The Coastal navigation is where you'll learn sizes occlude or direct even though

below the cingulum plateau of the appearances This is defined by the British
Standards Institute or BSI for short. The upper incisor inclination is average and
the overjet is within the normal range of two to four millimetres. The AP
relationship is usually class one, and there will be discrepancy within the arches
or in the transverse and vertical relationships. It's important to remember that
the term class one malocclusion refers to the size of relationship only. Within
this group, you'll see a spectrum of dental alveolar problems. Molar relationship
and canine relationship can vary from class one through to class three, but the
incisors will always by definition be class. One. It's the commonest malocclusion
in the UK at 44%.

aetiology can be broken down into skeletal soft tissue and if we look at skeletal
initially usually patients will have a skeletal one pattern but they may be class
two or class three with inclination of the incisors compensating for the underlying
skeletal discrepancy and we call this Danto alveolar compensation. So if you have a
skeletal one pattern this is where your SNA is just slightly ahead of SMB and this
represents a normal relationship of the maxilla to the mandible. Dental alveolar
compensation is a condition that you see where the incisors tip in order to try and
achieve a class one incisor relationship despite an underlying altered skeletal
pattern. So if you are slightly close to the lower incisors will pro incline and if
you ask at class three you'll see rhetoric a nation of the lower incisors usually
if you have a class two or class three skeletal pattern this will be mild in these
cases. Because if it was very severe, you wouldn't be able to achieve a pass one
malocclusion. You will also see transverse discrepancies here. So this is commonly
seen as crossbites. There are two types of cross bite. There's a buffalo cross bite
and a lingual cross bite and prospects are quite common in class one malocclusion
cases because a common cause of cross bite is crowding and crowding is often seen
in this malocclusion. In the vertical dimension, the Overbite is either normal or
slightly increased. It's important to remember that you won't see a severely
increased Overbite because this will won't be compatible with a class one
malocclusion definition. If you've got a very deep bite you your patient will be
either class two division one or class two Division Two generally, the Overbite can
be reduced in these cases. And in fact, you can even have what's called an anterior
open bite. And anterior open bite is where you have no vertical overlap of the
upper incisors or the lower incisors. When the posterior teeth are in contact.

Moving on to look at soft tissues. In most cases, one cases of soft tissue
environment is favourable an exception to this as bimaxillary proclamation This is
where both your upper and lower sizes are pro inclined. And this may be a result of
reduced lip tonicity. So with normal soft tissue behaviour, the incisors will tend
to erupt into a class one incisor relationship. soft tissues do not play a big role
in class one malocclusion generally they play a much bigger role in patients who
are either cost two is sizes or cost three in sizes. In this condition of
bimaxillary proclamation we do have a role of soft tissues playing a part in
developing the condition. Our teeth generally lie in what's called the zone of
balance or neutral zone. This is an imaginary so lying in the lower incisor region
where the balance of forces both within inside the mouth and outside mouth are
balanced in patients who have bimaxillary proclamation they may have reduced tone
of their lips. And because of this, you get an alteration of that balance of forces
and the incisors can get moulded forward by the tongue. And this condition has an
increased incidence in the efficacy and patient looking at dental factors. Now
dental factors are in fact the main etiological influences in class one
malocclusion and the commonest is to size arch length discrepancy, and this will
result in crowding or less frequently spacing within the arches to size arch length
discrepancy is a mismatch between jaw and tooth size and this will lead to commonly
crowding more rarely spacing. And this is genetically determined so the size of
both the jaw and the teeth is genetically determined. But you can have
environmental factors playing a role also, a common one would be early loss of
primary teeth. In particular only loss of ease which will lead to crowding of the
fives. Only loss of primary teeth. In particular the ease that leads to loss of
leeway space. Meanwhile space is defined as the difference in the medial distal
width of C D E compared to the permanent successes. So that's three fours and fives
in the maxilla. The library space is 1.5 millimetres and in the mandible, it's 2.5
millimetres bilaterally. And the reason it's wider in the mandible is because the
lower E is a wider tooth.

Moving on to look at some other dental factors. And actually looking at some local
factors This would include displays T impacted teeth and anomalies in tooth size,
number and form. It's important to remember that these local factors can also be
seen in different malocclusion such as class two and class three. Just considering
displaced teeth initially, this is where you have an abnormal positioning of the
tooth germ. Commonly it will affect other canines and second molars. Management for
displaced two. If it's a mild displacement often by extracting a primary tooth it's
still in place will lead to self correction of the problem. If you have a more
severely displaced two, you may need to carry out a procedure called surgical
exposure and bonding of gold chain. And if it's a very displaced tooth, then you
would have to carry out surgical removal of the tooth. So you will need to assess
the case to see how bad the displacement is with respect to impaction. The
definition of infection is a tooth that's prevented from erupting into its normal
position due to tooth bone or soft tissue. After the third molars, the commonest
impacted tooth is the upper canine so other canines are in fact quite common.
clinical problem within the population 2% of patients will present with no pacted
upper canine in 8% of cases this is a bilateral condition and impacted teeth will
attract an IoT and have five AI where the AI stands for impaction it's important to
try and prevent this problem and we do that by carrying out annual palpation for
the maxillary canine so once a year of guidelines suggest that we should be
palpating in the buccal sulcus from the age of nine and if it's not present,
luckily to check politically, things that would warrant further investigation would
be absence of a battle back or bulge or a symmetry with both on one side and not on
the other. Or indeed if you can palpate a plate or bulge. So here you would carry
out some more investigations and radiographs. And then, depending on what you're
finding, so I'll refer the patient on appropriately. The management of impacted
teeth again will vary depending on how badly displaced or ectopic the tooth is. So
you can carry out a very simple interceptive treatment. interceptive treatment is
when we carry out a simple procedure for a patient who's in the mixed dentition.
And here it would involve extraction of the upper seas, in cases where the canine
is politically impacted, and this is in fact the commonest group by taking out the
emphases in some cases you can correct the position of the canine and the canine
will go on to erupt normally. If this doesn't work, or if the tooth is more
severely ectopic, you may need to carry out the surgical exposure and bonding of
gold chain I mentioned in the previous slide. And if it's very ectopic or very
displaced, then you will need to carry out surgical removal for canine

moving on to look at supernumerary teeth. These are the four types of supernumerary
teeth, conical tubercular, supplemental, and Adelanto we defined supernumerary
teeth. It's those teeth that are extra to the normal complement. They are commonly
in males and females. And there's no for instance of two cents in the permanent
dentition conical supernumerary will be a small hedge shaped tooth often, it's
usually found in the upper anterior and if it lies in the midline, we can call that
a meteor dens. So a meteor dent is a conical supernumerary that is found in the
midline of the upper arch. So conical superiors are the commonest type of
supernumerary and they comprise 70% of all supernumeraries. They rarely prevent the
eruption of incisors and in fact they usually just an incidental finding when
you're taking a wage graph prior to starting orthodontic treatment. So it's
important to remember that they don't generally present a version of teeth. The
management here would be you would need to make a decision as to whether the
superior tooth needs to be removed prior to carrying out orthodontic treatment,
especially perhaps if you're carrying out space closure and it's in the middle line
and it's causing a diastema. So you wish to take some advice from your surgical
colleagues and make a decision on that. The tubercular The Second in the list is a
barrel shaped tooth. It is late for me it doesn't tend to have roots, and it very
rarely erupts. It's often associated on the political aspect of upper ones. And in
fact, it's linked to impaction of upper ones. The management here would be if it is
in fact preventing a eruption of an adult tooth. And it tends to be the upper
Central's then to carry out surgical removal of the supernumerary of the tuberculum
and then this will generally allow a eruption of the central sometimes you might
need to put gold chain on the on erupted incisor and use of orthodontic traction to
a route the tooth. The supplemental sipping URI is a duplicate tooth within the
normal series, and it's found at the end of the series. So often it will be distal
to the lateral and the upper arch, or the pre molar the five to sort of five or
indeed distal to the terminal molar. It will often result in crowding because it's
a tooth extra to normal number in the arch. The management for supplemental to that
is to extract the tooth that has the least favourable crown or root position. So
because they resemble a normal tooth, you'd look to take the one that has the least
favourable crown or root position. Lastly, on our list we have a Don tome these can
be divided into complex and compound. These are rarer, so these are not seen so
frequently. The complex type is a mass of poorly organised dental tissues, and it's
usually in the pre molar molar region. So it's posterior. The compound is a massive
tooth like structures sometimes called denticles. And this is usually in the
anterior portion of maxilla. Just going to show a few clinical slides now, this is
a case strain and impacted lower right five. When it comes to disrupting with pap
to teeth we can give the direction of the tooth so this will be a DISTO angularly
impacted tooth, we can also describe them as meteo, Angular, or horizontal or
vertically impacted. So here's an impacted five with an enlarged ridicu space this
is the same patient just to clinical image. Patient has been bonded up with fixed
appliances and the tooth has been surgically exposed and a gold chain has been
bonded. Then the orthodontist will use the orthodontic wires to carry out extrusion
of the tooth and to bring it into the line of the arch. So here's that tooth being
pulled into the line of the arch using the arch wire there

is a patient that has bilateral impaction of upper canines and these would be
described as museo Angular. Again, slightly large lecture spaces. Both the seas are
retained in this case, you can see that the tip of the canine is in fact overlying
the lateral roots. And when we see overlap of the canine onto the lateral roots,
that that is a very clear sign that the teeth are ectopic. Atopic just means out of
position. And so these aren't bilaterally impacted canines. It's really important
in these cases to check for resorption because unfortunately, sometimes the topic
tooth can cause very severe resorption on the lateral roots, and in fact, sometimes
even on the central root if they're very out of line. So it's really important to
check for resorption in these cases is a clinical image of a patient who has had
surgical exposure of an impacted canine in the palate and has had bonding of gold
chain and then again, a force is going to be used to bring that tooth into the line
of the arch. Looking at supernumerary teeth now this is an example of a
supplemental lateral that's erode in the image. It's a good reminder that we should
always count the teeth it's quite easy if the teeth are particularly crowded to
miss extra teeth. And indeed, we can miss missing teeth and hypodontia patients if
we don't always make a practice of counting the teeth. So it's a really, really
good tip to get into a practice of always cutting the teeth in every single patient
you see within your practice. Present that will prevent those mistakes occurring.

Gonna look at crowding. So crowding is the manifestation of inherent dentoalveolar

disproportion. This is genetically determined and in essence, it's a mismatch
between tooth and jaw size. There are some other causes of crowding. So this would
include things like a loss of primary t, in particular ease, the presence of extra
teeth, and large teeth. So looking at crowding, we can divide crowding into three
different types primary, secondary and tertiary. Primary crowding is the crowding
that's due to dental alveolar disproportion, so that's genetically determined.
Secondary crowding is where you have early loss of a primary tooth, this is
environmental or this can also be thought of as the local cause local factor, and
tertiary crowding is late lower incisor crowding that scene. In the late teens. So
just looking at late Larry sizer crowding, this is deemed to be multifactorial.
Lots of different causes have been implicated. And these include things like the
fact that we have major migration of our teeth throughout life. We have a forward
growth of our jaws. steady growth will slow down but growth actually never stops.
So we say growth reaches adult levels, and adult levels will be very low, but it's
still continuing. Another factor would be the presence and position of third molars
so it's not the only cause to consider but a cause within many causes is the
possibility of the presence of third molars in this condition called late lower
incisor crowding. With respect to large teeth, if you've got a megadonor or
microdot two, this is a tooth that's larger than normal. You'll often say on the
upper Central's sometimes on lower fives incidents overall in the pendant.
dentition is 1%. And you can differentiate a large two from a double tooth by the
fact that you won't have coronal notching and you'll also have normal pulpal
morphology if it's just a large tooth. Crowding can be defined as mild, moderate or
severe. And given the ranges there, it's important to remember that crowding is
endemic in developed countries. profiter Tao in 1998 gives a prevalence of 70 to
80%. And commonly you'll find crowding in the anterior region. It's rare
posteriorly and if you see posterior crowding that may be due to local factors such
as early loss of an E. If you have very mild crowding at zero to four millimetres.
If this is the only condition that the patient presents with, then no NHS treatment
would be offered to this patient because they would have a low iotium for their
crowding. And NHS treatment is is rationed, and so they wouldn't be offered NHS
treatment. Because that would be deemed to be just a small clinical and cosmetic
problem rather than have a large clinical need for treatment. When we look at the
ITN and crowding, we use the letter D and the D there stands for contact point
displacement and we look at the single worst contact point displacement in the
patient's mouth. And we use that in millimetres to give the patient a score for
their crowding. And then we can work out whether the patient would be eligible for
NHS treatment. Here's the clinical image of a patient with what we define as severe
crowding. So there's exclusion or almost exclusion of the upper canines. And
similarly the lower left canine is excluded from the lower arch. You can see some
mild rotations of the anterior teeth. It's important to remember that rotations in
the front of the mouth are a manifestation of crowding, but rotations posteriorly
actually represents spacing in the arch. So you just need to remember that
difference

with respect to relief of moderate to severe crowding, we will normally need to

carry out extractions and this will commonly be the first or second pre molars pre
primer as a good teeth to extract in orthodontic cases because they're the middle
of the arch so they're quite well placed to relieve either anterior or posterior
crowding. And also the crown form of the four and five is very similar. So when you
lose one of those teeth you have at an acceptable contact point with the tooth that
you're left with tooth for the tooth adjacent to it. So the things we need to
consider when we're planning which teeth takeout are given. So for example, quality
of teeth, the amount of crowding and anchorage requirements. So with respect to
quality or prognosis of teeth, it makes sense to extract teeth of poor prognosis
over sound teeth. Sometimes this may compromise the orthodontic results so you
would need to just advise your patient accordingly. But if you have for example, a
heavily restored five perhaps with an unrestored four, you may choose to extract
five even though this may give you less space than you need at the front of mouth.
That that would be a sensible compromise. When we're looking at the choice of fours
or fives, false gives us more space anteriorly to relieve either anterior crowding
or indeed if you had an increased overjet you wanted to reduce in a patient who's
asked to do one and so it makes sense to take fours out where you have a higher
need for space at the front of the mouth. And this has to do with your anchorage so
it's linked to Anchorage requirements. Your anchorage balance where you extract
force favours more movement at the front of the mouth. So it allows you more space
at the front of the mouth to correct your increased crowding anteriorly. Whereas if
you take out fives the anchorage balance here favours forward movement of the six.
So that actually eats up some of that space and so you have less space anteriorly
so in fact, you would go for fives when you had milder crowding. anteriorly and
it's important to remember that sometimes we do take other teeth out so it's more
rare. But for example, if you had a patient with poor prognosis, six years perhaps
they had NIH and they had hypoplastic enamel severely on their 60s, then we would
consider to take six years out in such a case

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