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OUTLINE
The orthodontic equation
ETIOLOGY OF Primary etiologic sites
MALOCCLUSION Time
Dr. Fe Jozemar Rigor-Salazar Causes and clinical entities

THE ORTHODONTIC THE ORTHODONTIC

EQUATION EQUATION
Certain original causes act for a time at a site Dockrell group original causes into:
and produce results  Heredity
 Developmental causes of unknown origin
 Trauma
 Physical agents
 Habits
 Disease
 Malnutrition

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THE ORTHODONTIC THE ORTHODONTIC

EQUATION
Primary sites
 Made up of a different tissue
 Bones of facial skeleton
 teeth
 Neuromuscular system
 Soft parts (except muscle)
 Grow at different rates and in different manners
 Adapt to environmental impact in different ways
EQUATION
Primary sites
•Significance: Regardless of the cause of growth
variation, the place where that cause shows its
effect is important  the difference in tissue
response during development is a determining
factor in differentiating among many clinical
problems that are similar in appearance

THE ORTHODONTIC THE ORTHODONTIC

EQUATION EQUATION
Primary sites
•Rare for one site alone to be involved
•Result is: malocclusion (teeth), malfunction
(neuromusculature) or osseous dysplasia
(craniofacial skeleton)

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THE ORTHODONTIC
EQUATION PRIMARY ETIOLOGIC SITES
Malocclusion  Neuromuscular system
 Most are simply clinically significant variations  Causes dentofacial deformity through the effects of
from the normal range of growth or morphology reflex contractions on the bony skeleton and the
 May result from a combination of minor variations dentition  imbalanced contraction patterns are a
from the normal significant part of nearly all malocclusions
 Treatment of malocclusion must involve
conditioning reflexes to bring about a more
favorable functional environment for the growing
craniofacial skeleton and the developing dentition
and occlusion or relapse may occur

PRIMARY ETIOLOGIC SITES PRIMARY ETIOLOGIC SITES

Bone  Bone
The maxilla and the mandible serve as bases  Orthodontic treatment of skeletal disharmony
for the dental arches must either:
 Alter the growing craniofacial skeleton
Aberrations in their morphology may alter
occlusal relationships and functioning  Camouflage by moving teeth to mask
disharmony

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PRIMARY ETIOLOGIC SITES PRIMARY ETIOLOGIC SITES

Teeth  Teeth
 Can cause dentofacial deformity through gross  May be moved in orthodontic treatment to correct the
variations in: malocclusion, camouflage a skeletal dysplasia or aid in the
removal of neuromuscular dysfunction
 Size
 Shape
 Number
 Position

PRIMARY ETIOLOGIC SITES TIME

Soft parts (excluding muscle) A cause may be either continual or
 Role in etiology of malocclusion is not clearly intermittent and it may show its effect either
discernible nor important prenatally or postnatally.
 Malocclusion can result from periodontal
disease and loss of the attachment apparatus
and from a variety of soft tissue lesions
including the temporomandibular joint
structures

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CAUSES AND CLINICAL

HEREDITY
ENTITIES
Heredity  Long been indicted as a
cause of malocclusion.
Developmental defects of unknown origin
 Aberrations of genetic
 Trauma origin may make their
Physical agents appearance prenatally or
they may not be seen
Habits until many years after
birth (e.g., patterns of
Disease tooth eruption).
malnutrition

DEVELOPMENTAL DEFECTS DEVELOPMENTAL DEFECTS

OF UNKNOWN ORIGIN OF UNKNOWN ORIGIN
 Definition: gross defects of a rare type probably  Ex:
originating in failure of differentiation at a critical  Congenital absence of some muscles
period in embryonic development.  Micrognathia
 Facial clefts
 Some instances of oligodontia and anodontia
 Some gross craniofacial syndromes

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TRAUMA
 Prenatal trauma and birth injuries
 Hypoplasia of the mandible  can be caused by
intrauterine pressure or trauma during delivery.
 "Vogelgesicht“ inhibited growth of the mandible
due to ankylosis of the TMJ (may be a
developmental or from trauma)
 Asymmetry  knee or a leg may press against the
face promoting asymmetry of facial growth or
retardation of mandibular development.
TRAUMA
 Postnatal trauma
 Fractures of jaws and teeth.
 Habits  may produce "microtrauma" operative
over an extended period.
 Trauma to the TMJ  impairs growth and function
leading to asymmetry and temporomandibular
dysfunction.

PHYSICAL AGENTS PHYSICAL AGENTS

 Premature extraction of primary teeth  Nature of food
 Primitive, fibrous diet
 Stimulates muscles to work more  increases the load of function on the teeth
 Produces less caries
 Greater mean arch width
 Increased wear of occlusal surfaces of the teeth

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PHYSICAL AGENTS HABITS

 Nature of food  Definition: Learned patterns of muscle
 Highly refined, soft, pappy modern diets  play a contraction of a very complex nature
role in some malocclusions due to lack of adequate  Some serve as stimuli to normal growth of the
function
jaws  interfere with the regular pattern of facial
 Contraction of the dental arches growth if abnormal
 Insufficient occlusal wear
 Absence of occlusal adjustment normally seen in the
maturing dentition

HABITS HABITS
 Deleterious habitual patterns of muscle behavior  Thumb-sucking and finger sucking
often are associated with:  Tongue thrusting
 Perverted or impeded osseous growth
 Tooth malpositions  Lip-sucking and lip-biting
 Disturbed breathing habits  Posture
 Difficulties in speech  Nail-biting
 Upset balance in the facial musculature  Other habits
 Psychological problems

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THUMB-SUCKING AND THUMB-SUCKING AND

FINGER-SUCKING FINGER-SUCKING
 Non-nutritive digital sucking  Time of appearance of digital sucking has
 Most begin very early in life and outgrown by 3 or 4 years of significance
age  Before during the very first weeks of life  feeding
 May be a direct cause of a severe malocclusion problems

THUMB-SUCKING AND THUMB-SUCKING AND

FINGER-SUCKING
 All digital sucking habits should be studied for
their psychologic implications  may be related
to hunger, satisfying of the sucking instinct,
insecurity, or even a desire to attract attention.
FINGER-SUCKING
 Theories:
 Freudian theory
 Orality in the infant is related to pregenital
organization and that sexual activity is not yet
separated from the taking of nourishment  the
object of one activity (thumb-sucking), is also
that of another (nursing)
 An abrupt interference will lead to the
substitution of antisocial tendencies such as
stuttering or masturbation.

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THUMB-SUCKING AND THUMB-SUCKING AND

FINGER-SUCKING
 Theories:
 Inadequate sucking activity
 It was found in a series of studies that there was
less thumb-sucking in both animals and humans
when fed ad lib than when feedings were widely
separated.
FINGER-SUCKING
 Theories:
 Sears and Wise oral drive theory
 The strength of the oral drive is in part a function
of how long a child continues to feed by sucking.
 In keeping with a Freudian hypothesis that
sucking increases the erotogenesis of the mouth.

THUMB-SUCKING AND THUMB-SUCKING AND

FINGER-SUCKING FINGER-SUCKING
 Theories:  Theories:
 Benjamin  Benjamin
 Less thumb-sucking among those whose nutritive  Thumb-sucking arises from the rooting and
sucking experience had been greatly reduced  placing reflexes common to all mammalian
thumb-sucking is an expression of a need to suck infants which are maximal during the first 3
that arises because of the association of sucking months of life
with the primary reinforcing aspects of feeding.

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THUMB-SUCKING AND THUMB-SUCKING AND

FINGER-SUCKING FINGER-SUCKING
 Theories:  Theories:
 Non-Freudian theories:  Non-Freudian theories:
 Thumb-sucking is one of the earliest examples of  No support for the psychoanalytic interpretation
neuromuscular learning in the infant and that it of thumb-sucking as a symptom of psychologic
follows all the general laws of the learning disturbance.
process.
 Simple learned response

THUMB-SUCKING AND THUMB-SUCKING AND

FINGER-SUCKING FINGER-SUCKING
 Theories:  Does digital sucking cause malocclusion?
 Non-Freudian theories:  Type of malocclusion that may develop in the
 Thumb-sucking habit should be viewed by the thumb-sucker is dependent on a number of
clinician as a behavioral pattern of multivariate variables
nature.  Position of the digit
 Associated orofacial muscle contractions
 Position of the mandible during sucking
 Facial skeletal morphology
 Duration of sucking, and so forth

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THUMB-SUCKING AND THUMB-SUCKING AND

FINGER-SUCKING FINGER-SUCKING
 Does digital sucking cause malocclusion?  Does digital sucking
 Anterior open bite  most frequent malocclusion cause malocclusion?
 Maxillary incisors tipped labially  Protraction of the
maxillary anterior teeth
particularly if the pollex
is held upward against
the palate

THUMB-SUCKING AND THUMB-SUCKING AND

FINGER-SUCKING
 Does digital sucking cause malocclusion?
 Mandibular postural retraction  if the weight of
the hand or arm continually forces the mandible to
assume a retruded position
 Mandibular incisors may be tipped lingually.
 Associated simple tongue-thrust  to effectand
anterior seal in the presence of anterior open bite
FINGER-SUCKING
 Does digital sucking cause malocclusion?
 Narrowing of the maxillary arch  due to negative
pressure produced by buccal wall contractions
 Nasal floor unable to drop vertically to its expected
position during growth  narrower nasal floor and
a high palatal vault.
 Maxillary lip becomes hypotonic and the
mandibular lip becomes hyperactive

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THUMB-SUCKING AND
TONGUE-THRUSTING
FINGER-SUCKING
 Does digital sucking cause malocclusion? Normal swallow:
 May be self-corrective:  Teeth in occlusion,
 The habit is stopped early the lips lightly closed,
 The deformity has been mild and the tongue held
 There is a teeth-together swallow against the palate
 The associated neuromuscular habits are of a mild behind the anterior
nature. teeth

TONGUE-THRUSTING
 Tongue-thrust swallows that may be etiologic to
malocclusion are of two types:
 Simple tongue-thrust swallow
 Associated with a normal or teeth-together swallow
 Associated with a history of digital sucking and pacifier sucking
TONGUE-THRUSTING
Tongue-thrust swallows that may be etiologic
to malocclusion are of two types:
 Complex tongue-thrust swallow
 Mouth-breathing
 Dropping the mandible and protruding the tongue
provide a more adequate airway  a large freeway
space is seen
 The jaws are held apart during the swallow so the
tongue can remain in a protracted position.

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TONGUE-THRUSTING TONGUE-THRUSTING
 Tongue-thrust swallows  Tongue-thrust swallows
that may be etiologic to that may be etiologic to
malocclusion are of two malocclusion are of two
types:
 Complex tongue-thrust types:
swallow  Complex tongue-thrust
 Tonsillitis swallow
 Root of the tongue may  Tonsillitis
encroach on the enlarged
facial pillars  to avoid, the  The teeth and growing
mandible drops, separating alveolar processes
the teeth, providing more accommodate
room for the tongue to be themselves to the
thrust forward during attendant upset in
swallowing
neuromuscular forces

TONGUE-THRUSTING TONGUE-THRUSTING
Tongue-thrust swallows that may be etiologic Tongue-thrust
to malocclusion are of two types: swallows that may be
 Complex tongue-thrust swallow etiologic to
malocclusion are of
 Chronic nasorespiratory distress two types: both favor
 Pharyngitis the development of:
 Distoocclusion
 Extreme maxillary
overjet
 Open bite

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TONGUE-THRUSTING TONGUE-THRUSTING
Other tongue habits that often are confused  Skeletal open bite
 Most frequently
with tongue-thrust swallow: confused with tongue-
 Tongue-sucking thrusting
 Mandibular plane is
 Retained infantile tongue posture steep and the anterior
 Retained infantile swallow face height much greater
than the posterior face
height
 Tongue has great
difficulty sealing the
anterior portal during
the swallow.

LIP-SUCKING AND LIP- LIP-SUCKING AND LIP-

BITING BITING
Lip-sucking  When the mandibular
 May appear by itself lip is repeatedly held
or it may be seen with beneath the maxillary
thumb-sucking anterior teeth:
 Involves the lower lip  Labioversion of
maxillary anterior teeth
Lip-biting  involves  Open bite
both the upper and  Linguoversion of the
the lower lip mandibular incisors

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POSTURE
The summated expression of muscle reflexes
Capable of change and correction
POSTURE
Persons with faulty body posture frequently
demonstrate undesirable mandibular postural
positioning as well  both are expressions of
poor general health

POSTURE POSTURE
Those who hold themselves straight and erect Abnormal tongue
with the head well placed over the spinal posturing
column will almost reflexly hold their chins  Frequent cause of
forward in a preferred position. open bite
 Many are intractable
to treatment.

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NAIL-BITING OTHER HABITS

Frequent cause of Constant holding of a
tooth malpositions. very young baby
Displayed by high- supine on a hard, flat
strung, nervous surface  can mold
children and shape the head
Of greater clinical by flattening the
importance is their occiput or producing
social and psychologic facial asymmetry.
maladjustment

OTHER HABITS OTHER HABITS

Habitual sucking of Craniocervical
pencils, pacifiers, or angulation was related
other hard objects  to steepness of the
as deleterious to mandibular plane.
facial growth as
thumb-sucking and
finger-sucking.

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DISEASE DISEASE
Systemic diseases Systemic diseases
 Affects the quality rather than the quantity of  No malocclusion is known to be pathognomonic
dentitional development. of any usual childhood disease.
 Ex: Febrile diseases  upset the dentitional  Malocclusion may be a secondary result of some
developmental timetable during infancy and neuropathies and neuromuscular disorders and
early childhood. may be one of the sequelae of treatment

DISEASE DISEASE
Endocrine disorders Local diseases
 Do not cause malocclusion  Nasopharyngeal diseases and disturbed respiratory
 Prenatal endocrine dysfunction  hypoplasia of function
the teeth.  Gingival and periodontal diseases
 Postnatal endocrine disturbances  Tumors
 Retard or hasten the direction of facial growth
 Caries
 Affect the rate of ossification of the bones, the time of
suture closure, the time of eruption of the teeth, and the
rate of resorption of the primary teeth.
 Affects the periodontal membrane and gingivae  teeth
are affected indirectly.

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DISEASE DISEASE
 Nasopharyngeal diseases and disturbed respiratory  Nasopharyngeal
function diseases and disturbed
 Basic assumption: enlarged adenoids obstruct the respiratory function
airway, causing mouth-breathing  necessitates  Changes:
changes in tongue, lip, and mandibular posture   Increased anterior face
upsets "soft-tissue balance" leading to alterations in height
craniofacial form and to malocclusion

DISEASE DISEASE
 Nasopharyngeal  Nasopharyngeal
diseases and disturbed diseases and disturbed
respiratory function respiratory function
 Changes:  Changes:
 Narrow and high palate  Retroclined incisors
 Open bite
 Tendency to crossbite

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DISEASE DISEASE
 Nasopharyngeal diseases  Gingival and periodontal
diseases
and disturbed respiratory  Infections and other
function disorders of the periodontal
membrane and gingivae
 Changes: have a direct and highly
localized effect on the teeth.
 Increased lower face  Loss of teeth
height  Changes in the closure
patterns of the mandible to
avoid trauma to sensitive
areas
 Ankylosis of the teeth
 Other conditions that
influence the position of the
teeth

DISEASE DISEASE
Tumors Caries
 May cause  Greatest single cause
malocclusion of localized
malocclusion
 Severe malfunction will  Responsible for:
result when they are
 Early loss of primary
found in the teeth
articulatory region.  Drifting of permanent
teeth
 Premature eruption of
permanent teeth

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DISEASE DISEASE
 Premature loss of  Premature loss of
primary teeth primary teeth
 Loss of primary tooth  Bone reforms atop the
before the permanent permanent tooth
successor has started to delaying its eruption 
erupt (crown formation more time is available
completed and root for other teeth to drift
formation begun) into space that would
have been occupied by
the delayed tooth

DISEASE
 Premature loss of primary teeth
 Space occupied by the primary molars closed as a
consequence of caries or loss of the primary teeth.
 Loss of the first primary molar in the maxilla blocks
out the permanent cuspids while loss of the
maxillary second primary molar tends to impact
the second premolar.
 Most space loss is due to mesial movement of the
molars, but distal migration of the cuspids occurs
DISEASE
 Premature loss of primary teeth
 Lower primary molar extractions prematurely tend
to cause maleruption of the second premolar.
 Molar and canine occlusal relationships are
significantly affected by premature loss of primary
molars in either arch.
 Early loss of the primary second molar resulted in
the earlier eruption of the second permanent
molar.

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DISEASE DISEASE
 Premature loss of primary teeth  Premature loss of primary
 Need for more orthodontic treatment in cases incisors
where primary molars had been lost early and that  Not a matter of concern
it was necessary to extract more permanent teeth  If lost before the crowns of
in the treatment of such cases. the permanent incisors are
in a position to prevent
drifting of the more
distally placed primary
teeth, malocclusion of the
primary dentition may
result

DISEASE DISEASE
 Premature loss of  Premature loss of primary cuspids  of great
primary incisors concern.
 If a primary incisor is lost  Maxilla
before age 4,  Loss before the central and lateral incisors have
radiographs should be moved together  permanent cuspid erupts late
taken of the developing and causes permanent spacing of the anterior teeth.
permanent incisor and
the space observed
regularly.

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DISEASE
 Premature loss of primary cuspids  of great
concern.
 Mandible
 Primary cuspid loss is more frequent and more
serious  results in lingual tipping of the four
mandibular incisors if there is abnormal activity of
the mentalis muscle.
DISEASE
 Premature loss of primary first molars
 Maxilla
 Effects are not so profound  first bicuspid is not
misplaced during its eruption since it is narrower
mesiodistally than the first primary molar
 Mandible
 Second primary molar shifts forward at the time the
first permanent molar is erupting
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DISEASE
 Premature loss of primary first molars
 Not thought by some to be of clinical importance
 problem does not manifest itself for some time
after the tooth's removal.
 Cause the permanent canine and first permanent
molar to move mesially
DISEASE
 Premature loss of primary second molar
 Importance of the tooth:
 Wider mesiodistally than its successor  difference
in widths provides space for the permanent cuspids
 Plays an important role in the establishment of
occlusal relationships and in the maintenance of arch
perimeter
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DISEASE
 Premature loss of primary second molar
 If lost early:
 First permanent molar moves forward
 Canine drifts distally, followed by the incisors 
alters the midline
 Canine erupts with no space to occupy
 In the mandible  the second bicuspid is blocked out
of position
DISEASE
 Premature loss of two or more primary molars
 Drifting
 Loss of posterior dental support forces the
mandible to provide some sort of adaptive occlusal
function and a resulting accommodative posterior
crossbite  effects on the temporomandibular
joints, the musculature, the growth of the facial
bones, and the final positions of the permanent
teeth.
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DISEASE
 Premature loss of primary second molar
 Loss of crown substance to caries in this tooth may
be more serious than the loss of an entire other
tooth.
DISEASE
 Factors related to migration of the first
permanent molar after loss of the second or first
and second primary molars:
 Amount of leeway space  more drift occurred in
arches with less leeway space
 Cusp height  high permanent molar cusps inhibit
drifting
 Age when the primary teeth are lost  the
greatest loss occurred when the primary molars
were lost prior to the eruption of the first
permanent molars.
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DISEASE DISEASE
 Interproximal caries  Disturbances in Sequence of Eruption of
 Plays a most important Permanent Teeth.
role in shortening of  The normal sequence of eruption of the permanent
arch length. teeth will provide the highest percentage of
 Any decrease in the normal occlusions
mesiodistal width of a
primary molar may
result in the forward
drifting of the first
permanent molar.

DISEASE DISEASE
 Disturbances in Sequence of Eruption of Permanent  Disturbances in Sequence of Eruption of
Teeth.
 Abnormal orders of arrival may permit shifting of the Permanent Teeth.
teeth, with resultant space loss.  One of the most important sequences to observe is
 Premature loss of any primary tooth  earlier or delayed that of early arrival of the second permanent molar
arrival of successor or it may delay it
 Periapical pathology of the primary teeth  hastens  when this tooth develops ahead of any anterior
eruption of the successor due to loss of bone and teeth, it may have a dramatic effect in shortening
increased vascularity of the region. arch perimeter
 Tumors and supernumerary teeth  deflect or impede
the course of eruption and upset the order of arrival.
 Prolonged retention of primary teeth  disturbs the
sequence of eruption.

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DISEASE
 Loss of Permanent Teeth.
 Results in a major upset in the physiologic
functioning of the dentition  break in mesiodistal
contacts permits shifting of the teeth.
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MALNUTRITION
 More likely to affect the quality of tissues being
formed and the rates of calcification than the size
of parts
 No malocclusion is pathognomonic of any typical
and common nutritional deficiency  good
nutrition plays an important role in growth and in
the maintenance of good bodily health and oral
hygiene.
 Ex:
 Roles of fluoride intake and refined carbohydrates in
caries production
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