maxilla, bones of the
maxillary posterior teeth arc used as anchors during cranium such o s parietal and occipital were also
rapid maxiilary expansion. Tnese teeth show buccal found to be displaced.
tipping (fig 4) and are also believed to extrude to a
Effects of R.A/I.E. on n as a/ cavity : Following rapid
limited extent.
maxillary expansion an increase in intranasal spoce
Effect on mandible : Most authors have observed a occurs due to the outer walls of nasal cavity moving
downward and backward rotation of the mandible apart. This increase in nasal cavity width is maximum
following rapid expansion. This is accompanied by a in the inferior region of the nasal cavity and gradually
slight increase in the mandibular plane angle. The decreases towards the superior aspect. Similar
reason attributed for the mandibular rotation is the gradient is also found in an anterio-posterior direction
extrusion and buccal tipping of the maxillary molars. with the greotest increase being in the anterior region.
Effect on adjacent crania.1 bones and sutures : Air flow resistance is believed to reduce by
Rapid maxillary expansion not only results in opening of 45 - 60 %, thereby improving nasal breathing.
the mid - palatal suture but also has for reacning effects
on adjacent cranial


Numerous appliances have been used for rapid

maxillary exponsion. Broadly they can be classified as :
1. Removable appliances
2. Fixed Appliances
a. Tooth borne
b. Tooth and tissue borne

Fig 5 Rerrovab e appliance incorcoroting jock screw for arch


The reliability of these appliances in producing skeletal

Derfcfcswe//er type
expansion is highly questionable. Although it is possible
to split the sutures using removable plates, it The first premolars and Ihe first molars are banded.

nevertheless is unpredictable. Treatment during the Wire tags are soldered onto the palatal aspect of the

deciduous or early mixed dentition is considered more bands. These wire tags get inserted into a split palatal

favorable in producing appreciable skeletal effects. acrylic plate incorporating a screw at its center (fig 6.a).

A removable type of rapid maxillary

Hass type
expansion device consists of a split acrylic plate with a
The first premolor and molar of eithe' side are banded.
midline screw. The appliance is retained using clasps
A thick stainless steel wire of 1.2 mm diameter is
on the posterior teeth. The disadvantages of a
soldered or the buccal and lingual aspects connecting
removable rapid expansion applionce is the need for
the premolar and molar bands. Tne lingual wire is kept
patient co-operation and the difficulty in retaining the
longer so as lo extend past the bands both anteriorly
plate inside the mouth.
and posteriorly. These extensions are bent palatally to
FIXED APPLIANCES gel embedded in the palatal acrylic. The split palatal
acrylic has a midline screw. The plpte does not extend
Appliances that are fixed onto the teeth are more
over the rugae area (fig 6.b).
reliable and found to produce consistent skeletal
effects. These fixed rapid expanders con be classified Isaacson type
into tooth and tissue borne appliances and tooth borne This is a tooth borne anpliance without any acryl'c
appliances. Two of the commonly used tooth and tissue
palatal covering. This design makes use of a
borne oppliances ore :
1. Derichsweiler type
2. Hasstype
Examples of tooth borne appliances
include :
1. Isaacson type
2. H y rax type
adapted to follow the palotal contour and are

Fig 6 (A) Derichsweiler type of expansion appliance (BJ Moss type a: exnansion appliance (C) Isonr.son type of exponsion apoliance
using Minne expander (D) Hyrax ^ype cf oxpans on appliance
spring loaded screw called a MINNE expander soldered to bands on premolars and molars {fig 6.d).
(developed at the University of Minnesota, Dental
Bonded R.M.E
The first premolars and molars are banded. Most of the rapid maxillary expansion appliances

Metal flanges are soldered onto the bands on the described earlier are banded appliances. They

buccal and lingual sides. The expander consists of a incorporate bands on the first premolars and

coil spring having a nut which can compress the spring.

This coil spring is made to extend between the lingual
metal flanges that have been soldered. The expander is
activated by closing the nut so that the spring gets
compressed (fig 6.c).
Hyrax type
This type of appliance makes use of a special type of
screw called HYRAX (Hygienic Rapid Expander). The
screws have heavy gauge wire extensions that are
Fig 7 ;A; Removable appliance Tncorporalmg a jack screw for slow exponsion (B) Hyrax appliance used for rapid expois'or
(C!& (D) Prelrea'ment end posl-t'eatr-en- photograph of a pctient Irsa-ed with hycx -cpid axaa-idcr (EJ & (FJ
Ptelrea'rren! Or d post-treatnen" occlusal radiographs of th« same potient
254 Orthodontics - The Art and Science

molars. An alternative design of the appliance would be

to have a splint covering variable number of teeth on
either side to which the jack screw is attached. Splints
can be of two types :
1. Cast Cap Splints
2. Acrylic Splints
The cast cop splints are made of silver-
copper alloy. The acrylic splints are mode of
polymethyl-methocrylate. A wire framework may be
adapted around the teeth to reinforce the acrylic. These
splints are bonded to teeth using oither glass ionomer
or other bonding adhesives, after adequate etching.

Fig 8 (A) Typical expansion sere?/ JB) <ey jsad tor activation of
A typical expansion screw consists of an oblong body the appliance

divided into two halves. Each half has a threaded inner Schedule by Zlmrlng and Isaacson
side that receives one end of a double ended screw.
In young growing patients, they recommend two turns
The screw has a central bossing with four holes. These
if each day for 4 - 5 days and later one turn per day till the
holes receive a key which is used to turn the screw (fig
desired expansion is achieved. In case of non growing
8). The turning of the screw by 90 degree (i.e. one turn)
adult patients, they recommend two turns each day for
brings about a linear movement of 0.18 mm. The
first two days, one turn per day for the next 5- 7 cays
pattern of threading on either side is of opposite
ond one tum even/ alternate doy till desired expansion
direction. Thus turning the screw withdraws it from both
is achieved.
sides simultaneously.
Various authors have advocated different activation
Clinically, the most noticeable feature during rapid
schedules to achieve the desired results.
maxillary expansion is the appeoranee of o midline

Schedule by Tlmms diostema. Studies by various authors show that the

amount of incisor separation is roughly half the amount
For patients of upto 15 years of age, 90° rotation in the
of jack screw separation. But the amount of diastema
morning and evening. In patients over 15 years, Timms
should not be taken as o reliable factor iri estimating
recommends 45" activation 4 times a day.
the amount of expansion. Maxillary occlusal radiograph
cephalogram are more reliable in estimating -he a. Palatal osteotomy
amount of maxillary expansion. b. Lateral maxi 11 cry osteotomy
c. Anterior m axil I cry osteotomy
Some cases where R.M.E. is contraindicated are :
1. Single toolh crossbites. 1. Oral hygiene instructions should be given to the
2. In patients who are u n-cooperative, R.M.E. is patient and reinforced during the procedure.
contraindicated os the appliance requires frequent 2. Orthodontic movement of the anchor teeth should
activation and maintenance of good oral hygiene. be avoided prior to rapid maxillary expansion, as
3. Rapid maxillary expansion is not carried out after mobile teeth do not offer odequate anchorage for
ossification of the mid - palatal suture unless it is palatal split. Recently moved teeth tend to tip.
accompanied by adjunctive surgical procedures. 3. The potient should be trained to use the key. The
Skeletal asymmetry of maxilla and mandible and key should be tied to a string and the free end
adult cases with severe antero-posterior skeletal should be secured around the oatient's wrist to
discrepancies, f. Vertical growers with steep avoid accidental swallowing.
mandibular plane 4. Moxillary occlusal radiographs should be
ongle are usually a contra-indication. 6. As the posterior
teeth are used as anchors to move the bones apart, the
procedure is not indicated in a periodontal^ weak


Failure to retain the expansion results in relapse. Most

authors recommend a retention period of -ot less than 3
- 6 months. Isaacson recommends -e use of the R.M.E.
appliance itself for the purpose of retention. The screw
Fig 9 Jack screw immobilized with cold cure acrylic
should be immobilized using cold cure acrylic (fig 9}.
-Jternatively, either a removable or fixed retainer e.g.
TPA) can be used.


-atients who exhibit unusual resistance to separation of

the palatine bones may require sjrgical intervention.
This usually occurs in female patients over 16 years of
age and male patients over 18 years of age in whom
the m id-pa lata I suture has ossified. Surgical
separation may also be required in patients exhibiting
increosed circum-maxillary rigidity as a result of aging.
Maxillary expansion can be brought about
by surgery alone or by Surgery along with a rapid
exponsion appliance. The surgical procedures usually
carried out ore :
taken at regular intervals to monitor the expansion.
expansion, producing greater stability and relapse
5. The possible immediate effects of premature
potenTiol Than :n rapid exponsw procedures.
cppl'ance removal include dizziness, pressure at
the bridge of nose, pressure under eyes, APPLIANCES USED FOR SLOW EXPv SION
branching a? soft tissues under the eyes, etc.,.
These symptoms may occur on removal of the
Jack screws for repair or recementcnon. The
patients should therefore be kept seated ond The various jack screws incoraorated in appliances

asked not to stand immediateiy after appliance described for rapid expansion can 2 used for slow
rernovol. expansion (fig 10), bu" with a mc spread out
activation schedule. The screws us for slow
SLOW EXPANSION expansion have a smaller pitch than th used in
According to the proponents of slow expansion, the
results a-e more stoble when the maxillary arch is Coffin spring
expanded slowly at a rate of 0.5-1 mm per week. The
Tnis copliance was designed by Walter Corf - around
forces generated by such procedures is much lower :.e.
the beginning of this century (fig 11 ). fc is a removable
2-4 pounds as against 10-20 pounds generated during
appliance capable of slow dentc- alveolar expansion.
rapid maxillary exponsion. Unlike in rapid maxillary
The appliance consists of an omega shaped wire of
expansion where the treatment is completed in 1 -2
1.25 mm thickness, placed in tne mid-palatal region.
weeks, slow expansion may take as much as 2-5
The free enc:- of the omega wire ore embedded in ocry
ic covering the slopes of the palate. The spring is
Slow expansion has traditionally been termed
cctivated by pulling the two sides apart manually It con
denfo-alveolcr expansion, although some skeletal
also be activated by using three prong pliers. Coffin
chcnges can be observed. Tne slower expansion
spring is believed to bring about a
techniques have also been associated with a more
w and rapid expansion
physiologic adjustment to the maxillcry
Rapid expansion


Slow expansion

Wore irau malic

Type of expansion Rats of Moaily dental Slow
Greater forces
expansion . Type of :.issje Mora physiologic W ider force
More frequent
reaction Force used Less Frequent long
Frequency of activation Eiiher iixed c 'enwable Any
Mostly iixec appiance Before tuson of
Duration of treatment sge
micpaalal s,1ure More c'ancG of
Type ot appliance Age lesser chance of relapse
Bg 10 (A| Removable moxillory slow cxcansion appliance. (B) Mandibular slow expansion appliance incorporating retferior bite plare.

cento-alveola r expansion. However use of this between Ihe anterior and posterior helices is called the
appliance in younger patients is believed to bring palatal bridge. The free wire ends adjacent to the
cbout some amount of skeletal expansion. posterior helices are called outer orms. They rest
against the lingual surface of the buccal teeth and are
Quad helix
soldered on to the lingual aspect of Ihe molar bands.
One of the appliances used to expand a narrow -yjxilla The quad helix can be used to expand a
is the quad helix (fig 12). It is said lo ~ave evolved from narrow arch as well as to bring about rotation of molars.
the original Coffin loop. The quad helix incorporates It can be pre-aclivaled by stretching the two molar
four helices that increase —e wire length. Therefore bands apart prior to cementation or by using three
the flexibility and range cf action of this appliance is prong pliers after cementation (fig 13).
more. The oppliance s constructed using 0.038 inch The quad helix brings about a slow
wire and is dento-alveolar expansion. But when it is used in
children during the deciduous and early mixed dentition
periods, o skeletol mid-palatal splitting can be

Arch expansion using fixed appliances

Arch expansion can be achieved in a patient who is
undergoing fixed mechanotherapy. Mild expansion can
be brought about by using expanded arch wires. In
addition appliances such

soldered to bands on the first molars.

The quad helix consists of a pair of anterior
helices and a pair of
posterior helices. The
portion of wire between the
Fig 11 Co:fin spring
two anterior heliccs is called
the anterior bridge. The wire
2. Bjcrklir <, Ku<ol J . Ectaoic eruption of maxillc
References nerrnanent motors: rtiolcgic
"ac-o's. Am J 1983; 84 :
3. Carut J. 3uga C : Morphological analysis o'" wi'h
ectosic eruption of maxillary first perm mob's. Ejro J
Orthod 1983; S: 249-253.
4. Dr. James P Moss : Scpid Expansion of tne Arch. J
Clin Orhod 1968 ; 215-223
5. Feurnier A, Turcctt J. Bernard C : Orthod
considera'icns in the treatment o; max I cry inr
can.res. Am J O-tnod 1982, 51 : 236-239.
6. Fro n k and Engel : Effects of maxillar,- CLod- opp
iance expansion on cepholorne'ric meo mcnts. Am J
Orthod 1982; 378-389
7. Glcssmor, N'ahigian, Mecv/ey, find Aronow;*-
Conservctive surgical orhodontic adjlt rapid p- exparsion.
Am .1 Orthod- 1984; 207-2" 3
Fig 12 Qviac helix
S. Graber l\V : Congenita abscence o; reetn : R with
emphases on inheritance patterns. J Am Assoc i
978. 94:246-275
9. Hoos : JCO Interviews: Dr. Andrew J . J Clin Or 1973;
as the quad helix or the transpolatal ctrch con be used 227-245
"0. H e as : Paloto expansion: Just the beginning centofocial
along with fixed mechanotherapy.
crthccecics. Am J Orthod 19/0 ;21 255
1". Hass: Rapid exponsion of the m cxi lla ry dentn I arcs one
'he ncsal covity by opering the mid pcla'r suture. .Angle
Orthod 1961; 31 : 73-90
12. Hass : Long term post treatment evaluation o: rap>d
uala'al excansion. Angle orthod 1980; 50 : 189- 217.
13. iciss : Treotmen- of maxillary deficiency by coenrng he
miopolatl sutjre. Angle Orthod 1965; 66 : 20d 2" 7.
14. Jacobs : Control of rho dimension wit n
surgen,- ond orthodontics. Arn J Orthod 1980 ; 284-
306 s
15. Longford : Soot resorption extremes resulting from
clmical RME. Am J Orhod 1982 ; 371-377

Fig 13 (Aj Quad hel'x activotion for mol c r expansion using
three orcng pliers (B) Quad helix activation for oremolar ond
con'ne expansion using tnrec prong pliers
1. Adkins, Ncnda, and Currier: Arch perimeter on rap'd
pr.latal expansion . Am J Ortnod
he philosophy of extraction in conjunction with of the orthodontic patients hod extractions of some
orlhodontic treatment is not new. Establishment of teeth, usually but not always first premolars.


normal functional usion in balance with supporting

structures ional'.y requires the reduction of one or

Most extractions are pe-^ormed as part 3 general

plan of treatment which also involves use of an
appliance. The noture of -elusion and the age of the
patient may be rtant factors in deciding whether or not
to ft to extraction. Extractions in orthodontia ude serial
extraction carried out as an -eptive procedure during
the mixed dentition and therapeutic extractions
carried out as tment procedure for gaining space.
To extract or not to extract has always and will always
remain a controversy in Pontics. The great extraction
controversy of 's was based on two schools of thought
king the philosophy of two pioneers in
orthodontics namely, Edward Angle and his student
Calvin Case. "Hie former advocating non- extraction
while the latter recommened extraction.
Edward .Angle believed that an individual wo
s capoble of having 32 teeth in normal occlusion and
orthodontic treatment for every patient involved
expansion of arches.
Calvin Case argued that although arches
could always be expanded so that teeth could be
placed in alignment, neither esthetics nor stability
would be satisfactory in the long term for many
patients. He thus advocated extraction of teeth.
By the late 194Q's extraction was
reintroduced into orthodontics by Charles Tweed who
observed that the post-treatment occlusion wasfJ53
more stable in patients treated with extraction of
four first premolars. By the early 1960's more thon half
THE NEED FOR EXTRACTION also to discourage the forward development of the
upper arch.
There ore a number of circumstances that necessitate
In Angle's Class II cases, where there is
extraction of teeth as a part of routine orthodontic
lower arch crowding orthe molars aro not in full Class II
treatment. They are listed as follows :
occlusion, it may be necessary to extract in both the
Arch length - toot/) material discrepancy upper as well as the lower arches to achieve proper
Ideally the arch length and tooth material should be in inter-arch relation ond to correct the crowding.
harmony with each other. The size of the dentition and
orch length are usually genetically determined. The
presence of tooth material in excess of the arch length
can result in crowding of teeth or proclination of
anteriors (fig 1).
In many cases the tooth material- arch length

Fig I 'oo-h material in EXCESS of arch length CCUSBS crowding of lectn. (A) Severe crowding due to tooth materiel crch lengfci discrepancy
(B) ronning o: lower anteriors n an indication of crch leng-h deficicncy
disproportion cannot be treated by increasing the orch
length. Hence reduction of tooth material is the only
alternative. Extraction of one or more teeth is resorted
to in case of severe tooth material - arch length

Correction of sagittal Inter-arch


Abnormal sagittal malrelationships such as Class II or

Class III malocclusion may require extraction of teeth to
achieve normal sagittal inter-arch relation. The
extraction of teeth in such cases in ec'oblishing normal
incisor and molar
It is a known fact that extraction of teeri
impairs the forward development of the dentc! arches
and the alveolar process. Thus extraction of certain
teeth in Angle's Class II and Class II malocclusions
improves the sagittal relationship not only by tooth
movement but also by selective forward growth

Angle's Class / : These patients are characterized by a

normal sagittal inter-arch relarion. Thus it is not
advisable to discourage the development of one dental
arch more than the other. Hence in Angle's Class I
cases, it is preferable to extract in both the arches.

Artg/e's Closs // : In most Class II cases, the upper

dental arch is forwordly ploced or the lower arch ploced
back. Thus by extracting only in the upper arch it is
possible to reduce the abnormal upper proclination and
Fig 2 (A) In Ang'c's C loss I. patten it is advisab'o to extract n bo-h -he arches so "hef 'he growth oa-e'n o; the jows is maintained (B) In Angle's Class II, upocr
arch extractions help in discouraging the forward growth of moxillo (Cj In Anglo's Clcss III, lower orch ex^actions help :n discouraging the -orword growh
of mandible
Severe skoletal malrelationship of the jaws may not be
satisfactorily treated using orthodontic appliances
Angle's Class III : It is beneficial to avoid extraction
alone. Surgical resective procedures along with
in the upper arch as it may affect the :cfward
development of the maxilla. Angle's Cass III cases are extraction maybe required in such cases.

preferably treated by extraction only in the lower arch

or by extraction in both crches.
The decision to extract teeth during orthodontic
Abnormal size and form of teeth
therapy should be based on a sound diagnostic
"eefh that are abnormal in size or form may exercise. Premolars are the most commonly extracted
-«ecessitate their extraction in order to achieve teeth as part of orthodontic treatment.
s^sfactory occlusion. Such anomalies include
-acrodontia, severely hypoplastic teeth, r cceration
and abnormal crown morphology.
Skeletal Jaw malreletlons
The maxillary incisors are rcrely extracted as a port of Extraction of lower incisors should as far as possible
orthodontic therapy. However, there are certain be avoided. The extraction of a lower incisor to relieve
conditions when one or more of the upper incisors may lower anterior crowding is often followed by the
262 f Orthodontics - The Art and Science
have to be socrificed.The following are some of them : narrowing of lower

Fig 3 (A) Mucrodonlic incisor i.ndioaled for exlroctioil(B) rod ogroph cf Ine same patient |Q and ID) Scpplemental la-era incisor incicaled
for extraction
inter-canine width, retroclination of lower incisors,
EXTRACTION OF UPPER INCISORS deep bite and re-appearance of crowding. This leads
a. An unfavorably impacted upper incisor thor
to a collapse of the lower arch.
cannot be brought to normal alignment.
b. A buccally / lingually blocked cut lateral incisor
with good contact between the central incisor and
canine can be extracted.
c. If one of the lateral incisors is congenilally
missing, the opposite lateral may have to be
extracted in order to maintain arch symmetry.
d. A grossly carious incisor tnat cannot be restored
may have to be sacrificed.
e. Malformations of incisor crowns that conno* be
restored by prosthesis, may necessitate their
extraction (fig 3.a).
f. Trauma or irreparable damage to incisors by
fracture may indicate their removal.
g. An incisor with d i lacerated root cannot be
efficiently moved by orthodontic therapy. It is
hence preferable to extract them.


b. A lower incisor that was

Fig 4 (A) & (B)lowe' lateral

incisor impacted. The position
of the lower incisor is deep and
is unfavourable for surgical
oxoosu-e fol owed by
ortnocontic treatment. (Q
Radiograph o: the same pa'ient.

traumotized, or exhibiting severe

caries, gingival recession or bone loss
may have a poor prognosis.
c. Presence of severe arch length
The reduction in lower intcr-canine width
deficiency is often characterized by the presence
often leads to a secondary reduction in upper
of fan - shaped flaring out of the lower incisor
nter-canine width resulting in upper anterior crowding.
crowns. In these cases it may not be possible to
The extraction of a lowe" anterior may -hus have for
flatten the lower anterior segment by extracting
reaching consequences 'hat are best avoided.
teeth further distally in the arch. Thus one of the
There are however some conditions when incisors may have to be extracted so as to
improve the crowding ond axial inclinationof rest
of the incisors.
d. In mild Class III cases with lower incisor

. Fig 5 Lower la-eral 'reiser *ot'ly clocked linguaIIy will contact

between the cen'rcl incisor crd corinc. Sucn cterals -nay bo

a lower incisor moy have to be extracted.

a. If one of the incisors is completely out of the cch
with good inter-dental contact between the rest of
the teeth (fig 5).
midi Tie. Such a ccnine may be ndiccted ror cxvaction !B| rodiograpn of Ine sane patien*.

crowding, one of the lower incisors nay be

extracted to achieve normal overjet, overbite and
to relieve crowding.


Canines are not frequently extracted as a part o* orthodontic treatment.

The extraction of canines is said to cause flattening of face, altered
facia! balonce and change in focial expression. In addition the contact
produced between the premolar and lateral incisor is rarely
Some of the conditions under which canrnes may
have to be extracted are :
a. The canines develop faraway from their final locotion. In addition
they nave a long path of eruption from their site of development
to their final position in the oral cavity. Thus the canines arc highly
susceptible to ectopic eruption end impaction (fig 6 and '/).
Such unfavorably impacted canines or canines that have
erupted in unusual locations may hove to be removed.
b. A canine that is completely out of the arch with reasonably good
contoct between the lateral incisor and first premolar is an
indication for its extraction.

Fig 7 (A| A orfovojrob'y impeded jppc o:t carine ccn be c. Premature shedding of o deciduous canine
extracted as it is ci^icj.t to sirgicaily expose arc allign with
orthodontic TectTieiv. (B) Radiograph of the aa'ient

Fig 8 (A) Ext'cction of f:rst cremolars gives g'eater posterior

anchorcco -hcreforc more space is ova lable for anterior refraction. (B) extraction of secorc prernclor resu'ts in less onchorage pos'e'icly
end the'e:ore -he posteriors move forwards . Thus esser space is ova lab!c :or an-cic rotrodion

usually indicates the extraction of its fellow on the anchorage for the retraction of the six anterior
opposite side of the arch to restore symmetry. teeth.
d. In Class II coses if the lower deciduous canines The following a'e some of the indications
are shed early, the upper deciduous canines for first premolar extraction :
should also be removed so as to avoid worsening a. They are the teeth of choice for extraction to
of the post-normalcy (Class relieve moderate to severe onterior crowding of
II tendency). the upper or lower arch (fig 9.a).
e. In Class III cases if the upper deciduous canines b. The first premolars ore extracted for correction of
are shed early, it moy necessitate the extraction of moderate to severe anterior proclination as in a
the lower deciduous canines to avoid worsening Class II, division 1 malocclusion or a Class I
of the pre-normalcy (Closs bidentel protrusion {fig 9. b &c).
III tendency)
Deciduous canines moy be extracted as a part of
serial extraction procedure.
The indication for extraction of second premolars
The first premolars are the most commonly extracted a.
teeth as part of orthodontic treatment. The reason for The extraction of second premolars instead of the
their extraction is as follows : first premolars results in the anchorage of the
a. Their location in the arch is such that the space anterior segment being strengthened {fig 8). Thus
gained by their extraction can be utilized for an environment is creoted that favors mesial
correction both in the anterior as well as the movement of the posterior teeth. The second
posterior region. premolars are usually extracted to treat mild
b. The contact that results between the canine and anterior crowding. The remaining space can be
second premolar is satisfactory. closed by controlled mesiol movement of the
c. The extraction of the first premolar leaves behind a molars.
posterior segment that offers adequate

b. The second premolars ore usually extracted when
4-5 mm of anchorage loss is deliberately desired.
c. Whenever the second premolars are unfavorably
impacted, it is preferred to extract them rather than the
first premolars (fig 10. a & b ) .
d. If extractions are to be undertaken in open bite
cases, it is preferable to extract the sccond premolors as
their extraction encourages deepening of the bite.
e. In case of grossly carious or deeply filled second
premolars, it is wise to extract them and preserve the first
f. Early loss of a deciduous molar may cause forward
movement of the first permanent molar leaving
inadequate space for the second premolar to erupt. In
such coses, the second bicuspid erupts completely out
of the arch. Such a tooth may be indicated for extraction
{fig lO.c&d).

Fig 9 Indications for firs- premolar cxtraction(A) Severe crowd

ng is usually -rented by ermoion o: first premo'of (8) ond fC!
8imax llory protrusion ere also treated by extraction of first
The first molars are not commonly extracted in premolars
conjunction with orthodontic therapy. Extraction of the
first permanent molars is avoided for the following
b. The extraction of the first molar results in
deepening of the bite.
a. The extraction of the first molar does not give
adequotc space in the incisor region. c. The
mild second
crowdingond molar
or mild may tip into the
extraction spacc.
d. Mastication may be affected.
The indications for first rnolor extraction are
os follows:
a. Minimal space'requirement for corrcction of
^ 10 Indicat ors h' second prerrola' extraction fAJ ond s entirely (ft! ectopic second n'enolar fC) end (D) Seconc premolar "hat loss o:
blocked ling-jally. This cfen occurs due -o ecrfy -clar drihinq decidjo'js second mo cr resulting n the ;irst permanent moy erupt
rnesia ly. The second premolar in such coses lingua ly dee to inadeqjacy ot soace

r. Grossly dccaycd molar or heavily filled teeth. : Open c. The removal of the first molars deprives the

bile coses can benefit from extraction of first molar as orthodontist of adequate anchorage for any

there is a tendency for the bile to deepen ofter orthodontic appliance.

extraction of first molars.

Wilkinson extraction
Wilkinson advocated extraction of all the four first
permanent molars between the age of 81/2 - ?T/2
years. The basis for such extractions is the *cct that the The extraction of second permanent molars although not
first permanent molars are highly r.sceptible to caries. common, is advocated fora number of reasons, as
The other benefits of exacting the first molars ot an follows:
early age are : Their extraction provides additional
spoce for eruption of the third molars. Thus impaction
of third molars can be avoided, ir. In general, crowding
of the arch is minimized. Thus the other teeth have a
lower risk of caries.
Wilkinson's extraction has a number of
drawbccks. The following ore some of them :
a. The extraction o* first molars offers limited space
to relieve crowding.
b. The second bicuspids and second molars rotate
and may tip into the extraction space.
A. To prevent third molar impaction : The the extraction space car also move distally into the space.
removal of second molars has been advocated for the Thus the midlines of the arch may shift to the side of the
prevention of lowerthird molar impaction. The cases extraction space. To avoid such unestheticshife of the
268 f Orthodontics - The Art and Science
that benefit from such extractions are those where tne dental arch, balancing extractions are advocated.
third molars are upright or not tipped mesially more Balancing extraction refers to removes of another tooth
than 30g. Upper second molar extraction if carried out on the opposite side of the same arch.
prior to the eruption of the third molars, results in
satisfactory third molar position.

8. To relieve impaction of second premolar: Compensating extraction refers to extraction o*' teeth in
The premature loss of second deciduous molars is opposite jaws. Compensating extractions are carried out
usually followed by forward drift of the first permanent to preserve the buccal occluso; relationship. In a Class I
molars leaving inadequate space for the second relation it is usually advisoble to extract in both the arches
bicuspids to erupt. The extraction of second molars in to preserve the buccal occlusal relationship.
such coses may allow the distal movement of the first
permanent molars thereby offering sufficient spoce for EXTRACTIONS OF PERMANENT TEETH
the second premolars to erupt. WITHOUT APPLIANCE THERAPY

C. Lower mdsor crowdr'ng : Very mild crowding in Most therapeutic extractions are followed by active
the anterior part of the arch can be relieved by appliance therapy. However there may be instances
extraction of the second molars. Some authors when extraction of a permanent tooth not be followed by
suggest that extraction of second molars minimizes orthodontic therapy for varied reasons such as
anterior imbrication and crowding.
non-availability of specialist,
D. To enable distalization of first molars : In
cases where the first permanent molars are to be
distalized, the extraction of second molars can benefit
the procedure.

E. Open bite cases : The extraction of the second

molars deepens the bite. Thus they can be considered
in open bite cases.


Extraction of third molars during orthodontic treatment

does not yield spaco that can be used for decrowding
or reduction of proclination. Third molars are extracted
for otner reasons as follows: a. Grossly impacted third
molars that are unable to erupt into ideal position are
b. The erupting third molars have b implicated to
be the cause for late I r anterior crowding.
Although this theory not been confirmed it
nevertheless may some role in lower anterior
c. Malformed third molars that interfere wtii normal


Removal of a tooth from one side of a dei arch results

in a tendency for the rest of thete to move towards the
extraction space. The tee*" distal to the extraction
space move into the spcce while the teeth mesial to
Maxillary A. Unfavourably impacted incisors B. Totally
space leading toExtractions ^289
blocked bucalty or lingualty
C. In case one lateral is congenitalty missing, the non-coincidence of the
midlines and asymmetry. Another factor is the buccal
occlusal relationship. iVicsial migration tendencies

Teeth Indications may often upset the buccal occlusol relationship of the
dentition. In order to preserve the relationship,

other maybe extracted to maintain symmetry

extractions may have to be done in both the orches
Grossly carious unless undue migration or tooth movement is required
Malformed incisors that cannot be restored with
in a particular arch.
Dilacerated indsor
Mandibular A. Totally blocked bucally or lingually incisors B. Severly
1. Beck and Harris : External apical 'oot resorption. Am
traumatized, gingival recession or bono toss C. Severe arch length J Orthod 1994 ; 350-361
deficiency with fanning of leaver anteriors 2. Berrstein : Edward H. Angle versus Calvin S. Cose:
Extraction versus nonextraction. Am J Orthcd 1992 ;
Canines A. Ectopically erupted or unfavourably impacted
B. Totaly blocfced bucally or lingually 464-470
C. Dedduous canine extracted as part of serial 3. Bisharo aid Andreasen : Third molars. Am J Orthod
extraction 1983,131-137
4. Bisharo and Burke/ : Second molar extractions. An J
First premolar To relieve moderate to severe crowding and prodlnation Ortnod 19S6 ;415-424
5. Bisharo, Cummins, ond Jokobsen : Morphologic basis for
Second A. To relieve mild crowding and premolar proclination where
extraction decision. Am J Orthod 1995 ; 129-135
anchorage loss is desirable
B. Unfavourably impacted
C. In open bites, they are preferred over first
6. Ch'pmcn : Second and third molars: Their role in
1-ic iheropy. Am J Orthod 1961 ,- 498-520
premolars as deepening of bite is encouraged. orthedon
D. If grossly decayed or has a targe filling vrfth
questionable prognosis, then they are extracted
Instead of first premolars.
First molar A. Minimal spsce requirement to
correct mild crowding or proclination
B. Grossly decayed or heavity fitted
C. In open bites as their extraction encourages
deepening of bite.

Second molar A. To prevent third molar impaction

B. To relieve impaction of second bicuspid
C. To enable distalization of first molar

Third molars Not extracted for orthodontic

purposes. May be extracted for other reasons such
as carles, malformed or impacted tooth.

patient unsuitable for fixed appliance thercpy etc.

Teeth have a natural tendency to drift into
extraction space. The extent of this tipping varies
from patient to patient and depends on various
factors such as the extent of crowding and age of
the potient. The long term effect following extraction
of permanent teeth is the mesial migration of the
posterior teeth, the mesial drift is usually rapid in
young age when the teeth are still in a state of
active eruption and the jaws are still growing.
Extractions of the lower first premolar is
often associated with spontaneous decrowding of
Ihe lower anteriors. Such spontaneous decrowding
by drifting of teeth, referred to as driftodonticsare
less frequent in the upper arch.
While considering such extractions it is
always advisable to extract in a balonced manner
so as to preserve the integrity of the arch. Extraction
of a permanent tooth on one side of the arch would
result in shifting of the teeth towards the extraction
Orthodontics - The Art and Science
7 Dewel : Prerequisites in sere I extraction. Am J Orthod
8. Dewel : Serial extraction orthodontics: Indicators,
objectives and treatment prccecures . Am J Orthod
195^ 906 -926
9. Dibbols ard van der Weele : Exlradion. orthodontic
treatment, and CM3. Am J Crthcd 1991; 210-2" 9
10. IHcte ; Gjidcnce Ot eruptions verses serial exlruc- ton. Air
J Orthod 1970; '-20
11. Klapper, Ncva-ro, Bov/nior, ond Pawlowski : E "tecs ot
extrnd'or ard ronex'radion trea'ment on growtn pafcrns.
Arr- J Orhoc 1992 ; 425-430
12. Little, Wallon, and R edel : Mandibular cnterior
alignment first premolar extraction cases trected by «
Bdgewise onhocort cs Am v Crthcd 1981 ;349-365
13. Profir WR: Contemporary Grtnorfonl cs, St Louis, CV
Mosby, 1986.
' 4. Rofcer E Moyers : Hand book ot Ofthcdonrics. Year
book mediccl publishes, inc. 1988 "5. Slodov, Benrents, and Dobrowski : Clinical experience with
ttiiro rno ur orthodontics. Am J Orhod 1989; 453-46" 16. Staggers : First premolar extraction. Am J
Ortnod 1994; 19-24
17- Vig, Weintraub, Brown, and Kowa ski : Djrat'on ot
orthodontic veawen- with and without extractions. Am J
Ortnod 1990 ; 45-51 18 Weintrctb, V'g, Brown, and Kowa so :
Orthodontists' extraction 'ctes. Am J OnhoO 1989 ; 462-466
rthodontic elastics, screws, etc.,. These appliances can be

O treatment aims at
improving the
esthetics and
further classified as removable and fixed appliances.
Myofunctional applionces are loose fitting or
passive appliances that harness the natural forces of
function of the the oro-faciol musculature which are transmitted to the
orofacial region. teeth and alveolar bone through the medium of the
Most of these appliance. These appliances either transmit, eliminate
or guide the natural

odontic Appliances perioral

forces on
to the

eral Concepts dentition

. Unlike

jnges are appliances the myofunctional appli-

brought about
using devices
which /e teeth or
modify the
growth of the jaws. These /ices are called orthodontic
Orthodontic appliances ore devices by ins of
which mild pressure may be applied to ; 'ooth or
group of teeth and their supporting tures so as to
bring about necessary changes lin the bone which
will allow tooth movement.


5-oadly the appliances can be classified info two

~oups : Mechanicol appliances
a. Removable appliance
b. Fixed appliance
2. Myofunctional appliances
a. Removable appliance
b. Fixed applianc

Mechanical appliances exert mild pressure

on a tooth or a group of teeth and their supporting
structures in a pre-determined direction with the help
of active components which are part of the appliance
itself. The active components may include springs,
282 f Orthodontics - The Art and Science


t J The■ removable nature ot -he

appLance makes it possible for the

patient to maintain good orai- hygiene,curing .ortftcctonlic therapy. In -

acdtior) the applianoo can be Kept o'ean by fte patient. 1) As the appliance can. be removed, partem

21 Most nalocdivs'ons requiring lipping type of tooto movement can cooperation is vitally, important for the

vv^v^5,feadily;cctrtied out usitg removable:'appliances. success of the ireatmeni:^^:

3j Many tooth movements like lipping, over bile reduction can be undertaken. 2) . Removable appliances are capable ot

4} Removable appliances are fabricated in the laboratory utilizirg less chair side time oniy tipping tooth movements. This is a

of the orthodontist, major limitation of removable appliances.

51 As these.appliances lake less chair side time, the orthodontist cari handle, mote 3} Whenever multiple tooth movements are to be

number at patents. • earned outfit should be dene one at a time.

6) Removable appliances, bring 3bout lipping loo'h movement. Thus . Jesse? Thuslfto treatment durafon is prolonged in

lorces are used than those needed for bodily tooto movement. case of severe malocclusion.

As forces employed are less, the strain on the anchor teeth is lesser lhan in 4): Multiple rotations are difficult'to treat using

fixed appliance therapy. removable appliances.

7) Removable appliances can be used by general dental practitioners who have 6) In cases requiring extraction, it &Veiy

received adequate training. This makes is possible tor tl>e specialists: to difficult to close residual space by forward

concentrate on more atftcu-t cases. movement of posterior leeih.

8) The fabrication ol removable appliances need less inventory. 7) ' As the appliances are removable, there

9) They are relatively less expensive than, fixed appliances. is a greats chance of patient misplacing or

10} As removable appliances take less chair side time and are by far less expensive damaging them.

than fixed appliances, tteycan bo 'used in community, based programs where 8) Patients should exhibit enough skill to

in a large number bt patients are treated, remove and replace the appliance without

Removable appliances, are less conspicuous than roultibanded. fixed, distorting them.

appliances. ?j They cannot be used to treat severe cases of

Damaged appliances thai apply undesirable forces can be removed by the Class II and Class 111

patient O malccdusions.wlh unfavorable growth pattern,

ancesdo not usually contain active components. including the ability to maintain oral hygeine and the
Functional appliances are used for growth modification need for less chair side time. The main drawback of
procedures that are aimed at intercepting and treating these appliances is the need for patient cooperation
jaw discrepancies. and the inability lo perform complex tooth movements.
Both mechanical and the myofunctional Refer to table 1 for advantages and disadvantages of
appliances can be classified as removable and fixed re-
appliances. Removable appliances as the name
suggests are appliances which can be inserted into
and removed from the oral cavity b, the patient.
Removable appliances offer a number of advantages

^g 1 Orthodontic opplicnces (AJ How-ley's appliance with Z springs - n removable mechanical applionce (3) A removable inechonica!
opplicnce incorporating a screw for arch expansion (C) & |D; Fixec mechonical appliances (E) Hyrex expander ; fixed mechonical
appliance used for skclcta exparsion (F) Quad helix • a fixed mechcnica appliance for expansion

movable appliances. Removable appliances are also to a lorge extent remove the need for patient
jsually used for simple tooth movements that can be compliance. Table 2 gives the advantages and
brought about by tipping. disadvantages of fixed appliances. Fixed appliances
Fixed appliances are those that are fitted can bring obout various types of tooth movement
onto the tooth surfoce and can only be removed only including tipping, bodily movement, rotations, intrusion
by the operator. These appliances ere versalite and ond extrusion.
offer a number of advantages overthe removable
appliances. These appliances offer better control ond


1} Patent cooperation is dispensed with to a large removable appliances, they nevertheless have a number of disadvantages

extent in the use ot lixed appliances. The which are lisled as follows :

orthodontist does nol depend on ihe patieni 1 ) The most important disadvantage of a fixed appliance is oral hygisne maintenance

for timely wear ard management of Ihe which becomes more difficult. Plaque and food debris tend 1O accumulate around

appliance. the attachments and cleaning of teeth becomes more difficult tor the patieni due to

2) It is possible to bring about various types of their enirapmenl around the various attachments.
tooth movements, such as tipping, bcdjfy 2 ) . Fixed appliances are more lime consuming to fix and adjust. Thus tney take

movement, rotation, intrusion and extrusion. up more chair skla time unlike removable apples which can be fabricated at the

3) Multiple tooth movements are possible laboratory.

simultaneously. As many tooth movements 3} Fixed appliances are more conspicuous man removable appliances. Unless modern

are undertaken at the same time, the tooth colored appliances are used, Ihey may not be pleasing esthetically.

trealment duration is considerably reduced. 4) Fixed orthodomic appliances require special training of the operator and ar8

4) More precise tooth movements and detailing invariably handled by specialized orthodontists.

ot occlusion is possible using fixed appliances. 5) Damaged appliances, that apply mis-directed forces cannot be removed by the

5) Fixed appliances can be used to treat mosi patient.

malocclusions including very complicated 6) The patient has to visit Ihe orthodontist at regular interval.

ones. 7) Fixed appliances are by lar more expensive than removable appliances.

6) Fixed appliances offer better control over 8) Unless the treatment is done by a skilled operator who has been irained to use fixed

anchorage. appliances, there is a greater possibility ot producing adverse

Although t«ed appliances have a number of . tooth movements.

advantages as compared to

Passive and active appliances

Orthodontic opplionces con also be classified as active and
passive appliances. Active appliances exert a force on Ihe
teeth or Ihe supporting structures to bring about the
necessary tooth movement. Passive applionces are mostly
used to retain teeth which have been moved to ideal
location. Active and passive appliances can also be
classified as removable and fixed appliances



Appliances which are used for orthodontic purposes should

fulfill certain requirements. These requirements can be
discussed under the following four headings:
Fig 2 Ortiodontic appliances (A) Bonded retairer • a fixed passive oppliance (B) Bandec relciner • a :ixec pessive appliance (C) Hav/leys
reta'nsr - a re-iovable passive oppl'cncs (Dj Herusl appliance - a fixed r-.ycfj-ic'ional appliance T) Activator • a removable myo'vrctknal
appliance (F) Jasp-cr jumper • a fixed myofunctional cppl'cnce.

1. Biologic requirements d. It should not interfere with normal function.

2. Mechonicol requirements e. The appliance should not bring about sudden
3. Esthetic requirements changes.
4. Hygienic requirements

B/o/og/c requirement
o. The appliance should bring about Ihe desired tooth
b. The orthodontic appliance should not produce
pathologic changes such as root resorption, periodontal
damage or non vitality of the teeth.
c. The appliance should not interfere with normal growth.
f. It should not bring about unwanted tooth movement.
g. The material used in its fabrication should be
276 Orthodontics Theshould
Art not
andproduce toxic effects.
h. The appliance should not disintegrate in oral fluids.

Mechanical requirement
a. The appliance should be simple ro fabricate.
b. It should not be bulky. The patient should be
comfortable using them.
c. The applionce should be strong enough to withstand
d. The appliance should be able to deliver controlled
force. It should apply a force of desired intensity,
direction and duration.
e. The appliance should be universally applicable i.e. it
must be able to handle various malocclusions.

Hygienic requirement
The orthodontic appliance should ideally be self- cleansing.
If not it should be eosy 1o clean them. The appliance should
not interfere with oral hygiene maintenance.

Esthetic requirement
The orthodontic appliance should be esthetically
acceptable. It is desirable to have an appliance that is os
inconspicuous as possible.


1. Adams : Removoble appliances yesterday and today. Am v

Orthod 1969 ; 202-213
2. Adams CP: Tne design and corstrjclion of removable
Orthodontic appliances, 5th edition,Wright, Bristol. 1984.
3. Foster TD : A textbook of Orthodontics, Bluckv/eil Scientific.
Oxford, 1 982.
't. Goullschin and Zilberman : G rgivel response ro removaale
orthodontic appliarces. Am J Orthod
1982 ; \4 7-149
GrabBr Tfvl, Neumann B : Removable Orth Appl-'onces, WB
Saunders, Philadelphia, 1984.
Protitt WR: Contemporary Ortncdonrics, 5t CV Mosby,l 986.
Robert E Moyers : Hanc hook of Orlhodon'ics, book medical
publishers, inc,1988.
Sclzman JA : Proclice of Orthodontics, J3 Lippi company, 1966
Tang end Wei : Treatmeni effectiveness of orth tic appliances.
Am J Orlhod 1990 ; 550-556

emovable orthodontic applionces, as the term
suggests, are devices that con be in serted into
and removed from the oral cavity by the patient at
will. Removable appliances were used routinely in the 19th
century. However they were crude and were made of
precious metol wires which lacked the mechanical
advantage of ♦he modern wires. The development of the
modi- ;ied arrow head clasp by Adorns in 1950 brought
about a see chonge in the way the removoble appliances
were looked at. The modern day appliances are fabricated
using stainless steel and acrylic ond ore more efficient than
their predecessors.
Although removable appliances can be
effectively used to treat a number of minor mal-
occlusions, they are often ignored and the more complex
fixed appliances used instead. However removable
appliances continue to be the appliance of choice in treating
certain conditions. Removable appliances can olso be used
in conjunction with fixed appliances and for retention ofter
treatment with fixed oppliances.
In America, the term removable appliances
generally means functional appliances that use the orofacial
musculature. In the European countries, removable
appliances are considered to be of two kinds. The first
catagory includes appliances which ore clasped to the teeth
and are referred to os fixed plates. The other cofagory
includes removable appliances, which lie loosely in the
mouth and produce their effect by modifying the pattern of
activity of the orofacial musculature and hence the
pressures produced on the teeth by these activities. In this
chapter we limit our discussion to the clasped mechanical
appliances that are used to bring about various tooth
movement. The appliances that make use of
muscle forces ore discussed separately os myofunctional Appliances that are loosely fitting end do no: have
appliances. adequcte intraorc i anchorage cannot bring about the
Removable orthodontic appliances offer a necessar. -ooth movements. Adequate retention of a
number of advantages including tne ability to maintain oral removable appliance is ochieved by incorporating
nygiene and the need for less chair side time. The main certain wire components that engoge undercuts on the
disadvantags of removable appliances is the need for reeth. These wire components that aid in retention of a
patient cooperation. Failure to adhere to prescribed removable appliance cro called clasps.
removable cppliance wear schedules will result in either
slow trectment response or no response ct all. Table 1 Mode of action of clasps
summarizes the advantages and the disadvantages of the Closps act by engaging certoin constricted areas of the
removable appliances. teeth that arc colled undercuts. When clasps are
fabricared, rhe wire is mode to engage these
undercuts so thot their displacement is prevented.

Removable appliances work by applying a single force on There are two types of undercuts that are found in

to the crown of the teeth. Thus removoble applionces act by natural dentition.

tipping -he tooth around its centre of resistance. Tipping a) Buccal and lingual cervical undercuts (fig l.a).

can be brought about in the mesio-distal or bucco-lingual b) Mesial and distal proximal undercuts (fig

direction. Tne key point ro be considered is 'he posi tion of l.b&c}.

rhe root apex before the begining of trectment. Tee"h thct Buccol / lingual cervical undercuts : The buccal
have their apex or the correct position are ideally suired for and lingual surfaces of molars have a distinct undercut
treatment with removable cppliances. In such patients the at the cervical margin. These can be seen from the
irregularis/ is usually due to rhe crown being tipped from its mesial aspect of a molar.
correct position and therefore respond well to tipping tooth
movements possible using a removable orthodontic
Removable appliances are generally considered
ineffective in bringing about bodily translation, derotation
and uprighling of teeth due to the single point of contact of
these appliances. Intrusions and extrusions using
removable applionces are often mediated using the forces
of eruption and occlusion. In addition the acrylic base plate
of the oppliances also can be designed by incorporating
biteplanes that can aid in selective extrusion or intrusion of
the tooth. The bite planes include the anterior ond the
posterior bite planes.

Removable appliances are made up of three bc- sic

a. Rerentive components
b. Active components
c. Base plate


They are components rhat help in koeping the opplicnce in

place and resist displacement of the appliance. The
success of a removable appliance is to c large extent
dependent upon gooc retention of rhe applicnce.
2) It should permit usage in both fully erupted as
Removable Appliances • jj^J

well as partially erupted teeth.

3) It should offer adequate retention even in the
presence of shallow undercuts.
4} They should not by themselves apply any active
force that would bring about undesirable tooth
movements of the anchorage teeth.
5) It should be easy to fabricate.
6) It should not impinge on the soft tissues.
7) It should not interfere with normal occlusion.

Circumferential clasp

Fig 1 (A) Cervical undercut (B) & [C) Mes ol and dis'ol oroximal
The circumferential clasp is also known by the terms
unde'cut three-quorter clasp or 'C clasp. They are simple clasps
thot are designed to engage the bucco-cervical
Examples of clasps that engage these buccal and
undercut (fig 2). Wire is engaged from one proximal
lingual cervical undercuts are the circumferencial
undercut along the cervicol margin then carried over
clasp and Jackson's clasp. These undercuts are
the occlusal embrasure to end os o single retentive
available for clasp fabrication only in those teeth that
arm on Ihe linguol aspect thot gets embedded in the
are fully erupted.
acrylic base plote.
Mesia) and distal proximal undercuts : The molars Advantage of this clasp is its simplicity of
are widest mesio-dislally at the contoct point and design and fabrication. Disadvantage of this
gradually taper towards the cervical margin. These
surfaces slopping from the mesial and distol contact
areas towards the neck of the teeth are called the
mesial and distal proximal undercuts. They can be
seen when the mo- 'or is viewed from the buccal
aspect. These proximal undercuts aro more
pronounced than the cervical undercuts and therefore
offer more retention. Examples of clasps that engage
undercuts are the Adams clasp and Crozat clasp.

Requirements of an Ideal clasp

1) II should offer adequate retention.
The Adams clasp offers a
Fig - Adams clasp (A) Buccal view (BJ Occlusal view

number of ad vantages which are listed

clcsp is that it cannot be used in partially erupted teeth below:
wherein the cervical undercut is not available for clasp 1) It is rigid and offers excellent retention.
fabrication. 2) It can be fabricated on deciduous as
well a: permanent teeth.
Jackson's ctasp 3) T hey can be used on partially or fully
erupted teeth.
This clasp was introduced by Jackson in the year 1906. It is
4} It can be used on molars, premolars
also called full clasp or 'U' clasp. This clasp engages the
and incisors.
bucco-cervical undercut and also Ihe mesial as well as
5) No specialized instrument is needed to
distal proximal undercuts (fig 3). Wire is adapted along the
fabricate the clasp. Young's universal
bucco- cen/ical margin and both the proximal undercuts,
pliers that is used routinely for most wire
then corried over both the occlusal embro- sures to end as
bending can be used.
retentive arms on both sides of the molar. The advantage of
6} It is small and occupies minimum space. 7)
this clasp is that it is simple to construct and offers adequate
The clasp can be modified in a number of
retention. The disadvantage of Jackson's clasp is that it
ways.(fig 8)
The Adams clasp con be modified in
offers inadequate retention in partially erupted teeth. a number of ways. These modifications permit ad-
ditional uses or enhanced retention. The following are
Adams clasp
some of the modifications of Adams clasps:
The Adams clasp was first described by Professor Phillip
Adorns. It is also known as Liverpool clasp, universal clasp
and modified arrowhead clasp. When properly constructed
this clasp offers maximum retention. The closp is
constructed using 0.7mm hard round stainless steel wire.
The Adams clasp is made of the following parts :
a) Two arrowheads
b) Bridge
c) Two retentive arms The two
arrowheads engage the n
and the distal proximal undercuts (fig 4}. arrowheads are
connected to each other by bridge which is at 45° to the
long axis
Fig 5(A) Tho lergth of -he bridge is determined by mo iking 'he proximol crdercuts (B) & (Cj Two right onglc cerris
are mode to :0'm the bridge (D)&(E) "no f rst orrov/hocc is formed (FJ The arrowhead is scueezed slighty'o hove the
correct width of arrowhead [G) The second arrowhead is comple'ed (H) Thefi'starrowhead s bent fo a oryle of 45
degrees tothebricce
292 f Orthodontics - The Art and Science

Fig 6 Ma<ing of Adams clasp continued (A) The second arrownead is also hep.M5derjreesto the bridge to sent the
arrowheads over tne proximal undercuts. (6) I ho outer aim of the arrowhead is bent 90 dcgices at a level that is holf
Ihe height of the bridge. The wire snould pass over tne embrasure when the closp is placed in normal position |Q
,(D)&(E) The cross over wire is bent to pass over the occlusal embrasure (FJ The cross over wire tt stepped down
jus* beyond the proximo contact [G) A small step is made in ihe retentive arms to go over the pelalai marginal
gingiva (H) The retentive tags a.'e bent a: the end of the retentive arms.
Removable Appliances

last erupted molar. The bridge is modified to encircle

the tooth distally and ends on the polafal ospect as a
retentive arm (fig 8. a).

Adams with J hook : A J hook can be soldered on to

the bridge of the Adams clasp. These hooks are useful
in engaging elastics (fig 8. b).

Adams with incorporated helix : A helix can be

incorporated into the bridge of the Adams clasp. This
also helps in engaging elastics (fig 8. c).

Adams with additional arrowhead : Adams

clasp can be constructed with an additional ar-
rowhead. The additional arrowhead engages the
proximal undercut of the adjacent tooth and is
soldered on to the bridge of the Adams. This type of
clasp offers additional retention (fig 8.d).

Adams wrfb soldered buccal tube : A buccal tube

can be soldered on to the bridge of the Adams clasp.
This modification permits use of extra-oral anchorage
using face bow - head gear assembly (fig 8.e).

Adams with distal extension : The Adams clasp can

be modified so that the distal arrowhead hos a small
extension incorporated distally. This distal extension
helps in engaging elastics P9 8.f|.

Adams on incisors and premolars : Adams clasp

can be fabricated on the incisors and premolars when
retention in those areas are required. They can be
constructed to span a single tooth or two teeth (fig
^g 7 Completed Adams closp (A) Occlusal view - bridge -zvay 8.g).
from the teelh and parallel to the buccal surface. |B) rrdge 45C 'o
long axis of toolh. (c)9uccal view - bridge dose to middle third
ond parallel to occlusol sur'ace
Southend clasp

The Southend clasp is used when retention is required

in the anterior region. The wire is adapted along the
Adams wiffi srng/e arrowhead : The Adams dasp cervical margin of both the.central in-
can be modified to have a single arrowed. This type of
clasp is indicated in a partially erupted tooth which
usually is the last erupted •-olar. The single arrowhead
is made to engage -e mesio • proximal undercut of the
284 Orthodontics - The Art and Science

Fig 8 Modifications of Adorns closp (A} Single orrowheod Adams clasp IB) Adams with J hook }C) Adams with helix (D.i Adorns with
additional arrowhead \C> Adorns with soldered buccal tube {F| Adams with distol extension (G) Adams on incisors.

cisors. The distal ends are carried over the occlusal

additional retention is needed (fig 9 c). Ball
embrasures to end as retentive arms on •he palatal side (fig
- end clasp

Triangular clasp This closp is fabricated using stainless steel wires

having a knob or a ball like structure on one end (fig 9
They are smoll triangular shaped clasps that are used
B). The ball can be made at the end of the wire using
between two adjacent posterior teeth. Thus ♦hey engage the
silver solder. Pre-formed wires having a ball at one end
proximal undercuts of two adjacent teeth. Triangular clasps
are also available.
are indicated when
The ball engages the proximal undercut
between two odjacent posterior teeth as in a triangular This type of labial bow is constructed using 0.7m."
clasp. The distal end of the wire is carried over rhe hard round stainless steel wire. The short labio bow
occlusal embrasure to end on the palatal aspect as a consists of a bow that makes contact wi~ the most
286 f Orthodontics - The Art and Science
retentive arm. The ball-end clasp is indicated wnen prominent labial teeth and two U loops that end as
additional retention is required. retentive arms distal to the canines (fig 10). This type
of labial bow is very stiff ore exhibits low flexibility.
Schwarz clasp
Thus they are indicated on!, in cases of minor overjet
The Schwarz closp or the arrownead clasp can be said to reduction and anlerio- space closure. The short labial
be the predecessor of the Adam's clasp. The clasp is bow can also be used for purpose of retention at the
designed in such a way that a number of arrowheads termination of fixed orthodontic therapy.
engoge the inter-proximal undercuts between the molars The short labial bow is activated by com-
and between premolars and molars (fig 9 a). This clasp is pressing the U loops. The activation should be such
not ; used routinely due to a number of drawbacks : that the labial bow is displaced palotally by 1mm.
1) Needs special arrowhead forming pliers to fobricate.
2) Occupies a large amount of space in the buccal
3) The arrowheads can injure the interdental soft
4) It is difficult and time consuming to fabricate.

Crozat clasp Fig 10 Shorr Icbicl bow

This clasp resembles a full clasp but has an additional
piece of wire soldered which engoges into the mesial and
distal proximal undercuts. Thus it offers better retention
than the full clasp(fig 9 d).



They are components of the appliance which exert forces

to bring about the necessary tooth movement. The active
components include :
1) Bows
2) Springs
3) Screws
4) Elastics

Bows are active components that are mostly ui=3 for incisor
retraction. There are various types bows routinely used by
the orthodontist. The lowing is a list of some of the
commonly u labial bows.
1. Shon labial bow
2. Long labial bow
3. Split labial bow
4. Reverse labial bow
5. Robert's retractor
6. Mills retractor
7. High labial bow with apron springs
8. Fitted labial bow

Sftort labial bow

Removable Appliances 287

Fig 12 Reverse Icbicl bow is

activated by opening the
loop. This resul'8 in
lowering of 'he bow rrorc
incisally. (B! Compensatory
bend given to r-antain
proper level of bow
Fig 1 1 Long labial bow
vation of this labial bow is done in two steps. First the U
Long labial bow loop is opened. This results in lowering of the labial
This labial bow is similar to the short labial bow ; except that bow in Ihe incisor region. A compensatory bend is then
it extends from one first premolar to —e opposite first given or the base of the U loop to maintain proper level
premolar. The distal arms of the > I loops are adapted over of the bow (fig 12).
the occlusal embrasure between the two premolars to get
embedded n the acrylic plate(fig 11).
Robert's retractor
The indications of long labial bow are : Minor This is a lobiol bow mode of thin gauge stainless steel
anterior space closure Minor overjet reduction Closure wire having a coil of 3 mm internal diameter mesial to
of space distal to canine Guidance of canine during the canine. The use of thin 0.5 mm diameter wire along
canine retraction using palatal retractor As a retaining with increased wire length due to the incorporation of a
device at the end of fixed orthodontic treatment coil makes the
The activation is similar to that described •b'short
labial bow. A modified form of the long cbial bow can be

n. made by soldering Ihe distal crm of the U loops on to the

bridge of the Adams e'esp.

Split labial bow

This is a labial bow that is split in the middle. This results in
two separate buccal arms having a L loop each (fig 13.a).
This type of labial bow exhibits increased flexibility as
compared to the conventional short labial bows.
The split labiol bow is used for anterior —•'action.
A modified form ofsplit labial bow can be used for closure of
midline diastema (fig 13.b). In this form, the free end of the
buccal arms are made to hook on to the distal surface of the
opposite central incisor.
The split labial bow is activated by compressing
the U loop 1 -2mm at a time.

Reverse labial bow

This is also colled reverse loop labial bow. Here the U loops
are placed distal to the conine and the free ends of the U
loops are adapted occlusally between the first premolar and
canine {fig 13.c). As a longer span of wire is incorporated,
the bow exhibits increased flexibility. Indications for use are
similar to that of short labial bow. The acti-

Fig 13 (A) Split laoial bow for retraction of onleriors (B) Sp it labial bow for closure of midline diastema (C) Reverse lobtci bow (D)
Roberts retractor (E) Mills retractor (F) High labial bow with apron spring
labial bow highly flexible (fig 13.d).
As very thin wire is used for its fabrication, the bow
is highly flexible and lacks adequate stability in the vertical
plane. Thus the distal part of the retractor is supported in a
stainless steel tubing of 0.5 mm internal diameter.
The Robert's retractor is indicated in patients
having severe anterior proclination with over jet of over 4
mm. As Ihe bow is highly flexible it generates lighter forces.
Thus they can be used in adult patients in whom lighter
forces are desirable.

Milts retractor
This is a labial bow having extensive looping (fig 13.e) of the
wire so as to increase the flexibility
zr.d range of action (ability to remain active over tended Springs that are designed to bring about various tooth
periods of time). movements should possess certain ideal requisites.
Mills retractor or extended labial bow as * is
Removable AppliancesThey are listed below:
sometimes called is indicated in patients with c large a. The spring should
overjet. The disadvantages of the Mills -"'roctor include be simple to fabricate.
difficulty in construction and roor patient acceptance due to b. It should be eosily adjustable.
the complex de- of the bow. c. It should fit into the available space without

discomfort to the patient.
labia t bow with apron springs

E consists of a heavy wire bow of 0.9 or mm

ickness that extends into the buccal vestibule Sg
13.f). Apron spring made of 0'4 mm wire is reached to the

It should be easy to clean.
It should apply force of required magnitude and
It should not slip or dislodge when ploced over a
high labial bow. The apron spring be designed for
sloping tooth surface.
retraction of one or more •=efh. This type of labial bow is
g. It should be robust.
highly flexible ond s "hus used in cases of large overjet. As
h. It should remain active over a long period of time.
very ght forces are generated by them they can be I ised in
adult patients. Factors to be considered In designing a spring
The apron spring is the active compo- Irent that Diameter of Wire : The flexibility of the spring to o
is activated by bending it towards the =eth. As it is highly large extent depends upon the diameter of wire used.
flexible, activation of upfo 3 I rn at a time can be done. The Thus the force generated is
disadvantages ■indude difficulty in construction and risk of
soft | *ssue injuries.
L3 ../'where,
F = Force
fitted labial bow
D = Dia met re of wire L = Length of wire
I lb this type of labial bow the wire is adapted to I femfirm to
the contours of the labial surface (fig The U loop is usually
small. The fitted la- 1 foci bow cannot be used to bring
about active 'oath movement. They are used as retainers
at ^completion of fixed orthodontic therapy.

Icings are active components of removoble orthodontic
appliances that are used to effect various

I -ec* movements.
There are a number of ways by which —rngs
can be classified. Table 1 gives the vari-

ous classification of springs.

Ideal requisites of a spring

Finger spring
The finger spring is also called single cantileve- spring
Based on the presence or absence of helix they can be claasllted as one end is fixed in acrylic and the other end is free. It
290 f Orthodontics - The Art and Science
as; is constructed using 0.5 mm or 0.6 mm hard round
a. Simple - wthput helix
stainless steel wire.
b. Compound : • with hetix
The finger spring is used for mesio-dis- tal
movement of teeth. It can be used only or. those teeth
Based on the presence of loops or helix they can be classified as :
that are located correctly in the bucco- lingual direction
a. Helical Springs - have a helix
i.e., the teeth should be within the line of the arch.
b. Looped Springs • have a kx>p
The finger spring consists of an active arm of
12 - 15 mm length which is towords the tissue, a helix of
ggiased on Ihe nature ot stability ol the spring they
3 mm internal diameter and o retentive arm of 4-5 mm
length which is kept away from the tissue and ends in a
a. Salt • supported springs - They are usually made:;'0t - ' thicker
small retentive tag (fig 15.a).
gauge wire. Thus they can support lhemsoives,.
The finger spring should be constructed in
b. Supported springs • They are made of thinner gauge • wire and
such a way that the coil should lie along the long axis of
thus lack adequate stability. Hence a section ol
the tooth to be moved, perpendicular to the direction of
the spring is encased in:a. metallic tubing to give it .. .^adequate
movement {fig 15 .b). The

Thicker wires when used, decrease the flexibility of the

spring and apply a greater force on the tooth. By
doubling the diameter, the force increases by almost
16 times. Thus by decreasing the dia meter the force
applied is lesser and therefore the spring remains more
flexible and active over a longer period of time.

(.engfh of wire : Force can be decreased by

increasing the length of the wire. Thus springs that are
longer are more flexible and remain active for a long
duration of time. Helices ond loops can be incorporated
into springs to make them more active. By doubling the
length the force con be reduced by 8 times.

.Force to be applied : The force that should J* 'be generated

by the spring is calculated based on the number of teeth to be
moved, root surface
orea and patient comfort. On an average, f of about 20
gm/cm2 of root area is recomme for most tooth

Patient comfort : The spring should not any patient

discomfort by way of its design, or the force it generates. The
patient should 41 able to insert the appliance with the spring
in proper position so as to bring about the desi tooth

Director? of tooth movement : The direi tion of tooth

movement is an important consi otion in designing a spring.
The direction of t movement is determined by the point of
cont between the spring and the tooth. Palatally placec
springs are used for labial and mesio-distal ti movement.
Buccally placed springs are used whs~\ the tooth is to be
moved palatally and in a mi distal direction.
15 (A^l Finger spring |B) Activation of finger sp'ing Cranked single cantilever spring
This spring constructed with 0.5 mm hard stainless
steel wire is used to move teeth labially (fig 16.a). The
spring consists of a coil, close to its emergence from
the base plate. The coil helps in increasing the
flexibility of the spring by increasing the length of the
wire. Ths spring is cranked to keep it clear of the other
teeth. The coil is so designed that the spring is
activated by unwinding the coil.

Z spring
The 'Z' spring is also called double cantilever spring.
tion of the coil is opposite
The Z spring is used for labial movement of incisors.
to that of intended
They can also be used for bringing about minor rotation
movement. Prior to
of incisors.
acrylization, the helix the active arm are boxed in
The Z spring is made of 0.5 mm hard round
wax so that the ig lies in an recess between the
stainless steel wire. The spring can be made for
mucosa and i base plate.
movement of a single incisor or two incisors (fig 16.b).
The finger spring is activated by moving i
The spring consists of two coils of very small internal
active arm towards the teeth intended to be
diameter. The spring should be perpendicular to the
moved. This is done os close to the coil as pos-
palatal surface of the tooth. It has o retentive arm of
sible. Activation of upto 3 mm is considered ideal
when 0.5 mm wire is used for its fabrication. When 10-12 mm length that

ever 0.6 mm wire has been used the activation

should be half of that.

Fig 16 (A) Cranked single caniilcvcr spring |B) Z spring

302 f Orthodontics - The Art and Science

Fig 1 7 T spring

gels embedded in acrylic. Z spring should be boxed in Fig 1 8 Coffin spring

wax prior to acrylization.

Tne Z spring is activated by opening both the first molors and the first premolars or deciduous
helices by about 2-3 mm ot a time. Incase of minor molars.
rotation correction, one of the helices is opened. The Coffin spring con be activated
manually by holding both the ends at Ihe regies of the
T spring
clasps and pulling the sides gently cpc~; Activation of
Buccal movement of premolars and sometimes 1 -2 mm at a time is considered appropriate.
canines can be brought about using a T spring. It is
made of 0.5mm hard round stoinless steel wire. The Canine retractors
spring consists of a T shaped arm whose ends are Canine retractors are springs that are used to mo.=
embedded in ocrylic {fig 1 7). Loops can be canines in o distal direction. The canine retractors can
incorporated in both the orms of the T so that as the be classified by a number of ways (Tabic
tooth moves bucolly the head of the T can be made to -3).
remain in contact with the crown by slightly opening the
U loop canine retractor
It is made of 0.6 mm or 0.7 mm wire. It consists of a U
The spring is activated by pulling the free
loop, an active arm and a retentive arm which is distal.
end of the T towards the intended direction of tooth
The base of the U loop should be 2-3 mm below the
cen/ical margin (fig 19). The mesial arm of the U loop
Coffin spring is bent at right angles and adapted around the conine

This is a removable type of arch expansion spring that below its mesic' contact point. Mechanically it is least

was introduced by Wolter Coffin (fig 18}. It is used to effective and

bring about slow dento-alveolar arch expansion in

patients where the upper arch is constricted or there is
a unilateral crossbite.
The Coffin spring is made of 1.2 r-.n^l hard
round stainless steel wire. It consists of c J or omega
shaped wire placed in the mid - pcl;- tal region with the
retentive arms incorporc'ei into base plates. The
appliance gains retention from Adams clasps on the
Based on I heir localion I hey can bB class'rfrad

a. Buccal - bucally placed"

b. Palatal • palatal!/ p'aced

Based on the presence ol helix or loop they

can be clwsllled as :

a. Canine retractor with helix

b. Can'f-e retractor wth leep

Based on their mod» of action Ihey can be classified as :

a. Push type

b. Pull type

is used when minimal retraction of 1 -2 mm is required.

It is activated by closing the loops by 1 - 2 mm or
cutting the free end of the octive ami by 2 mm and
readapting it. Advantages of this redactor are ease in
fabrication and less bulk.
Fig 20 Heliccl ccnine rciractor

tal arm is active and is bent at right angles to engage

the canine below the height of contour. The coil is
ploced 3-4 mm below the gingival margin (fig 20). The
height of the coil adjusted based on the
vestibular height.
It is activated by opening the helix by 1 Palatal can/ne retractor

It is made up of 0.6 mm stainless steel wire. It consists

of a coil of 3 mm diameter, an active arm and a guide
arm (fig 21). The active arm is placed mesial to canine.
The helix is placed along the long axis of the canine. It
is indicated in re-

mm or by cutting 1
Fig 19 U loooconine 'ctracor
mm of the free end

Helical canine retractor and re- adapting it around the

h is also called reverse loop canine retractor and :s

made of 0.6 mm wire. It consists of a coil of 3 mm
diameter, an active arm (towards the tissue) and a
retentive arm. The mesial arm (retentive arm) is
adapted between the premolars. Thedis-
Fig 21 Palotal canine retractor
canine. It is indicated in patients with shallow sulcus,
and specially in the mandibular orch.
It is indicoted in case of bucally placed canines and Removable applionces having screws

Fig 22 3ucca coninc rc-rcc-cr jAiSjaported corine retractor hoving a stainless steel sloeve to give support (B) Seit succored canine
retracor made of thicker gcuge w re to support itso.f
usually consist of a split acrylic plate and Adams
fraction of canines that are palatally placed. Activation clasps on the posterior teeth. The screw is placed
is done by opening the helix 2 mm at a time. connecting the split acrylic plate. These appliances
can bring about various types of tooth movements
based on the location of acrylic split, the location of
Buccal canine retractor the screw and the number of screws used in Ihe
canincs placed high in Ihe veslibule.They are used to
Broadly the removable applionces that
move rhe canine in a distal as well as palatal direction.
make use of screws can bring about three types of
It consists of a coil of 3 mm diameter, an active arm
tooth movements.
(away from the tissue) and a retentive arm. The coil is
a. Expansion of arch {fig 23.a).
placed distal to the long axis of canine. The buccal
b. Movement of one or a group of teeth in a buccal or
canine retractor can be of two types- supported ond
labial direction (fig 23.b).
self supported. The self supported canine retractors
c. Movement of one or more teeth in a distal or
are made of thicker gauge wire (0.7mm) so that Ihe
mesial direction (fig 23.c).
spring can support itself, (fig 22.b)The supported
canine retractors are made of thinner gouge wire
(0.5mm). Thus they are more flexible and therefore
mechanically efficient. The supported canine
retractors lack the stability and are therefore enclosed
in a stainless steel tubing os shown in thefigure(fig
22.o). The self supported canine retractors are
activated by closing the helix 1 mm at a time, while the
supported canine retractors can be activated upto 2
mm at a time.
Screws are active components that can be incor-
porated in a removable appliance. Screws con be used
to bring about many types of tooth movements. The
screws are activated by the patient c? regular intervals
using a key that is supplied for this purpose. Thus
appliances incorporating screws are a valucble aid in
patients who cannot visit the dentist frequently for
reactivation of the appliance.
Removable Appliances £95

F'g 24 Elastics used c s act ve com pone nt

Elastics as active components are seldom used along with
removable appliances. They are mostly used in conjunction with
fixed appliances. Removable appliances using elastics for anterior
retraction generally make use of a labial bow with hooks placed
distal to tne canines. Latex elastics are stretched between them
and lie over the incisors (fig 24). The disadvantages of such an
appliance includes the risk of tne elastic slipping gingivally ond
causing gingival trauma and the risk of the arch form getting


base plate also help in retention of appliance and for

The following are the uses of base plotes in
removable appliances.
a. The base plate unites all the compo-nents of the
appliance into one unit.
b. Helps in anchoring the appliance in place.
c. It provides support for the wire components
C d. Helps in distributing the forces over a larger
Fig 23 Removable applionces incorpo'ating screws [A)
Anoyance for nrch expansion (Bj Appliance fo' bucca
movement of o group of reeih (C) Appliance for d'sia
movement of teeth
The bulk of Ihe removable appliance is made of the
acrylic base plate. The prime function of the base plate
is to incorporate ell the components (active and
retentive} together into a single functional unit. The

Fig 26 Ortnodontic clasps (A| Crcjnfe'eitial clasc (B) Jackson's clasp [C) Schwarz clasp JDJ Triangular clasp (E) Adams Cftsp (rj
Adorns claso wih J hook JO) Adar-w c csp with helix (H) Adams with njcca- tube \IJ Adomswith distal extension |J) Single anowhesc
Adams |<) Adans with add'tional arrowhead |LJ Adams on incisors

Removable Appliances 297

Fig 26 Springs and Bows (A) Finger spring (B) Z spring \Q T soring (D) Shor lab-cl bow (El Long labiol bow (F) Split labia' bow |G)
Robe-fs retractor {HJ Mills retracto' (I) High cbial bow (J) Fitted lebial bow IK) Reverse labial bow (LJ Labial bow soldered to
298 Orthodontics - The Art and Science

for this ir should be made thicker to increase the

strength. The base plate should; - snugly around the
necks of teeth that are not being moved. This helps in
avoiding food accumulating under the base plate.
Tho bose plate is made of cold cure- acrylic
or heat cure acn/lic. Cold cure acrylic is more
frequently used as it is less time consuming and
simpler to use. The disadvantages of co:c cure acrylic
are that there is more chance of porosity and it is not
as stable as heat cure acrylic During construction of
the appliance care should

F:g 27 Anterior bite p one

e. Bite planes can be incorporated into the plate to treat
specific orthodontic problems.
Tne bose plate should be of minimum
thickness to help in patient acceptance. Thick plates
are not tolerated by patients. Base plates of 1.5 - 2 mm
thickness offer adequate strength and at the same time
are tolerated well by patients.
The maxillary bese plate usually covers the
entire palate till the distal of the first molar.
This full coverage helps in gaining odequcss strength.
Narrow maxillary bose plales rese- bling a horse shoe
are less stable and are like-, lo gel dislodged during

Fig 28 Posterior bite plane

movements of Ihe tongue

The mandibular base plate is usuc.'. shallow
to avoid irritation to the linguol sulcui To compensate
be 'aken to block ou- undercuts so that insertion and
removal of the appliance will not be o problem. This is
more so in case of mandibular appliances. o
Bite planes can be incorporated into the v
base plates. These bite planes help in disengaging the
occlusion. The cnterio-- bite planes are fabricated by
thickening the base platebehindthe maxillary anteriors e
(*ig 27}. Anterior bite planes are useful in trea'ment of
deep over bites by selective eruptuion of the posterior a
teeth relative to the onteriors. Posterior bite plane are
formed by extending the base pla+e cover the occlusal l
surace of the teerh (fig 28). They are generally used in i
the trea'ment of crossbites as they help in removing the a
interference o; opposing *eeth.
Delivery of the appliance
There ore a number of factors that should be looked t

into at the time of appliance delivery. e

1. The tissue surface of the appliance should not
have ony sharp creas or nodules. Run your fingers a
over Ahe tissue surface of the appliance to feel for y
ony sho'p areas tha- may injure the tissues. They
should be trimmed to avoid tissues irritction.
2. The base plcle may need some trimming to help in c
easy insertion and removal of the appliance. This
is mostly so in case of undercuts being present. r
3. The clcsps should be examined for adequate
retention. If not they should be cdjusted *o engage
the undercut, so as to increase retention. y
4. The active components should rest at the desired .

location. They should no* impinge on

the gingiva, sulcus or-he trenum.
5. The patiert should be educated on how to insert
ard remove tne copliance. It is a good idea to J
show the appliance o the patient and
demonstrate to them xhe ac'ion o 8 the various
8 o
d 1
o 9
r 6
n 9
s ;

: 2
R 2
e -
m 2
components of the appliance. They should be
irstruced not to distort the various active
components of the appliance.
6. The octive components con be activated after c
few days once the oatien- gets used to the

/nstract/ons to the patient

The patient is given instructions be'ore he 'eaves the
dental ofice on the use ond core of *he appliance. Sim
ale verbal instructions often serve the purpose.
However printed instruction shee^orfu- ture reference
car be given to 'he patient. The following are some of
the instructions given.
1. Patient should be instructed on the number of
hours of wear. Most apoliances are to be worn
both dcy and nignt i.e. 24 is
recommended that they be worn during the meal
time as well. r~
2. The apoliance ard the teeth should be cleaned
after every meal. They should oIso be cleoned
before retiring to sleep.
3. The parent is asked *o clean the appliance using
detergen-solution and c brush. While cleaning the
cppliance, ca'e should be taken not to bend or
dislodge ony of the components of the appliance.
4. In case of removable appliance that incorporate
screws, the patient and parents should be given
clear instructions on now to activate Ihe
5. The patients are instructed to report immediately
to the clinic in case of appliance damage or any
other oroblem while wearing them.

6. The potient should be instructed not to leave the
appliance out of rhe mouth for a long poriod of
time as it increases the risk of loss ond damage.
300 f Orthodontics
Prob/eros - The Art
encountered /n and Science
appliance therapy
Ora/ hygiene mainJenonce : Patient who fail to clean
the appliance and teeth pose the risk of gingival
inflammation and hyperplasia.

Soft tissue irritation : Removable plates that are not

trimmed and polished properly can leod to tissue
irritation and ulceration. Caro should be taken to avoid
shorp nodules and irregularities in the appliance. In
addition wire components that extend deep into the
vestibule offer risk of vestibular irritation and injury.

Cones ; Improper oral hygiene can result in caries. The

appliance should be designed in such a way that areas
of food stagnation do not occur.

Pain ; Excessive forces applied by the active

components can cause tenderness or even pain of the
teeth being moved.

Tootf) mobility : Presence of traumatic occlusion

orthe use of excessive force during therapy can cause
abnormal mobility of the teerh.

6. Pro' tt WR: Co-Temporary Orrhodortics. St Low^ CV
Mosby, 1986.
7. Robe't E Moycrs : riend bc-ok of Orthodon-ics, Yeo--
boo;< medicol publishers, inc. 1988.
8. Sa.'zmcn JA : Practice of Orthodontics, J3 Liopincc.-
compony, 1966
9. Tang and Wei : Trea'ment effectiveness of orhodor- <ic
appliances. Am J Orlhod 1990 ; S5C-S56
n important aspect of treatment planning is
choosing an appropriate appliance for a
particular patient. Various types of appliances
are available from which the orthodontist has to select
the one that is most
suited forthe patient.
Most malocclusions
require some form of
^Uu^a Ja

fixed therapy for their
correction, -ppliances
that are fixed or fitted
onto the teeth by the
operator and cannot
be removed by the
catient at will are
called fixed appliances.Patient cooperation is
dispensed with to a large extent in ~e use of fixed
appliances. The orthodontist does -iot depend on the
patient for timely weor and management of the
appliance. Unlike removable appliances that arc
capable of only tipping type of tooth movements^ fixed
appliances can bring about various other types of tooth
movements including bodily movement, rotation,
lipping, intrusion, extrusion and even root movements.
ixed appliances ore therefore very versatile and can
be used to treat most malocclusions.
The most important disadvantage of a fixed
appliance is oral hygiene maintenance which becomes
more difficult. Plaque and food debris tend to
accumulate around the attachments which mokes
cleaning of teeth difficult for the patient. In addition, the
fixed appliances are more time consuming to fix and
cdjust and require specialized services of an
orthodontist. Refer to chapter 24 for more details on
the advantages and disadvantages of fixed and
removable appliances.



A greot advantage of fixed appliances is their ability to

bring about more than one type of tooth movement at
the same time unlike removable appliances that can
only perform simple tooth movements. The various
tooth movements possible using fixed applionces are :
Tipping is the simplest type of tooth movement,
produced by the application of a single force on the
tooth crown. As a result, the crown moves in the
direction of the force around a fulcrum in the apical
region of the root. The root apex experiences a
counter-reaction and moves in the opposite direction.
Tipping type of toorh movement can be used to treat
only certain malocclusions. Most fixed appliances are
capable of producing tipping. However, s'ery rarely can
a malocclusion be treated entirely by tipping

Ffg 1 To o'h movements possible using 'ixed opplionccs. (A) Tipp'ng of c'owns |B) Bodily movement (C) Torqying (D)
Irtrvs.on (E) Ext'tsion (Fi Mes'o-distol uprighthg

Bodily movement
Bodily tooth movement implies an equal movement of
both the crown as well as the root in the same
direction. Certain fixed appliances

are capable of bodily movement.

Torquing implies root movements in the labial or
lingual direction. It is possible to move the roots in a
labial or lingual direction using fixed applionces.

Uprighting refers to mesio-distal movement of the
roots. Finer detailing of roots by moving them
mesio-distally con be brought about by fixed

Teeth that are rotated around their long axes can be
derotated using fixed appliances. The degree
of rotational control possible with fixed applicnces ■s 4) Although it is possible to bond attachments on teeth
not possible using removable appliances. that have porcelain or gold restorations or crowns,
banding is preferred in these cases.
Extrusion and Intrusion 5) It is preferable to band teeth that show recurrent
Extrusion and intrusion refer to vertical movements of breakage of the bonded attachments due to bond
teeth along their long axis. Ex'rusion and to a lesser failure.
extent intrusion of eeth or groups of teeth is possible 6} If is preferable to use banded attachments whenever
using fixed appliances. they are likely to contact the opposing dentition when
the jaws are closed.
THE TEETH Steps In banding
a. Seporation of teeth
The various attachments that ore used in fixed
b. Selection of band material
appliance therapy such as brockets and molar tubes
c. Pinching of the band
can be fixed directly onto the teeth with composite
d. Fixing the attachments
adhesives or can be ottached to metallic bands thot
e. Cementotion of the band
are cemented onto the teeth. The method of fixing the
attachments directly to the teeth is colled bonding. Separation of teeth : Due to the presence of tight
When ever the attachments are fixed to bonds which inter-dentol contact between the teeth, it moy not be
are cemented around the teeth, the technique is possible to force the band past the contact area. It is not
referred to os banding. advisable to force the bond through a tight inter-dental
contact as it is uncomfortable for the patient and also
BANDING difficult for the operotor. Tight contacts should hence be
broken using tooth separators prior to band pinching. The
Bonding involves the use of thin stainless steel strips
various types of separators are discussed later in the
called bands that are pinched tightly around the teeth
and then cemented to the teeth. The stainless steel
Most separators have to be left in the
tape is available in different widths and thicknesses to
suit different teeth. While the molor band material is
wider and stiffer, the anterior band material is relatively
thinner ond narrower in width. Tho outer surface of the
band materiol is smooth and glossy while the inner
surface is comparitively rough and dull, so os to aid in
retention of the cement.

Indications for banding

The following are some of the situations where
banding is advontogeous.
1) Banding is preferred over bonding in case of
posterior teeth. The banded attachments are
better capable of resisting occlusal forces than
bonded attachments. In addition, bonding needs
thorough moisture control which is difficult in the
posterior teeth.
2) It is preferable to band a tooth that requires buccal
as well as lingual attachments.
3) Bands are better likely to resist heavy forces, as in
the cose of extraorol devices such as head gears.
Orthodontics - The Art and Science



Fig 2 Separates (A) and (B| Placemert of ring separator (C) and (Dj Kcslngs scperotor.

mouth for 24 hours or more to bring about sufficient Fixing the attachments : Once the band pinching is
separation of the irrer-dental contact. completed, rhe appropriate artachmerits are fixed
onto the bond. The attachments include brackcrs for
Selection of band material : Bosed on which tooth is
being banded, the band material of appropria*e the anterior teeth and buccal or molar tubes for the

thickness and width is selected. posterior teeth. These attachments are fixed to :he
band by spot welding or by soldering.
Pinching of the bond : Bard material of adequate
length is taken and the two ends are welded together. Cemen/afion of fhe band : The final step involves

The bend is now passed through Ihe separated cementation of the band around the tooth. The inner

inter-dental contact around the tooth to be banded. surface of the band is rough in order to aid in retention.

Using band pinching pliers, the band is tightly drawn A well pinched band is one that has adequate retention
around the tooth to form a ring. The neck of the band is even without the use of cement. Nevertheless,
spot welded to retain the tight fit. The excess band cementation is required to eliminate the space
material is then cut off and the ends are adapted close between the band and tooth into which coriogenic
to the band. The beru portion is spot welded and the material may seep
gingival margins of the band are trimmed to conform to
the contour of the gingival margin. The weld spots

and rough margins are then smootnened and

n and stagnate.
During cementation, cdequate moisture
:ontrol is necessan/ by means of so live ejectors

end cotton rolls. Cements that can be used include zinc

E poly-carboxylcte, zinc phosphate,
glass ionomer cement etc.,.
g 3 S'eps in bonding (A) Sirip of bend molericl fenred nto welder used lo n rinq (B; Ba-td is placed around lie tooth and pinched (Q cut off (Ej The
form we c spots (D) Excess bend motercl i urs of the banc (F) Bond rema nhg band rrclerial is edeptsd along the
cemented in placc

Preformed seamless bands are now available in

various sizes. They hove eliminc'-ed the need lo pinch
custom made bands.
Fig 4 Electron microscope images of no'nal enamel and acid etched enamel (A) Norma c-ia -iel rrccritkxrior v. 500 |B) Normal enamel magrif cntion
x 1 500 (C| Acid etched enomel magnification x 50C iD'l Acid etchec enoTic-l -nagrif cction xSOO
BONDING 2. Enhances the surace area ond poros/fy: the etching
of the enamel increases the surface area and porosity
^ne method of fixing attachments directly overthe
of the enamel thus increasing the bond strength. The
enamel using adhesive resins is called bonding, "he
enamel is etched to a depth of 20-25 microns.
elimination of bands greatly enhances esthetics and
oral hygiene maintenance and has red to its popularity
Advantages of bonding
over banding. This procedure cfdireaattachment on
Bonding offers numerous advantages over banding
the *oolh surface requires crefreatment of enamel.
which can be listed as :
Enamel can be pretreated by various methods. The
1) It is est'netically superior.
most accepted method is the prctreatment by acid
2) It is faster to bond than to pinch bands around the
etching technique. This ^hnique was introduced in
1955 by Buonocore. The pretreatmen4, of enamel by
3) It enables maintenance of better oral hygiene.
acid etch technique ~elps in the following ways: 1.
4) It is possible to bond on teeth that have aberrant
Enhances the surface energy : The etching of the
shapes or forms. It might be impossible to band
enamel helps in removing surface deposits and
such teeth.
organic materials that are found on -ne surface of the
5} It is easier to bond than band in case of
teeth. It also increases the surface energy thereby
partially erupted and fractured teeth. 6) The risk of
enhansing the wettability of the enamel.
caries under loose bands is eliminated.

Pa 5 Bonding procedure ■ see next page for legend

Fig 5 BoicJing procedure (AJTee-h cleaned using
ojrrice (8) & (C) 30-50% phosphoric u c id esed to
etch enamel (D) Etcnant is washed o^ with water
(E) Teeth are d'ied using oir (F) Sealant is cpplied
(Gj & {HJ Sealont & adhesive applied on under
surface of bracket nicsh |IJ Brac<e» olaced o-i teetn
(JJ Excess' :lo'e ol adhesive 'emoved (K) Bonding
completed on a I teeth
7) Interproximal areos are accessible for restoration
ond proximal stripoing.

Disadvantages of bonding 5. Lock phs

1) Bonded attachments are weaker than banded 6. Ligstjre w re

attachmen-s and hence are more prone to bond

6] The bond is allowed to strengthen for some time
2) Bonding involves etching of the enamel with an
before placing the arch wires.
acid which may lead to enomel loss and an
increased risk of demineralization. BAWDS
3) Enamel fracture can occur during debording.
Bands are passive components that help in fixing the
Steps in bonding various attachments onto the teeth. They are
Bonding is done in the following steps (fig 4}: availoble in various sizes to suit different teeth. They
1) The crowns of the *eelh to be bonded are cleaned are made of soft stainless steel. The attachments like
using pumice and bristle brush so as to remove molar tubes and brackets are soldered or wolded over
olaque and other organic debris present on the these bands which are cemented in position around
enamel surface. the teeth. The use of preformed bonds or seamless
2) After thorough cleaning, the teeth arc washed and bonds is becoming popular. These bands are
dried. During the bonding procedure, adequate available in
moisture control should be maintained by the use
of saliva ejectors and cotton rolls. It is advisable to
use o cheek retractor to keep the lips and cheeks Band Thickness Band Width

away from the teeth to be bonded. (Inches) (inches)

3) 30-50% phosphoric acid in gel or liquid orm is Inciscr 0.003 0.125 '

used to etch enamel. This etching is usually done Canine 0.003 0.150
for 45-60 seconds, after which the etchant is