Essentials of

ORTHODONTICS
 Essentials of
ORTHODONTICS

Aravind Sivaraj BDS MDS

Professor and Head
Department of Orthodontics
Chhattisgarh Dental College and Research Institute
Rajnandgaon, Chhattisgarh, India

Foreword
A Venkatesan

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

New Delhi • London • Philadelphia • Panama
 ®

Jaypee Brothers Medical Publishers (P) Ltd.

Headquarters
Jaypee Brothers Medical Publishers (P) Ltd.
4838/24, Ansari Road, Daryaganj
New Delhi 110 002, India
Phone: +91-11-43574357
Fax: +91-11-43574314
Email: jaypee@jaypeebrothers.com

Overseas Offices
J.P. Medical Ltd.
83, Victoria Street, London
SW1H 0HW (UK)
Phone: +44-2031708910
Fax: +02-03-0086180
Email: info@jpmedpub.com
Jaypee-Highlights Medical Publishers Inc.
City of Knowledge, Bld. 237, Clayton
Panama City, Panama
Phone: +507-301-0496
Fax: +507-301-0499
Email: cservice@jphmedical.com
Jaypee Medical Inc.
The Bourse
111, South Independence Mall East
Suite 835, Philadelphia, PA 19106, USA
Phone: + 267-519-9789
Email: joe.rusko@jaypeebrothers.com

Jaypee Brothers Medical Publishers (P) Ltd. Jaypee Brothers Medical Publishers (P) Ltd
17/1-B, Babar Road, Block-B, Shaymali Shorakhute, Kathmandu
Mohammadpur, Dhaka-1207 Nepal
Bangladesh Phone: +00977-9841528578
Mobile: +08801912003485 Email: jaypee.nepal@gmail.com
Email: jaypeedhaka@gmail.com

Website: www.jaypeebrothers.com
Website: www.jaypeedigital.com

© 2013, Jaypee Brothers Medical Publishers

All rights reserved. No part of this book may be reproduced in any form or by any means without the prior permission of
the publisher.

Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com

This book has been published in good faith that the contents provided by the author contained herein are original, and is
intended for educational purposes only. While every effort is made to ensure accuracy of information, the publisher and the
author specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any
of the contents of this work. If not specifically stated, all figures and tables are courtesy of the author. Where appropriate,
the readers should consult with a specialist or contact the manufacturer of the drug or device.

Essentials of Orthodontics

First Edition: 2013

ISBN: 978-93-5090-329-2

Printed at
Dedicated to
My father
Mr K Sivaraj
 Contents vii

Foreword

In recent years, orthodontics has become one of the most vital subjects for study in the
understanding of general dentistry. Due to varied reasons, the subject has remained largely
unexplored among general practitioners and undergraduate students. There has been a huge
hurdle for the general practitioners and undergraduates, who want to explore further in the
field of orthodontics due to unavailability of compact text, highlighting all the essentials in
orthodontics.
I find, Dr Aravind Sivaraj has made an honest attempt to fill up this lacuna in elaborating all
the essentials of practical and clinical orthodontics.
What makes the book unique and hence worth possessing is its format and a large number
of illustrations and diagrams make the understanding of the subject easy. It is evident that a lot
of meticulous thinking and hard work have gone into this work and the labor would be fruitful
if the people for whom it is intended enjoy the book.
The interest and the efforts of Dr Aravind Sivaraj are highly commendable and the book
should stand as an example to other young teachers to emulate.
I am sure that the book would not only be accepted and appreciated by all, but also many
more editions of it, would be published with regular upgradation of the material contained in it.

A Venkatesan MDS
Former Principal, Professor and Head
Department of Orthodontics
Tamil Nadu Government Dental College and Hospital
Chennai, Tamil Nadu, India
 Contents ix

Preface

Essentials of Orthodontics is written in clear and simple language useful for the under­graduates
in dentistry, general practitioners and as a quick reference guide for the postgraduates in
orthodontics.
This book is edited from various textbooks, study materials and manuals in orthodontics. THe
purpose of the book is to educate the students with clear thoughts on the subject with emphasis
on the deep understanding of the concepts and theories in orthodontics.
The text is written for rapid and easy uptake, with only a few classical illustrations and a
handful of carefully chosen references. Many topics are well covered in other texts, and do not
need a lengthy description, but where clinical precision or a new concept is involved, a full
explanation is provided.
The book is designed for the dental students, orthodontic residents and general dentists to
understand the basic concepts and essential procedures regarding the diagnosis, treatment
planning and treatment of patients, who have relatively simple malocclusion problems and to
consult the specialist in case of complex problems.
Readers will essentially learn about the mechanics of how appliances move teeth, the different
types of appliances, and the latest orthodontic materials in the market. A much-needed text
for the dental students and also an excellent resource for dentists, who want to expand their
practice. The book is not intended to compete with the major texts on the theory and techniques
that form the basis of contemporary orthodontic teaching and practice. However, the book will
be a valuable and welcome addition to the existing texts in orthodontics.
Orthodontics is constantly changing and has become a dynamic field in dentistry and
medicine. Rapid advancement in the orthodontic technology and techniques has transformed
the field into the first and best specialty in dentistry. Every possible step has been taken to
prevent any errors and mistakes in the subject; any such occurrence is highly unintended and
unfortunate. Comments and suggestions are highly appreciated.

Aravind Sivaraj
 Contents xi

Acknowledgments

I believe that orthodontics is one of the finest professions, as it combines the best of both the
science and art of dentistry. The greatest appreciation, we can demonstrate to our profession is
to impart and pass on knowledge and expertise to students and fellow colleagues.
First of all, I wish to thank M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India,
for accepting my manuscript for publication into a book.
I sincerely thank all my teachers, well-wishers, colleagues, friends and students, who inspired
me to write the book.
My heartfelt thanks to my mother, wife, daughter and son. Their sacrifices and support have
been overwhelming.
I wish to take this opportunity to express my sincere gratitude to all the people responsible
for the publication of the book.
Finally, I thank God Almighty for this wonderful science of orthodontics.
 Contents xiii

Contents

1. Introduction 1
Introduction to Orthodontics 1
• Definitions 1 • Orthodontist 2
History of Orthodontics 4
• Orthodontics in India 5 • Evolution of Orthodontic Appliances 5

2. Growth and Development 9

General Principles and Concepts 9
• Definitions 9 • Factors Affecting Physical Growth 10 • Concepts of Growth 11
• Types of Growth Data 17 • Methods of Gathering Growth Data 18 • Methods of
Studying Growth 19 • Mechanism of Bone Growth 20 • Osteogenesis (Mechanism
of Bone Formation) 20 • Theories of Growth 23
Prenatal Growth and Development 28
• Period of Ovum 28 • Period of Embryo 28 • Prenatal Development of Maxilla 32
• Development of Palate 32 • Development of Maxillary Sinus 33 • Develop­
ment of Tongue 33 • Prenatal Development of Mandible 34 • Meckel’s
Cartilage 34 • Endochondral Bone Formation 35 • Prenatal Growth of
Temporo­mandibular joint 35
Postnatal Growth and Development 35
• Neonatal Skeleton 36 • Postnatal Growth of the Cranial Vault 36 • Postnatal
Growth of the Cranial Base 36 • Postnatal Growth of Maxilla 38 • Postnatal
Growth of Mandible 40 • Mandibular Rotation 42 • Postnatal Growth of
TMJ 43 Summary of Facial Growth Changes 44
xiv Essentials of Orthodontics

Development of Dentition and Occlusion 44

• Bud Stage 45 • Cap Stage 45 • Bell Stage 45 • Periods of Occlusal Development 46
• Predental Period 46 • Deciduous Dentition Period 48 • Mixed Dentition Period 50
• Permanent Dentition Period 53
Functional Development 57
• Normal Milestones of Development 58 • Puberty and Adolescence 59 • Masti­-
cation 59 • Deglutition 60 • Respiration 62 • Speech 64 • Trajectories of Force 65
• Wolff’s Law of Transformation of Bone 66
Psychological Development 66
• Psychology (Study of Psyche) 67 • Theories of Psychological Development 67
• Beha­vior in Orthodontics 72 • Behavior Development 73 • Behavior Mana­ge­ment 73
• Basic Approaches to Child Management in Orthodontics 77 • Ephebodontics 77
Clinical Importance of Growth and Development in Orthodontics 78
• Infancy and Early Childhood 78 • Juvenile Period 79 • Adolescent Growth 79
• Clinical Implications of Regional Development 79

3. Occlusion and Malocclusion 83

Occlusion 83
• Terminology 83 • Types of Cusps 84 • Arrangement of Teeth in Humans 84
• Imaginary Occlusal Planes and Curves 84 • Centric Relation and Cen­tric
Occlusion 85 • Centric Contacts 85 • Eccentric Occlusion 86 • Disclu­­­sion 86 • Angle’s
Concept of Normal Occlusion 87 • Begg’s Concept of Normal Occlu­sion (Attritional
Occlusion) 88 • Roth’s Concept of Functi­­onal Occlusion 88 • Andrews Six Keys to
Normal Occlusion 89
Classification of Malocclusion 90
• Malocclusion 90 • Classification 90 • Types of Malocclusion 91 • Systems of
Classification 93
Epidemiology of Malocclusion 101
Applications of Epide­mio­logical-Principles 101 • Study Designs 102 • Bias in
Research 104 • Statistics Measurement of Data 106 • Hypothesis Testing 106
Indices of Malocclusion 109
• Index 109
Anthropology 117
• Anthropology and Orthodontics 120 • Early Primates 121

4. Etiology 127
Etiology of Malocclusion 127
• Classification of Etiologic Factors in Malocclusion 127 • Etiology for Specific Types
of Malocclusion 133
 Contents xv

Habits 135
• Definition 135 • Classification of Habits 135 • Thumb Sucking and Finger
Sucking 137 • Tongue Thrusting Habit 142 • Mouth-breathing 147 • Lip Biting
and Lip Sucking 151 • Bruxism 151 • Finger Nail Biting 153 • Tongue Sucking 154
• Pillowing Habits 154
Nutrition in Orthodontics 154
• Effect of Nutritional Status on Tooth Movement and Tissue Response to
Appli­­­ances 154 • Dietary Counseling for Plaque Control and General Health in the
Orthodontic Patient 156 • Nutritional Considerations in the Orthognathic Surgical
Patient 156 • Nutritional Factors in the Etiology of Craniofacial Anomalies 157
Genetics in Orthodontics 158
• History 159 • Molecular Basis of Inheritance 159 • Genetics in Orthodontic
Perspective 161

5. Orthodontic Diagnosis 166

Orthodontic Diagnosis 166
• Esthetics in Orthodontics 166 • Golden Section 167
Diagnostic Aids in Orthodontics 171
• Essential Diagnostic Aids 171 • Supplemental Diagnostic Aids 172 • Case
History 172 • Clinical and General Examinations 173 • Functional Examination 180
• Orthodontic Study Models 185 • Total Dentition Space Analysis 193 • Inference
to Deficits and Decisions 195 • Radiographs Used In Orthodontic Diagnosis 196
Cephalometrics 198 • Facial Photographs 218
Computers in Orthodontics 236
• Characteristics of a Computer 237 • Uses of Computer in Orthodontics 238
Sterilization in Orthodontics 243
• Sterilization 243

6. Orthodontic Treatment Planning 246

General Factors in Orthodontic Treatment Planning 246
• Setting-up Goals 246 • Enlisting the Treatment Objectives 246 • Age Factor in
Orthodontics 249 • Treatment and Age 250 • Tooth Movement and Age 251 • Young
Versus Adult Patients 251 • Phases of Orthodontic Treatment 252 • Limitations in
Orthodontics 253
Methods of Gaining Space 253
• Proximal stripping (Reprox­im ­ i­­zation, Slenderization, Disking and Proximal
Slicing) 254 • Expansion 255 • Types of Appliances Used 257 • Slow Expansion 260
xvi Essentials of Orthodontics

• Extractions in Orthodontics 262 • Distalization 267 • Uprighting of Molars 269

• Derotation of Posterior Teeth 269 • Proclination of Anterior Teeth 269
Treatment Planning in Class I Malocclusion 269
• Clinical Features of Class I Malocclusion 269 • Midline Diastema 272 • Crossbite 275
• Impacted Teeth 281
Treatment Planning in Class II Malocclusion 284
• Class II Division 1 Malocclusion 285 • Class II Division 2 Malocclusion 287
Treatment Planning in Class III Malocclusion 288
• Clinical Features of Class III Malocclusion 288 • Skeletal Features of Class III
Malocclusion 289
Drugs Used in Orthodontics 290
• Prophylactic Antibiotics for Prevention of Infective Endocarditis 290

7. Biomechanics 298
Mechanics of Tooth Movement 298
• Newton’s Laws of Motion 298 • Types of Tooth Movements 299 • Types of Force 301
Biology of Tooth Movement 302
• Physiologic Tooth Movement 302 • Tooth Mobility 305 • Histology of Tooth
Movement 305 • Optimum Orthodontic Force 306 • Hyalinization 307 • Theories
of Tooth Movement 308 • Phases of Tooth Movement 309 • Biochemical Reaction
to Orthodontic Tooth Movement 310 • Bone Resorption 311 • Bone Deposition 311
Anchorage in Orthodontics 314
• Definition (Graber) 314 • Classification 314 • Sources of Anchorage 315
• Implants as Anchorage in Orthodontics 320 • Anchorage Loss 325

8. Preventive and Interceptive Orthodontics 326

Preventive Orthodontics 326
• Definition 326 • Caries Control 327 • Oral Habits Check-up and Educating Patients
and Parents 328 • Space Maintainers 328
Interceptive Orthodontics 333
• Definition 333 • Serial Extractions 334 • Developing Anterior Crossbite Correction
337 • Preorthodontic Trainers 340 • Clinical Management 341 • Muscle Exercises 341

9. Orthodontic Appliances 344

• Classification of Orthodontic Appliances 344 • Ideal Requirements of an
Orthodontic Appliance 345
 Contents xvii

Removable Appliances 345

• Indications for Removable Appliances 345 • Advantages of Removable Appliances
345 • Disadvantages of Removable Appliances 346 • Components of Removable
Appliances 346
Fixed Appliances 364
• Advantages of Fixed Appliances 364 • Disadvantages of Fixed Appliances 365
• Banding 366 • Bonding 367 • Components of Fixed Orthodontic Appliances 368
I. Active Components 369 • II. Passive Components 372 • Fixed Appliance
Techniques 375 • Oral Hygiene in Fixed Appliance Treatment 379

10. Dentofacial Orthopedics 382

Orthopedic Appliances 382
• Basis for Orthopedic Appliances 382 • Biomechanical Consideration 383
• Headgear 384 • Protraction Face Mask Therapy 388 • Factors Governing
Variability in Clinical Response 389 • Chin Cup Therapy 390
Functional Appliances 390
• Definition 391 • Classification of Functional Appliances 391 • Advantages of
Functional Appliances 393 • Limitations of Functional Appliances 393 • Action of
Functional Appliances 394 • Visual Treatment Objective 395 • Vestibular Screen
(Oral Screen) 395 • Activator 397 • Management of the Appliance 400 • Wunderer’s
Modification 401 • The Reduced Activator or Cybernator of Schmuth 402
• Pro­pulsor 402 • Karwetzky Modification 402 • Herren’s Modification of the
Activator 402 • Function Regulator (Frankel Appliance) 403 • Bionator 407 • Twin
Block Appliance 408 • Herbst Appliance 409

11. Retention and Relapse 412

Retention 412
• Schools of Retention 412 • Theorems of Retention 412 • Raleigh Williams Six Keys
for Retention 414 • Theories of Retention 414 • Methods of Retention: Retainers 415
Relapse 421 • Failures in Orthodontics 423

12. Surgical Orthodontics 429

Minor Surgical Procedures 429
• Extractions 429 • Surgical Exposure of Impacted Teeth 430 • Frenectomy 431
• Pericision (Circumferential Supracrestal Fibrotomy or CSF Procedure) 431
• Corticotomy 432 • Orthodontic Implants 432
Orthognathic Surgery 433
• Etiology of Dentofacial Deformities 433 • Orthognathic Surgery 434 • Presurgical
Orthodontics 436 • Maxillary 437 • Mandibular Surgeries 440
xviii Essentials of Orthodontics

Distraction Osteogenesis 442

• Definition 442 • Historical Perspective 442 • Indications 443 • Advantages 443
• Disadvantages 443 • Preoperative Clinical Examination 444 • Growth and Stability
after Distraction 446

13. Multidisciplinary Orthodontics 448

Adult Orthodontics 448
• Reasons for Increase in Adult Patients 448 • Biomechanical Considerations 450
• Diagnosis and Adult Orthodontics 451 • Treatment Aspects in Adult Ortho­-­
dontics 452
Orthodontics in Multispecialty Approach 455
• Multispecialty Ortho­dontic Treatment 455 • Orthodontic-periodontic Inter­
relation­ship 457
Orthodontic Management of TMJ and Occlusal Disorders 462
• Biomechanics 463 • Temporomandibular Joint Pathology 464 • Signs and
Symptoms of TMJ Disorders 465 • Orthopedic Dysfunction 466 • Diagnosis 468
Management 469
Orthodontic Management of Cleft Lip and Palate 472
• Incidence 472 • Embryological Background 473 • Family Counseling 480
Orthodontic Management of Craniofacial Syndromes 480
• Orthodontic Management of Cleidocranial Dysplasia 480 • Orthodontic
Management of Obstructive Sleep Apnea Syndrome 482 • Orthodontic and
Temporomandi­b ular Joint Considerations in Treatment of Patients with
Ehlers-Danlos Syndrome 483
Orthodontic Management of Medically Compromised Patients 484
• Management of Physically Handicapped Child 484 • Management of Orthodontic
Patients with a History of Rheumatic Fever or Congenital Heart Disease 485
• Orthodontic Management of Patients with Bleeding Disorders 486 • Orthodontic
Management of Patients with Hematologic Malignancies 487 • Orthodontic
Management of Patients with Endocrine Disorders 488 • Orthodontic Management
of Patients with Diabetes 489 • Orthodontic Management of Patients with Cystic
Fibrosis 491 • Orthodontic Management of Patients with Juvenile Rheumatoid
Arthritis 491 • Orthodontic Management of Patients with Renal Failure 492
Forensic Orthodontics 493
• Forensic Dentistry 493 • Role of Orthodontist 494 • Dermatoglyphics 495

14. Community Orthodontics 496

Orthodontic Practice 496
• Ideal Orthodontic Services 496 • Typical Orthodontic Practice Organization 496
• Orthodontic Work Environment 499
 Contents xix

Medicolegal Considerations in Orthodontics 504

• Legal Precedents 504

15. Materials Used in Orthodontics 507

Orthodontic Materials 507
• Classification of Orthodontic Appliance Materials 507 • Orthodontic Arch Wire
Materials 509 • Bracket and Attachment Materials 517 • Bonding Materials 518
• TEGDMA 520 • Orthodontic Cements 520 • Sealants and Adhesion Promoters 524
• Conditioning and Crystal Growth Systems 525 • Elastics and Elastomerics 526
• Magnets in Orthodontics 526 • Soldering and Welding 528 • Other Dental
Materials 534
Acrylic Materials 542
• Ideal Requirements for Dental Resin 542 • Acrylic Resins 542
Finishing and Polishing Materials 545
• Commonly used Abrasives 545
Implant Materials in Orthodontics 546
• History 546 • Metals and Alloys 546 • Other Metals and Alloys 547 • Endosteal
and Subperiosteal Implants 548
Orthodontic Instruments 549
• Adam’s Pliers (Universal Pliers) 549 • Arch-forming Pliers (Arch-contouring
Pliers, De la Rossa Pliers) 549 • Band Burnisher (Beaver-tail Burnisher) 549
• Band-contouring Pliers 550 • Band Pusher (Mershon Band Pusher) 550 • Band-
Removing (Debanding) Pliers, Anterior 550 • Band-Removing (Debanding) Pliers,
Posterior 550 • Band Seater (Band Biter) 551 • Bird-beak (No. 139) Pliers 551
• Bracket-positioning Instrument (Bracket-height Gauge, Boone’s Gauge) 551
• Bracket-removing Pliers (Debonding Pliers) 552 • Conversion Instrument 552
Coon Ligature-tying Pliers 552 • Distal-end Cutter 552 • Elastic Separator Pliers
(Sep­arator Pliers) 553 • Facebow-adjusting Pliers 553 • Hard Wire Cutter 553
• Hemostat (Mosquito Pliers) 553 • Howes Utility Pliers 554 • Ligature
Director (Pitchfork Instrument, Tie in Tucker) 554 • Light-wire Pliers 554
• Mathieu-style Ligature-tying Pliers 555 • Parallel-action Pliers with
Cutter (Sargent’s heavy-duty Pliers) 555 • Pin and Ligature Wire Cutter 555
• Serrated Band Plugger (Serrated Amalgam Plugger) 556 • Steiner Ligature-
tying Pliers 556 • Torquing Key 556 • Triple-beaked Pliers (Three Prong Pliers,
Three Jaw Pliers, Clasp-adjusting Pliers) 556 • Turret 557 • Tweed Arch-adjusting
(No. 142) Pliers 557 • Tweed Loop-forming Pliers (Omega Pliers, Optical Pliers) 557
• Weingart Utility Pliers 558

Bibliography 559
Index 561
 CHAPTER
1 Introduction
INTRODUCTION TO
ORTHODONTICS
The term orthodontia was apparently used first
by the Frenchman Le Foulon in 1839. The name
of the specialty Orthodontics comes from two
Greek words “ortho” meaning right or correct
“odontos” meaning tooth and “ics” meaning
science.
Orthodontics is the branch of dentistry
concerned with prevention, interception and
correction of malocclusion and other develop­
mental abnormalities of the dentofacial region.
DEFINITIONS
British Society for Study of
Orthodontics (1922)
“Orthodontics includes the study of the
gro­w th and development of the jaws and
face particularly, and the body generally,
as influencing the position 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
perverted development.”
Proffit (1975)
“Orthodontics is the area of dentistry concerned
with the supervision, guidance and correction
of the growing and mature dentofacial
struc­tures, including those conditions that
require movement of teeth or correction of
malrelationships and malformations of related
structures by the adjustment of relationships
between and among teeth and facial bones by
the application of forces and/or the stimulation
and redirection of the functional forces within
the craniofacial complex.”
American Association of
Orthodontics (1993)
American Association of Orthodontics (AAO)
renamed the specialty from Orthodontics to
Orthodontics and Dentofacial orthopedics in
1984. They modified the definition of orthod­
ontics in 1993 as, “The area and specialty of
dentistry concerned with the supervision,
guidance and correction of the growing or
mature dentofacial structures, including
those conditions that require movement of
teeth or correction of malrelationships and
malfor­mations of their related structures and
2 Essentials of Orthodontics
the adjustment of relationships between and
among teeth and facial bones by the appli­
cation of forces and/or the stimulation and
redirection of fun­ctional forces within the
craniofacial complex. Major responsibilities
of orthodontic practice include the diagnosis,
prevention, interception and treatment of
all forms of malocclusion of the teeth and
associated alterations of their surrounding
structures; the design, application and control
of functional and corrective appliances; and
the guidance of the dentition and its supporting
structures to attain and maintain optimal
occlusal relations, physiologic function and
esthetic harmony of facial structures.”
ORTHODONTIST
Orthodontist (Orthodontic Specialist)
A graduate of an accredited dental school who
additionally has followed a postgraduate full-
time academic program in orthodontics, in
accordance with the requirements of his/her
national, state, or provincial law. The duration
of the postgraduate orthodontic training
varies in different countries or areas of the
world. For example, in the USA a two-year
full-time academic training beyond general
dental school is required to obtain the title
of ortho­d ontist, whereas in the European
Union and India the minimum requirement
is three years.
Branches of Orthodontics
Orthodontics can be broadly divided into:
Preventive Orthodontics
It is the action taken to preserve the integrity of
what appears to be normal at a specific time.
Interceptive Orthodontics
It is that phase of science and art of orthodontics
employed to recognize and eliminate
potential irregularities and malpositions in
the developing dentofacial complex.
Corrective Orthodontics
Corrective orthodontics recognizes the
existing malocclusion and the need for
employing certain technical procedures to
reduce or eliminate the problem and the
attendant sequelae.
Surgical Orthodontics
They are the surgical procedures that are
undertaken in conjunction with or as an
adjunct to orthodontic treatment.
Aims of Orthodontic Treatment
The aims and objectives of orthodontic
treatment has been summarized by Jackson
as Jackson’s triad, they are:
1. Functional efficiency: The orthodontic
treatment should aim at improving the
functions of the stomatognathic system,
as many malocclusions tend to alter the
normal functions.
2. Structural balance: Orthodontic therapy
should maintain a structural balance
between hard tissues of teeth and bones to
that of soft tissues of muscles and tongue.
3. Esthetic harmony: Many malocclusions
are associated with poor facial appearance
and dental esthetics; hence orthodontic
treatment should aim at improving the
esthetics of face and teeth.
Unfavorable Sequelae of Malocclusion
Malocclusion leads to many problems that can
be listed as:

1. Unfavorable psychological and social
squeal.
a. Introversion, self-consciousness.
b. Response to uncomplimentary nick-­
names like Bugs bunny, Buckteeth
or Bucky beaver.
2. Poor appearance: Interference with
normal growth and development and
accomplish-ment of normal pattern
a. Cross bites causing facial asym­
metries.
3. Improper or abnormal muscle function
a. Compensatory muscle activities
such as hyperactive mentalis muscle
activity, hypoactive upper lip, increase
buccinator pressures and ton­gue
thrust that occurs as a result of spatial
relationship of teeth and jaws.
These activities are unfavorable and
serve to increase the departure from
normal.
4. Associated muscle habits
5. Improper deglutition
a. Changed function as a result of
adaptive demands
6. Mouth breathing
7. Improper mastication
8. Speech defects
9. Increased caries incidence
10. Predilection to periodontal disease
11. Temporomandibular joint problems:
Functional problems
12. Predilection to accidents
13. Impacted and unerupted teeth, poss­ible
follicular cysts, damage to other teeth
14. Prosthetic rehabilitation compli­c­ations:
Space problems, teeth tipped and rece­
iving abnormal stress.
Need for Orthodontic Treatment
Orthodontic treatment is required to:
1. Improvement of esthetics
2. Restoration of proper function of teeth
Introduction 3
3. Reduction of susceptibility of dental
caries
4. Elimination of pathological conditions
of the gingival and periodontal tissues
caused due to malocclusion of teeth
5. Correction of malposed teeth prior
to construction of partial denture or
bridge­work
6. Elimination of harmful habits
7. Prevention and correction of tempo-
romandibular joint abnormalities
8. To correct speech defects
9. Decompensation before taking up the
case for surgical correction
10. Additional treatment after surgical corr­
ection of congenital deformities and
skeletal malocclusions
11. As a result of accidental injury, loss of
teeth or interference with occlusions
may make orthodontic treatment
necessary
12. To improve the personality of an
individual.
Scope of Orthodontic Treatment
The scopes of orthodontic treatments are:
Orthodontic tooth movement: Application
of forces are responsible for altering the
tooth positions, dental malocclusions are
treated effectively by altering the tooth
positions. Orthodontics is mainly employed
to alter permanently the tooth positions. Tooth
movement can be undertaken in all three
planes, transverse, vertical and sagittal.
Dentofacial orthopedic growth modification:
Malocclusions associated with skeletal dis­
har­mony can be corrected to normal by appli­
cation of orthopedic forces which are capable
of redirecting, modifying and restraining
skeletal growth patterns.
Altering the soft tissue patterns: Favorable
changes can be brought about in the soft
tissues by orthodontic treatment that are
4 Essentials of Orthodontics
responsible for normal development and
maintenance of dentition and skeleton.
HISTORY OF ORTHODONTICS
Orthodontics is considered as the oldest
specialty of dentistry. Evidences suggest that
attempts were made to treat malocclusion as
early as 1000 BC. Primitive appliances to move
teeth have been found in Greek and Etruscan
excavations.
The Greek physician Hippocrates (460–377
BC) is believed to be the father of medicine. He
is the first person to establish medical tradition
based on facts rather than religion of rancy. A
number of references on teeth and jaws are
found in his writings.
Aristotle (384–322 BC) was a Greek philo­
sopher who gave medical science the first
system of comparative anatomy; he compared
human teeth with other species.
The first recorded suggestion for active
treatment of malocclusion was by Aulius
Cornelius Celcus (25 BC–50 AD) who advocated
the use of finger pressure to move the teeth.
Pierre Fauchard, a French dentist, is
considered the founder of modern dentistry
and he is known as Father of Dentistry. As early
as 1723, he developed what is probably the first
orthodontic appliance called a Bandelette that
was designed to expand the dental arch.
Norman Kingsley, an American dentist,
was the first to use extraoral force to correct
pro­truding teeth. He is considered as one of
pioneers in cleft palate treatment.
Emerson C Angell (1823–1903) was the
first person to advocate the opening of the mid
palatal suture, a procedure that later came to
be known as rapid maxillary expansion.
William E Magill (1823–1896) was the first
person to band teeth for active tooth move­
ment.
Henry A Baker in 1893, introduced what
is called Baker’s anchorage or the use of
intermaxillary elastics to treat malocclusion.
Edward H Angle (1855–1930) (Fig. 1.1)
is considered the Father of Modern Orthod­
ontics for his numerous contributions to this
specialty. Through his leadership, orthod­
ontics was separated from other branches
of dentistry to establish itself as a specialty.
Angle’s contri­butions include a classification
of malocclusion and orthodontic appliances
such as Pin and tube appliance, E-arch, Ribbon
arch and Edgewise appliance. Angle also
started a school of Orthodontics in St. Louis,
New London, Conn­ecticut in which many of
the pioneer orthod­ontists were trained. Angle
believed that the whole compliment of teeth
could be retained and yet good occlusion
could be achieved. He thus advocated arch
expansion for most patients.
Calvin S Case (1847–1923) believed that
facial improvement was a guide to orthodontic
treatment. Case also claims to be the first
orthodontist to use intermaxillary elastics.
He was a critic of Angle and opposed Angle’s
Figure 1.1: Edward H Angle

philosophy 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 nonextraction. Dewey also modi­
fied Angle’s classification of maloc­clusion.
In 1931, Holly Broadbent and Hofarth inde­
pen­dently developed cephalometric radio­
graphy, which standardized the positioning
of the head in relation to the film and X-ray
source. This can be considered a major
advance­ment in orthodontic diagnosis and
treatment planning.
Buonocore in 1955, introduced the acid
etch technique; this enabled direct bonding of
orthodontic attachments to the enamel which
greatly enhanced esthetics.
Raymond P Begg of Australia introduced a
light wire fixed appliance that was based on the
concept of differential force. He also advocated
the need for extraction of some teeth to achieve
stable results.
While 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 mono­
block, which protruded the mandible in cases
of glossoptosis.
Viggo Anderson in 1910, developed the
activator, which made use of the facial muscul­
ature to guide the growth of the jaws.
Rolf Frankel in 1969, proposed the function
regulator to treat variety of skeletal malo­
cclusions.
Lawrance F Andrews introduced the
Straight Wire Appliance in 1972; this was a
preadjusted appliance in which the brackets
were pre-programmed to accomplish the
desired tooth movements in all the three
Introduction 5
planes of space. This is considered a major
advancement in improving orthodontic
treatment results with minimal possible wire
bending.
ORTHODONTICS IN INDIA
In India, the first dental college, Calcutta
Dental College and Hospital was started in the
year 1920 by Dr Rafiuddin Ahmed in his private
chamber. Dr Ahmed, the Father of Dentistry in
India is also known as “The Grand Old Man of
Dentistry”. He is credited with the first edition
of “The Indian Dental Journal” in October
1925, foundation of the “All India Dental
Association” in the year 1927, drafting and
passing of the Bengal Dentist Act in 1939, and
the passing of the Indian Dentist Act in 1948.
Dentistry as a subject was introduced as a
2 years diploma course to “Licentiate in Dental
Science (LDSc). It was changed to the 3 years
course in the year 1926 and further modified
to the present 4 years BDS course in 1935.
EVOLUTION OF ORTHODONTIC
APPLIANCES
1728 In his work Le Chirurgien Dentiste,
Pierre Fauchard (Vannes 1678–Paris
1761) laid the foundations of ortho­
dontic science. Among other things,
he illustrated a number of orthodontic
treatises and a rudimental orthodontic
expansion device called a bandelette,
the invention of which was without
attribution because it had been use
for some time. This brace consisted of
a band of silver stabilized with metal
or plant—fiber bindings. He also
descri­bed the surgical straightening of
individual teeth.
6 Essentials of Orthodontics
1741 The term orthopedics in reference to the
stomatognathic apparatus appe­ared for
the first time in L’ Orthopédie ou l’Art de
Prevenir et de Corriger dans les Enfans
les Difformités du Corps by Nicolas
Andry De Bois Regard (1658–1672).
1771 John Hunter (Long Calder wood
1728–London 1793), an anatomist and
surgery teacher, devoted three cha­pters
of his Natural History of the Human
Teeth to malocclusions, even proposing
a classifi­cation of them.
1803 A chin cup for nonorthodontic pur­
poses was first described by Francois
Cellier, who used it to prevent postex­
traction hemorrhage.
1803 Joseph Fox (1776–1816), a student of
Hunter, published ‘The Natural History
of the Human Teeth—Describing the
Proper Mode of Treatment to Prevent
Irregularities of the Teeth’.
1809 JB Lamarck (1744–1829), a zoologist,
wrote of the importance of function
in the development of organs and the
species, forerunning Wilhelm Roux’s
theories on functional adaptation.
1819 Michael Faraday prepared the first
iron— chromium alloy, a precursor of
stainless steel.
1826 LJ Catalan (1776–1830) utilized the
principles and method of the inclined
plane.
1826 CF Delabarre, (1777–1862), in his Meth­
ode Naturelle de Diriger la Seconde
Dentition, accurately des­cribed tooth
transition, emphasizing the importance
of primary teeth.
1829 In his Manual of Human Anatomy,
JF Meckel (1781–1833) described the
cartilage of the first branchial arch.
1834 William Imrie named thumb-sucking
as an etiologic role in malocclusions.
1836 F Kneisel (1797–1883) published Der
Schiefstand der Zähne, the first work
in German on malocclusions.
1839 The American Journal of Dental Science,
the first journal devoted entirely to
dentistry.
1839 A French scholar, Jacoues Lefoulon, coi­
ned the term orthodontosie in a series
of articles on “Orthopedia dentaire”,
which appeared in the Gazette des
Hopitaux.
1840 C Goodyear (1800–1860) discovered
that natural rubber hardens when com­
bined with a small amount of sulfur.
1840 The initiative of Chapin Harris and
Horace H Hayden (1769–1844), the
first school of dentistry, the College of
Dental Surgery in Baltimore.
1840 CS Brewster (1790–1870), an American
dentist living in Paris, constructed a
rubber orthodontic device (Vulcanite
plate or Regulierungs platte, according
to Schnizer) equipped with springs,
introducing a material different from
those used until that time.
1841 JS Guinnell described the first ortho­
pedic chin cap appliance.
1843 Malagan-Antoine Desiderabode (1781–
1850) published ‘Nouveaux ele­ments
com­plets de la science et al l’art du
dentiste’, in which he intro­duced the
concept of Leeway space and the balance
of force between lips and tongue.
1848 WE Dwinelle (1819–1896) made an
orthodontic plate with screws to widen
dental arches. The screws used were
jackscrews.
1859 Lefoulon published a text entirely dev­
o­ted to orthodontics.
1860 Englishman CR Coffin first introduced
the use of piano wire to expand the
maxillary arch.

1864 T Ballard (1836–1878) reaffirmed the
etiologic role played by prolonged
sucking (fruitless sucking) in maloc­
clusions.
1866 Norman Kingsley perfected occipital
anchorage and extraoral forces.
1876 AH Thompson (1849–1914) recog­nized
the importance of occlusal forces in
den­t oal­v eolar development and in
orthod­ontic movement.
1881 Walter Harris Coffin (1853–1916), an
English dentist and son of CR Coffin,
perfected the expansion technique
introduced years earlier by his father.
1887 Edward Angle (1855–1930), an American
dentist, inaugurated fixed orthodontics,
presenting a method based on precise
mechanical principles and introducing
the use of gold multiband devices, the
‘braces’ that would. He was the author
of the term malocclusion and surely the
most important figure in the history of
orthodontics, making contributions that
were decisive for the birth of this new
science. He fought to transform ortho­
dontics into an independent specialty
and to have it officially taught. His
classification of malocclusion, based on
the position of the first molars, remians
funda­mental even today.
1888 John Nutting Farrar (1839–1913), a
New York dentist, published the first
volume of a basic work, Treatise on
the Irregul­arities of the Teeth and Their
Corr­ection. In his orthodontic work, he
paid great attention to the physiologic
and pathologic changes in tissues. His
teachings also deeply influenced Viggo
Andresen, whose writings show how
the activator fully respects the principles
Farrar established for intermittent forces.
1888 Wilhelm Roux ( Jena 1850 – Halle
1924), an anatomist and follower of
Introduction 7
the Darwin school, founded the first
research institute on development in
Germany. He devoted his life to the
subject, working out the theory of
functional adaptation.
1890 Walter H Coffin created a vulcanite
orthodontic appliance with a W-shaped
spring to expand the maxilla.
1895 The fundamental work by Wilhelm
Roux, devoted to the mechanisms that
regulate development, was published.
20th Century before and during
World War–I
1901 Edward Angle and a group of his
students founded the Society of
Orthodontics in St Louis.
1902 Pierre Robin (Charolles en Bourgogne
1867–Paris 1950), a French doctor and
professor of stomatology, described
the construction and properties of the
mono­bloc.
1908 Viggo Andresen (Copenhagen 1870–
1950) experimented with a removable
retention plate following active multi­
band therapy in his daughter and was
surprised to obtain further clinical
improvements. This device was named
an activator.
1909 Emil Herbst (1842–1917), a German
dentist, designed a fixed appliance for
forced mandibular advancement.
1911 In the wake of Sandstedt’s research, A.
Oppen­heim discovered the damage
done by excessive force and recom­
men­d ed the use of light and inter­
mittent pressure.
1918 Alfred Paul Rogers, a professor at Har­
vard Dental School in Boston, published
an article in which he defined muscles
as “living orthodontic appli­ances”.
1922 Pierre Robin published Eumorphia, a
collection of his writings.
8 Essentials of Orthodontics
1926 Edmondo Muzj (1894–1994) intro­
duced the teaching of orthodontics at
the University of Bologna.
1927 Studying craniofacial growth and
anthropometry, M Hellman came to
the conclusion that malocclusions are
caused by growth disturbances.
1929 Studying growth and comparing
humans with other mammals, W Todd
confirmed Heilman’s conclusions,
stating that growth leads to a modifi­
cation in the proportions of the various
parts.
1933 The Krupp company marketed the first
stainless steel dental crowns, shortly
followed by clasps, wires, and other
materials.
1934 Gustave Korkhaus invited FM Watry
to Cologne, where he expounded on
Robin’s idea and method. The text of this
conference was published in the journal
Fortschritte der Kieferorthopadie.
1936 After more than 10 years of close colla­
boration, Viggo Andresen and Karl
Haupl published a book on functional
jawbone orthopedics, Funktions-
Kieferorthopädie.
1938 Arthur Martin Schwarz (1887–Vienna
1963) published Gebissreinigung mit
Platten, entirely devoted to orthod­ontic
plates.
1939 HG Gerlach experimented with the
first open elastic devices, arousing
the strong opposition of K Haupl, who
criticized the changes made to the
activator.
1949 Hans Peter Bimler modified Andre­
sen’s activator and created the elastic
occlusal modeler (Elastischer gebiss­
former).
1949 Edmondo Muzi modified the activator,
eliminating the palatal part and intro­
ducing a metal slide curved on the
mandibular par to expand the arch.
1950 Wilhelm Balters (1893–1973) began to
modify Andresen’s activator together
with dental technician Fritz Geuer in
order to re-educate orofacial disorders.
1952 Hans Muhilemann created the propu­
lsion device similar to the activator but
without metal elements, which would
later be perfected by Rudolph Hotz at
the University of Zurich.
1953 Hugo Stockfisch created the kinetor,
an interesting modification of the
acti­­va­tor equipped with elastic mastica­
tion planes.
1954 H Van Thiel created an activator
devoid of the upper part of the palate,
predating Klammt’s work.
1960 Georg Klammt, a student of Bimler,
altered his teacher’s appliance because
he felt it to be too fragile and created the
elastisch-offene activator.
1960 Melvin Moss, a professor at Columbia
University, New York, formulated the
“functional matrix” theory together
with his wife, Letty Salentijn.
1960 Rolf Frankel published the first clinical
results obtained with the function reg­
ul­ator.
1960 Georg Schmuth created the kyber­
nator, an appliance deriving from the
Bionator with the addition of a classic
maxillary vesti­b ular arch and two
mandibular vestibular cushions.
1967 Alexander Petrovic formulated his fun­
da­­­mental theories about the different
types of cartilage involved in osteogen­
esis and individuated the peculiarities
of mandi­bular condyle cartilage, which
also res­ponds to local external stimuli,
such as tensing of the lateral pterygoid
muscle.
 CHAPTER
Growth and
2 Development
GENERAL PRINCIPLES
AND CONCEPTS
Orthodontic treatment requires a good knowl­
edge of anatomy, growth and development of
head, jaws and face. It is almost impossible to
plan the orthodontic treatment without having
an idea about the growth and development of
an individual.
DEFINITIONS
Growth
There is no universally accepted definition of
growth. Various clinicians have defined growth
in different ways.
“The self-multiplication of living substance”
(JS Huxley).
“An Increase in size” (Todd).
“Increase in size, change in proportion and
progressive complexity” (Krogman).
“Entire series of sequential anatomic
and physiologic changes taking place from
the beginning of prenatal life to senility”
(Meridith).
“Quantitative aspect of biologic develop­
ment per unit time” (Moyers).
“Change in any morphological parameter
which is measurable” (Moss).
Growth is generally a triad of events inclu­di­ ng
self-multiplication, differentiation and organi­
zation occurring in time as fourth dimen­sion.
Though growth is generally associated
with an increase in size, yet some conditions
involving regression are also considered to take
place during growth (e.g. atrophy of thymus
gland).
Development
Development occurs along with growth and is
inseparable from it.
“Progress Towards Maturity” (Todd)
“All naturally occurring unidirectional changes
in the life of an individual from its existence as a
single cell to its elaboration as a multifunctional
unit terminating in death” (Moyers).
Thus, development encompasses the
normal sequential events between fertilization
and death.
10 Essentials of Orthodontics
Maturation
Stabilization of the adult stage brought about
by growth and development.
Differentiation
Differentiation is the change from a generalized
cell or tissue to one that is more specialized,
thus differentiation is a change in quality or
kind.
FACTORS AFFECTING PHYSICAL
GROWTH
A number of factors affect the rate timing and
character of growth, they are:
Hereditary
Heredity is one of major factor affects physical
growth. Genes influences the size of parts, rate
of growth, and onset of growth and timing of
events. Genetic studies of physical growth
make use of twin and family data. Differences
between monozygotic and dizygotic twins are
assumed to be differences due to environment.
Nutrition
Malnutrition during childhood delays growth
and adolescent spurt in growth, catch-up
growth appears when a favorable nutritional
regimen is supplied early enough. Malnutrition
affects the timing of growth and texture of
tissues. These effects are reversible to some
extent as when the effects are not very severe
and when proper nutrition is provided.
Illness
The usual minor childhood illness ordinarily
may not have a major effect on physical
growth. Prolonged and debilitating systemic
illness however can have a marked effect on
normal physical growth and may lead to delay
in maturation.
Race
There are six races in world, Caucasian,
Negroid, Mongoloid, Alpine, Aboriginals, and
Medit­erranean. Each of these racial groups
shows characteristic growth patterns.
In India the common racial groups are
Dravidian, Indo-aryan, Mongoloid, and turko-
iranian. Although the differences in growth
among different races can be attributed to
other nutritional and environmental factors,
there seems to be some evidence that race does
play a role in growth process. For example in
American Blacks, calcification and eruption
of teeth occurs almost a year earlier than their
white coun­terparts.
Socioeconomic Factors
Children brought up in affluent and favorable
conditions show earlier onset of growth events.
They also grow to a larger size than children
living in unfavorable economic conditions.
Family Size and Birth Order
Studies have shown that the first-born babies
tend to weigh less at birth and have smaller
stature but higher IQ. The smaller the family
size, the better would be the nutrition and
other favorable conditions.
Secular Trends
Changes in size and maturation in a large
population can be shown to occur with
time. For example, fifteen years old boys are
approximately 5 inches taller than the same
age group 50 years back. Although there is no
satisfactory explanation offered regarding this
finding it could possibly be due to changes in
socioeconomic conditions and food habits.

Climatic and Seasonal Effects
Seasonal variations have been shown to
affect adipose tissue content and the weight
of newborn babies. Climatic changes seem to
have little direct effect on rate of growth.
Psychological Disturbances
It is seen that children experiencing
stressful conditions display an inhibition of
growth hormone secretion. Psychological
disturbances of prolonged duration can hence
markedly retard growth.
Exercise
Although exercises may be essential for a
healthy body, strenuous and regular exercises
have not been associated with more favorable
growth. Certain aspects of growth such as
development of some motor skills and increase
in muscle mass is found to be influenced by
exercise.
CONCEPTS OF GROWTH
Concept of Normality
Normal refers to that which is usually expected,
is ordinarily seen or is typical. The concept of
normality must not be equated with that of the
ideal. While ideal denotes the central tendency
for the group, normal refers to a range. Another
aspect of craniofacial growth is that normality
changes with age. Thus what is normally seen
or is expected for one age group may not be
necessarily normal for a different age group.
Rhythm of Growth
According to Hooton “Human growth is not a
steady and uniform process wherein all parts
of the body enlarge at the same rate and the
increments of one year are equal to that of
the preceding or succeeding year.” However
Growth and Development 11
there seems to be a rhythm during the growth
process. This growth rhythm is most clearly
seen in stature or body height.
The first wave of growth is seen in both sexes
from birth to the fifth or sixth year. It is most
intense and rapid during the first two years.
There follows a slower increase terminating
in boys about the tenth to twelfth year and in
girls no later than the tenth year. Then both
sexes enter upon another period of accelerated
growth corresponding to adolescence that is
completed in girls between the fourteenth and
sixteenth year, but extends in boys through the
sixteenth or eighteenth year. Following this, a
final period of slow growth is seen which ends
between the eighteenth and twentieth years
in females but goes on in boys until about the
twenty fifth year.
Growth Spurts
Growth does not take place uniformly at all
times. There seems to be periods where a
sudden acceleration of growth occurs. This
sudden increase in growth is termed “Growth
spurts.”
The physiological alteration in hormonal
secretion is believed to be the cause for such
accentuated growth. The timing of the growth
spurts differ in boys and girls and are sex linked.
The greatest increments of growth are actually
at the 3 years age level. Second peak is from 6–7
years. There is tendency for more boys to have
2 or 3 peaks (Fig. 2.1).
The following are the timings of growth
spurts:
Prenatal growth spurts: (Just before birth)
Postnatal growth spurts
a. One year after birth.
b. First peak (Deciduous dentition peak):
Boys: 3 years, Girls: 3 years.
c. Second peak (Mixed dentition peak): Boys:
8–11 years, Girls: 7–9 years.
12 Essentials of Orthodontics

Growth spurt is best time for interceptive

procedures like, functional appliances,
headgear orthopedics, maxillary expansion
and chin cup therapy.
Malocclusion requiring surgical correction
can be undertaken after the growth spurts are
completed.

Differential Growth
The human body does not grow at the same
rate throughout life. Different organs grow
at different rates to a different amount and
at different times. This is termed differential
growth.
There are two important aspects of differ­
Figure 2.1: Growth spurts
ential growth:

Scammon’s Growth Curve (Fig. 2.2)

The body tissues can be broadly classified into
d. Third peak (Pre-pubertal peak): Boys: four basic types. They are lymphoid tissue,
14–16 years, Girls: 11–13 years. neural tissue, general tissue and genital tissue.
Each of these tissues grows at different times
Clinical Implications of Growth Spurts and rates.
Knowledge of growth spurts is essential for Lymphoid tissue proliferates rapidly in late
successful treatment planning in orthodontics. childhood and reaches almost 200% of adult
This helps us to decide the timing of orthodontic size. This is an adaptation to protect child from
treatment, whether to start the treatment at the infection, as they are more prone to it. By about
time of peak growth or after the active growth
is completed.
These are obvious for orthopedic correction
of maxillomandibular relationships. Very few
girls seem to show the mixed dentition growth
spurt, all show the pubertal spurt. Pubertal
increments still offer the best time for a large
number of cases, as far as predictability, growth
direction, patient management and total
treatment time are concerned.
Malocclusions of dental arches can be
treated taking advantage of growth spurts
during the active growth period.
Arch expansion and rapid palatal expansion
can be undertaken during maximum growth. Figure 2.2: Scammon’s growth curve

18 years of age lymphoid tissue undergoes
involution to reach adult size.
Neural tissue grows very rapidly and almost
reaches adult size by 6–7 years of age. Very little
growth of 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 up to 2–3 years of age followed by a
slow phase of growth between 3–10 years. After
the tenth year, a rapid phase of growth occurs
terminating by the 18–20th year.
Genital tissue consists of reproductive
organs. They show negligible growth until
puberty; however they grow rapidly at puberty
reaching adult size after which growth ceases.
Cephalocaudal Gradient Growth (Fig. 2.3)
Cephalocaudal gradient of growth simply
means that there is an axis of increased
growth extending from head towards the
feet. A comparison of the body proportions
between prenatal and postnatal life reveals that
postnatal growth of regions of the body that are
away from the hypophysis is more.
This concept may be illustrated by
following.
Figure 2.3: Cephalocaudal gradient growth
Growth and Development 13
The head takes up about 50% of the
total body length around the third month of
intrauterine life. At the time of birth, the trunk
and the limbs have grown more than the head
thereby reducing the head to about 30% of
body length. The overall pattern of growth
continues with a progressive reduction in the
relative size of the head to about 12% in adult.
The lower limbs are rudimentary around
the 2nd month of intrauterine life. They later
grow and represent almost 50% of the body
length at adulthood.
This increased gradient of growth is evident
even within the head and face (Fig. 2.4). At the
time of birth, the cranium is proportionally
larger than the face. Postnatally the face grows
more than the cranium. The growth of maxilla,
which is close to cranium, is completed first
when compared to mandible.
Growth in Height
When a chart showing height for age is
constructed from date taken from a large
number of children variations in height can
be found out. When increments of growth
are plotted on a chart to form a velocity
curve the rate of growth is seen to decrease
from birth to adolescence at which time a
marked spurt in height growth is seen in both
sexes at puberty. This is known as adolescent
Figure 2.4: Cephalocaudal gradient in head
14 Essentials of Orthodontics
spurt, the prepubertal acceleration, or the
circumpubertal acceleration. The earlier onset
of the spurt in females is seen, at about 10.5–11
yrs in girls, and 12.5–13 yrs in boys. The spurt
lasts about 2–2½ yrs in both sexes. During
growth spurt boys grow about 8 inches in
height, whereas girls grow about 6 inches.
In girls, menarche always follows the peak
velocity of the adolescent spurt in height.
The conclusion of the spurt is followed by
rapid slowing of growth, girls reaching 98%
of their final height by 16½ years and boys
reach the same stage at 17¾ years. One reason
the females are shorter on average than
males is that they grow for a shorter period
of time than males during postnatal growth
(Fig. 2.5).
Six Types of Height Growth in Children
1. Average growers: They follow the middle
range of the distance curve and comprise
about 2/3 rds of all children.
2. Early maturing: These children are taller
in childhood because they have matured
faster than average. They are usually both
particularly tall as adults.
Figure 2.5: Height chart
3. Genetically tall: These children are taller
than average children and will be tall as
adults.
4. Late maturing: These children are shorter
than average in childhood because of their
late maturing and will eventually be adults
of average stature.
5. Genetically short: These children are short
as children and will be short adults.
6. The sixth group of children is made up
of the children who start puberty either
early or late and subsequently, have either
much less or much more growth in height
than expected. Those children who enter
puberty early finish growing much earlier
than those entering puberty at a late age.
Growth in Weight
In comparison to height, there is much more
variation in weight measurements. With
height, only three components are measured:
the bones, cartilage, and skin. However, with
weight, every tissue in the body is involved.
Weight at birth is more variable than length.
At birth, full-term females are on the average
about 5 oz. lighter than full-term males. Small
mothers have small babies. Later children in
a family are usually heavier than the first born
children. Weight gain is rapid during the first
2 years of postnatal growth. This is followed by
a period of steady increase until the adole­scent
spurt. At ages 11–13 years of age girls are, on
aver­age, heavier than boys. Following their
ado­lescent spurt, boys become heavier. The
velocity of weight growth decreases from birth
to about 2 years of age after which it slowly
acce­lerates until the onset of the adolescent
spurt. During the spurt boys may add 45
pounds and girls 35 pounds to their weight. The
average age for the adolescent weight spurt is
of less magnitude in girls compared with boys.
The peak velocity for weight spurt lage behind

the peak velocity for height on an average of 3
months. The adolescent first becomes taller
and then begins to fill out in weight. Similarly,
body does not reach its adult value until after
adult height has been attained.
Indices of Maturity
Several methods are used to assess the level
of mat­urity attained by child during postnatal
gro­w th. Children of the same age vary in
their maturity status a great deal, therefore,
several bio­lo­gic maturity indicators have been
developed to assess the prognosis toward
full maturation of an individual at various
times during growth. The dental age maturity
indicator based on eru­p tion age because
it is useful throughout the deve­lop­ment of
the teeth, not just during the narrow period
covered by eruption.
Maturity indicators differ for sexes, females
maturing earlier than males throughout
postnatal growth.
Biologic Maturity Indicators
Morphologic Age
It is based on height. A child’s height can be
compared with those of his same age group
and other age groups to determine where
he stands in relation to others. Height or
morphologic age is useful as maturity indicator
from late infancy to early adulthood.
Chronologic Age
The most commonly and easily determined
dev­e lop­m ental age parameter is the
chronological age, which is simply figured
from the child’s date of birth. Since child has
his own characteristics growth time clock,
there is early, middle and late maturation
chronological age, neither accurate indicators
of stage of development, not is a good predictor
of growth potential.
Growth and Development 15
Somatotypic Age
In overall assessment of child, a general body
type which is also called as somatotype is
considered. Sheldon divides somatotype into
three categories; ectomorph, mesomorph and
endomorph.
The ectomorph (high development of
ectodermal derivatives) is tall and lean with
digestive structures are not well-developed. The
endomorph (high development of endodermal
derivatives) is stocky, has abundant subcut­
aneous fat and has digestive viscera that are
highly developed; somatic structures are relati­
vely underdeveloped. The mesomorph (high
development of mesodermal derivatives) is
upright, sturdy and athletic, his extremities are
long and slender with minimal subcutaneous
fat and muscle tissue.
In general, the ectomorph is a late maturer,
whereas an endomorph is an early maturer
in terms of chronologic age. Although
somatotype may give a gestalt about the child’s
develop-mental pattern, it is not an accurate
predictor.
Height and Weight Age
Height has been considered as convenient
determinant of developmental age. The
standard growth commonly employed to
characterize a child’s height compared to that
of children of some chronological age is used
to assess developmental age. It is generally
seen that after age 2 each child tends to follow
the same percentile on the growth curve
until the puberty, when deviation may occur
because of timing of the spurt differs among
adolescents. Since each child’s height is related
to genetic and environ­mental factors as well
as to chronologic age, it is clear that a single
height measurement is limited as a predictor
of developmental age. Not all the children have
same height at the same percentile.
16 Essentials of Orthodontics
Dental Age
Dental age is based on two different methods of
assessment. The most commonly used method
is the observation of age at eruption of the
primary and permanent teeth. This might be
called tooth eruption age. The second method
involves rating of tooth development from
crown calcification to root completion using
X-rays of the unerupted and developing teeth.
Dental age maturity indicators are useful from
birth to early adolescence.
Sexual Age
Sexual age refers to development of secondary
sex characters, breast development, and
menarche in females; penis and testis
growth in males; and axillary and pubic
hair development in both sexes. This type of
indicator is useful only for adolescent growth.
Skeletal Age
Skeletal age is determined by assessing
the development of bones in the hand and
wrist. The development of bones from the
appearances of calcification centers to
epiphyseal plate closure occurs in the hand
and wrist throughout the entire postnatal
growth period and therefore provides a
useful means for assessing biologic maturity.
A total of 51 separate centers of bone growth
are located in the hand and wrist. An atlas of
hand wrist development has been developed,
which is useful in rating the maturity status of
an individual child.
Facial Age
The ultimate goal of developmental growth
assessment of children is the facial age in
order to identfy where they are on their
own facial growth curve and use this as a
predictor of future growth. In addition to
the developmental age assessment, the
most commonly used method of analysis
between the normal versus abnormal facial
development is cephalometric analysis. Other
measurements for assessing craniofacial
developments are, head circumference, eye
measurements, ear length and philtrum
lengths, and widths of the commissures.
Growth Assessment
Growth assessment is done to identify
grossly abnormal or even pathologic growth,
recognition and diagnosis of significant
deviations from normal growth. Planning
orthodontic or orthopedic treatment and to
determine the efficiency of the treatment.
Growth assessment can be done by:
I. Methods based on measuring animals:
1. Produces no interference with the
animals, e.g. Craniometry.
2. Growth is manipulated—may be
destructive, e.g. Subhumans are
used like guinea pigs.
II. Direct measurements:
1. Measurements done directly on the
subjects.
III. Indirect measurements:
1. Measurements made on negative
replicas of the original material, e.g.
X-rays.
IV. Three-dimensional facial measure­
ments:
1. Stereophotogrammetry
2. Sassouni’s physioprints
3. Rabey’s morphanalysis
4. Holography
5. Moire topography
6. Contour photography.
Growth Predictions
Growth prediction involves an understanding
of normal growth process. On this possible

effects of orthodontic or orthopedic therapy
must be superimposed. The starting point
for growth prediction must be an estimation
of growth changes that might occur without
orthodontic intervention. The dimensions of
growth in which we are interested in predicting
the growth of craniofacial complex are the
following.
The size of a part, relationship of parts,
timing of growth events, velocity of growth,
vectors of growth, effects of orthodontic
therapy on any one of the above parameters,
rate of growth and amount of growth.
Growth predictions are usually guess work
based on the available data and individual
growth based on genetic pattern. Actual
growth may or may not coincide with the actual
prediction of growth.
Various methods of growth prediction
are:
• Allometry
• Cephalometrics
• Implants
• Facial and other bodily dimensions
• Hand wrist X-rays
• Statistical methods
• Time series method
• Computers
• Growth curves
• Mathematical models
• Genetic and familial studies
• Cervical vertebra and growth assessment
• Growth grids
• Templates
• Visual perception
• Visual treatment objective (VTO).
TYPES OF GROWTH DATA
The physical growth and development can be
studied by a number of ways.
Growth and Development 17
Opinion
Opinion is the crudest means of studying
growth. Opinion is a clever guess of an
experienced person. This method of studying
growth is not very scientific and should be
avoided when better methods are available.
Observations
Another method of gathering growth related
information is by observation. They are useful
in studying all or none phenomena such as
presence or absence of Class II molar relation,
etc.
Ratings and Rankings
Whenever quantification of a particular data
is difficult, it is possible to adopt a method of
rating and ranking.
Rating makes use of standard conventionally
accepted scales for classification. Ranking
involves the arrangement of data in an orderly
sequence based on the value.
Quantitative Measurements
A scientific approach to study growth is one
that is based on accurate measurements. The
measurements made can be of three types.
Direct data: Direct data are obtained from
measurements that are taken on living persons
or cadavers by means of scales measurement
tapes or calipers.
Indirect data: The growth measurements can
also be had from images or reproduction of
the person such as photographs, radiographs
or dental casts.
Derived data: They are data that are derived
after comparing two measurements. These
two sets of measurements can be of different
time frames or of two different samples, e.g.
Mandible grew 2 mm between 7–8 years; here
we measure mandibular length at 7 years and
8 years to derive the value.
18 Essentials of Orthodontics
METHODS OF GATHERING
GROWTH DATA
The various growth studies can broadly gro­
uped as:
Longitudinal Studies
Longitudinal study is a type of study where
measurements made of the same person of
group at regular intervals through time. Thus
longitudinal studies are long-term studies
where the same sample is studied by means
of follow up examination.
Advantages
Variability in development among individuals
within the group and developmental pattern
can be studied and compared.
The specific pattern of an individual as
he develops can be studied, permitting serial
comparison with himself.
Variations in sampling are smoothed out
with time and any unusual event or a mistake
in measuring at a given time is seen move easily
and corrections are made at the same time.
Disadvantages
Time: If one wishes to study the growth of
human face from birth to adult by means of
longitudinal data it will take him a lifetime to
gather the data.
Expense: Longitudinal studies necessitate
the maintenance of laboratories, research
personnel and data storage for a long time and
thus are costly.
Attrition: The parents of children in long­
itudinal studies change their place, some
loose interest as a result; sample size gradually
reduces often reaches 50% in 15 years.
Cross-sectional Studies
A different individual or a different sample is
studied at different periods.
Thus one can measure a group of 6-year-
old boys and on the same day, at the same
place, measure a group of 9-year-old boys.
Changes between 6–9 years of age in boys at
that place are thus assumed after study of the
data obtained.
Advantages
These studies are of short duration and faster.
They are less expensive than longitudinal
studies as they are completed in a shorter span
of time.
It is possible to get a large sample, as the
duration of study is short.
It is possible to repeat the study in case
of any flaw. This may not be possible with
longitudinal study.
This method is used for cadavers, skeletons
and archeological data.
Disadvantages
It must always be assumed that the groups
being measured and compared are similar.
Cross sectional group averages tend
to obscure individual variations. This is
particularly obfuscating when studying the
timing of developmental events, for example
the onset of pubescence or the adolescent
growth spurt.
Semi-longitudinal Studies
(Overlapping Studies)
It is possible to combine the cross-sectional
and longitudinal methods so as to derive the
advantages of both the systems of gathering
growth data.

In this way one may compress 15 years
of study into 3 years of gathering data, each
subsample including children studied for the
same number of years, but started at different
ages.
METHODS OF STUDYING GROWTH
Proffit lists two main methods of approaches
to studying physical growth and development,
they are:
Measurement approaches: They comprise of
measurement techniques that are carried out
on living individuals. These methods do not
harm the animal.
Experimental approaches: These are destructive
techniques where the animal that is studied is
sacrificed. They are not usually carried out in
humans. They are:
Biometric Tests
They are tests in which physical characteristics
such as weight; height, skeletal maturation and
ossification are measured and compared with
standards based upon the examination of large
groups of healthy subjects.
Vital Staining
Belchier, in 1736 reported that bones of
animals that had eaten madder plants were
stained red. In 1739 Duhamel fed madder
to animals and then with held it for a period
prior to sacrifice, as a result bone contained
a band of red stain followed by a unstained
band. Subsequently the dye in the madder
plant, alizarin was identified and used for
bone research.
This technique involves administration of
certain dyes to the experimental animal that
get incorporated in the bones. It is possible to
Growth and Development 19
study the manner in which bone is laid down,
the site of growth, the direction, duration
and amount of growth at different sites in
bone. Dyes used are Alizarin red S (Alizarin S
sulphonate), Acid alizarin blue, Trypan blue,
Tetracycline and Lead acetate. The nature of
the combination alizarin with bone is said
to be a chelation with divalent cation on the
surface of the crystal. Antibiotic tetracycline
is also vital bone marker.
Radioisotopes
Radioisotopes of certain elements compounds
when injected into tissue get incorporated
in the developing bone and act as in vivo
markers. These radioisotopes can later be
detected by tracking down the radioactivity
they emit by means of Geiger counter or
by the use of autoradiographic techniques.
The radioisotopes used include: Technitium
33, Calcium 45, Potassium 32, and labeled
components of proteins such as Tritiated
proline.
Implants
Bjork in 1969 first devised this method of
implanting tiny bits of biologically inert alloys
like tantalum into growing bones of animals
or human beings. These serve as reference
markers during serial radiographic analysis.
The metallic implants used for studying growth
are usually very small, around 1.5 mm in length
and 0.5 mm in diameter.
The areas where the implants are placed in
maxilla to study the growth are, hard palate,
below the anterior nasal spine, in zygomatic
process, border between hard palate and
alveolar process medial to first molar. In
mandible they are placed in anterior aspect of
symphysis, mandibular body, and or ramus in
level with occlusal plane.
20 Essentials of Orthodontics
Natural Markers
The persistence of certain developmental
features of bone has led to their use as natural
markers. By means of serial radiography,
trabaculae, nutrient canals and lines of
arrested growth can be used for reference to
study deposition, resorption and remodeling.
Comparative Anatomy
Certain basic principles of growth that are
universal to all species can first be studies on
laboratory animals, and later can be compared
with human growth.
Radiographic Techniques
After Roentgen discovered X-rays different
radiographic techniques to study growth
and development were devised. The most
commonly used techniques are:
Cephalometry: It is a standardized radio­
graphic technique of the craniofacial region.
Serial cephalograms of the same patient over
a period of time gives the direction, amount of
growth. Cephalometry makes possible to study
growth and valuable in orthodontic diagnosis,
planning and evaluation of treatment results
for growth prediction.
Hand wrist X-rays: Radiographs of hand
wrist region are used to study the biological
or skeletal age of a person. The hand wrist
region has a definite schedule of appearance
and ossification.
Microradiography: A beam of X-rays at
the microscope level is passed through an
undecalcified thin section of bone or tooth
that has been placed over a sensitive emulsion.
The differential passage of the rays through
the different areas of the tissue section is
recorded on the film as varying blacks, grays
and whites.
Genetic Studies
Genetic methods currently being used are
to study of parent-child relationship, sibling
similarities and twin studies.
MECHANISM OF BONE GROWTH
Bone is a specialized tissue of mesodermal
origin. It forms the structural framework of the
body. Bone is a calcified tissue that supports
the body and gives areas of attachment to
musculature. Body has 206 bones of which 22
are in the skull; of which 14 bones are facial
bones and 8 are skull bones, but at birth skull
has 45 bones. Bone contains between 32–36%
of organic matters.
Skull bones are:
Cranial base bones: Frontal, ethmoid,
sphenoid and occipital.
Cranial vault bones (Paired): Parietal-2 and
temporal-2.
Facial bones are:
Paired bones: Maxilla, nasal, lacrimal,
zygomatic, inferior nasal concha and palatine
bone.
Unpaired bones: Vomer and mandible.
OSTEOGENESIS (MECHANISM OF
BONE FORMATION)
The process of bone formation is called osteo­
genesis. Bone formation takes place in two
ways:
Endochondral Bone Formation
(Flow chart 2.1)
In this type of osteogenesis the bone formation
is preceded by formation of a cartilaginous

Flow chart 2.1: Endochondral bone formation
model, which is subsequently replaced by
bone. Endochondral bone formation occurs
as follows:
Mesenchymal cells condensed at the site
of bone formation, some mesenchymal cells
differentiate into chondroblasts and lay down
hyaline cartilage, the cartilage is surrounded
by a membrane called perichondrium. This is
highly vascular and contains osteogenic cells.
The intercellular substance surrounding the
cartilage cells becomes calcified due to the
influence of enzyme alkaline phosphatase
secreted by the cartilage cells. Thus the nutri­
tion to the cartilage cells is cut off leading
to their death. These results in formation of
empty spaces called primary areolae. The
blood vessels and osteogenic cells from the
perichondrium invade the calcified cartilagi­
nous matrix, which now reduced to bars
or walls due to eating away of the calcified
matrix. This leaves large empty spaces between
the walls called secondary areolae. The
osteogenic cells from the perichondrium
become osteoblasts and arrange themselves
along the surface of these bars of calcified
matrix. The osteoblasts lay down osteoid that
later becomes calcified to form lamella of
Growth and Development 21
Flow chart 2.2: Intramembranous bone formation
bone. Now another layer of osteoid is secreted
and this goes on and on. Thus the calcified
matrix of cartilage acts as a support for bone
formation.
It is found in the bones associated with
movable joints and some parts of cranial base.
Intramembranous Bone Formation
(Membranous Bone Formation)
(Flow chart 2.2)
In this type of ossification, the formation
of bone is not preceded by formation of a
cartilaginous model. Instead bone is laid
down directly in a fibrous membrane. The
intramembranous bone is formed in the
following manner:
At the site of bone formation mesenchymal
cells become aggregated, some mesenchymal
cells lay down bundles of collagen fibers. Some
mesenchymal cells enlarge and acquire a
basophilic cytoplasm and form osteoblasts.
These osteoblasts secrete a gelatinous matrix
called osteoid around the collagen fibers. They
deposit calcium salts into the osteoid leading to
conversion of osteoid into bone lamella. Now
the osteoblasts move away from the lamella
and a new layer of osteoid is secreted which also
22 Essentials of Orthodontics
gets calcified. Some of the osteoblasts get
entrapped between two lamellae they are
called osteocytes.
Bone growth in intramembranous is only
appositional, bone grows in the direction of
least resistance and soft tissue dominates bone
growth.
Mechanism of bone growth can be cate­
gori­zed into:
Bone Deposition and Resorption
(Bone Remodeling)
Bone changes in shape and size by two basic
mechanisms, bone deposition and bone
resorption. The process of bone deposition and
resorption together is called bone remodeling.
Changes that are produced due to deposition
and resorption are, change in size, change
in shape, change in proportion, change in
dimensions, change in relationship of the bone
with adjacent structures.
Growth Movements
Two basic movements involved during growth
are growth drift and displacement.
Drift (Cortical Drift) (Fig. 2.6)
Direct deposition and resorption of bone tissue
and characteristic combinations of deposition
and resorption occurring in the different
bones of the skull result in growth movements
towards depository surface is termed drift. If
bone deposition and resorption on either side
of a bone are equal, then the thickness of the
Figure 2.6: Drift
bone remains constant. 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. Drift occurs in all areas
of growing bones, and produces generalized
enlargement as well as relocation of parts.
Displacement
It is the movement of the whole bone as a
unit. It is as a result of the pull or push by
different bones and their soft tissues away from
one another as they all continue to enlarge.
Displacement can be primary or secondary.
Primary displacement: If a bone gets disp­
laced as a result of its own growth, it is called
primary displacement. For example growth
of maxilla at the tuberosity region results in
pushing of the maxilla against the cranial base
that results in the displacement of the maxilla
in a forward and downward directions.
Secondary displacement: If the bone gets
displaced as a result of growth and enlargement
of adjacent bones, it is called secondary
displacement. For example, the growth of the
cranial base causes the forward and downward
displacement of the maxilla.
Overall process of craniofacial enlargement
is a composite of drift and displacement.
Directions of Growth
Surfaces oriented towards the actual direction
of growth undergo new bone deposition,
whereas surfaces directed away from the
course of growth generally are resorptive.
For example, posterior border of ramus
is depository and anterior border of ramus is
resorptive.
Soft Tissues Associated with Growth
The soft tissue matrix of bone is directly
respon­sible for many of the growth changes
that occur in the bone itself.

Growth Fields
The areas capable of producing an alteration
in the growth of the particular bone are called
growth fields. They are mosaic like patterns
of soft tissues, cartilage or osteogenetic
membrane.
Growth Sites
Growth sites are growth fields that have
a special significance in the growth of a
particular bone, e.g. maxillary tuberosity.
Growth Centers
Growth centers are special growth sites,
which control the overall growth of bone, e.g.
epiphyseal plates of long bones.
THEORIES OF GROWTH
Genetic Theory
This theory simply states that all growth and
development is controlled by genetic influence
and is preplanned. This is one of the earliest
theories put forward.
Sutural Theory (Sicher) (Fig. 2.7)
Sicher believed that craniofacial growth occurs
at the sutures. According to him paired parallel
sutures that attach facial areas to the skull and
the cranial base region push the nasomaxillary
complex forwards to pace its growth with that
Figure 2.7: Sutural theory of growth
Growth and Development 23
of the mandible. This theory also acknowledges
the genetic influence of growth.
A number of points were raised against this
theory. The following are some of them:
When an area of the suture is transplanted
to another location, the tissue does not
continue to grow. This clearly indicates a lack
of innate growth potential of the sutures.
Growth takes place in untreated cases of
cleft palate even in the absence of sutures.
Microcephaly and hydrocephaly raised
doubts about the intrinsic genetic stimulus of
sutures.
Cartilaginous Theory (James Scott)
(Fig. 2.8)
This theory was put forward by James Scott.
According to him intrinsic growth controlling
factors are present in cartilage and periosteum
with sutures being only secondary. He viewed
the cartilaginous sites throughout the skull as
primary centers of growth.
Growth of the maxilla is attributed to the
nasal septal cartilage. According to Scott, the
nasal septal cartilage is the pacemaker for
growth of the entire nasomaxillary complex.
The mandible is considered as the diaphysis of
a long bone, bent into a horseshoe shape with
symphysis removed so that there is cartilage
Figure 2.8: Cartilaginous theory
24 Essentials of Orthodontics
constituting half an epiphyseal plate at the
ends that are represented by the condyles.
Points in favor of this theory include:
In many bones, cartilage growth occurs,
while bone merely replaces it.
If a part of an epiphyseal plate is transpl­
anted to a different location, it will continue
to grow in the new location. This indicates the
innate growth potential of the cartilage.
Nasal septal cartilage also shows innate
growth potential on being transplanted to
another site.
Experiments on rabbits involving removal
of the nasal septal cartilage demonstrated
retarded midface development.
In cleft palate where midface is deficient
growth is taking place.
Functional Matrix Theory
(Melvin Moss) (Fig. 2.9)
The functional matrix concept of Melvin
Moss revitalized the studies on growth and
development at a time when the sutural
growth theory of Sicher and cartilaginous
growth theory of Scott were severely criticized
for their inadequacy. Moss introduced the
doctrine of functional matrix complimentary
to the original concept of functional cranial
components by Van der Klaaw, the functional
matrix concept attempts to comprehend the
relationship between form and function.
Figure 2.9: Functional matrix theory
The functional matrix hypothesis claims
that the origin, form, position growth and
maintenance of all skeletal tissues and organs
are always secondary, compensatory and
necessary responses to chronologically and
morphologically prior events or processes that
occur in specifically related nonskeletal tissues,
organs or functioning spaces.
A number of relatively independent
functional are carried out in the craniofacial
region of the human body. Some of the
functions carried out include respiration,
olfaction, vision, hearing, balance, chewing,
digestion, swall­owing, speech and neural
integration.
Each of these functions is carried out by a
functional cranial component. Each functional
cranial component consists of all of the tissues,
organs, spaces and skeletal parts necessary
to carry out a given function. The functional
cranial component is divided into:
Functional Matrix and Skeletal Units
All the tissues, organs and functioning spaces
taken as a whole comprise the functional
matrix, while the skeletal tissues related to
this specific functional matrix comprise the
skeletal unit. All skeletal tissues originate,
grow and function completely embedded in
their several matrices. Thus change in size,
shape and spatial position of all skeletal units
including their very maintenance is due to the
operational activity of their related functional
matrices.
The skeletal unit: All skeletal tissues asso­
ci­a ted with a single function are called
‘the skeletal unit’; the skeletal unit may be
comprised of bone, cartilage and tendinous
tissue. When a bone is comprised of several
contiguous skeletal units, they are termed
‘microskeletal units’. The maxilla and
mandible are comprised of a number of such
microskeletal units. For example, the mandible

has within it alveolar, angular, condylar, gonial,
mental, coronoid, and basal microskeletal
units. In case of maxilla it is made up of orbital,
pneumatic, palatal and basal microskeletal
units. When adjoining portions of a number
of neighboring bones are united to function
as a single cranial component, we term this
a ‘macroskeletal unit’. The entire endocranial
surface of the calvarium is an example of a
macro­s­­keletal unit.
The functional matrix: The functional matrix
consists of muscles, glands, nerves, vessels,
fat, teeth and the functioning spaces. The
functional matrix is divided into periosteal
matrix and capsular matrix.
Periosteal matrices act directly and actively
upon their related skeletal units. Alterations
in their functional demands produce a seco­
ndary compensatory transformation of the
size and or shape of their skeletal units. Such
transformations are brought about by the
interrelated processes of bone deposition
and resorption. The periosteal matrices
include the muscles, blood vessels, nerves,
glands, etc. These tissues act directly on their
related skeletal units thereby bringing about
a transformation in their size and shape. This
transformation due to the action of periosteal
matrices is brought about by bone deposition
and resorption.
Capsular matrices act indirectly and passi­
vely on their related skeletal units producing a
secondary compensatory translation in space.
These alterations in spatial position of skeletal
units are brought about by the expansion of the
orofacial capsule within which the facial bones
arise, grow and are maintained. The facial
skeletal units are passively and secondarily
moved in space as their enveloping capsule is
expanded. The kind of translative growth is not
brought about by deposition and resorption.
The neurocranial capsule and the orofacial
capsule are examples of capsular matrices. Each
Growth and Development 25
of these capsules is an envelop which contains
a series of functional cranial components
(skeletal units and related functional matrices)
which as a whole are sandwiched in between
two covering layers. In the neurocranial
capsule, the covers consist of the skin and dura
mater where as in the orofacial capsule the skin
and mucosa form the covering.
The neurocranial capsule surrounds and
protects the neurocranial capsular functional
matrix that is the brain, leptomeninges,
and Cerebrospinal fluid. The neurocranial
capsule is made up of skin, connective tis­
sue, aponeurotic layer, loose connective
tissue layer, periosteum, and base of the
skull and the two layers of dura mater. The
orofacial capsule surrounds and protects the
oronasopharyngeal spaces, which constitute
the orofacial capsular matrix. The growth of
the facial skull is influenced by the volume and
patency of these spaces.
van Limbourgh’s Theory
A multifactorial theory was put forward
by van Limbourgh in 1970. According to
him the three popular theories of growth
were not satisfactory, yet each contains
elements of significance that cannot be
denied. van Limbourgh explains the process
of growth and development in a view that
combines all the three existing theories. He
supports the functional matrix theory of Moss,
acknowledges some aspects of Sicher’s theory
and at the same time does not rule out genetic
involvement. van Limbourgh listed five factors
that he believed controls growth.
Intrinsic genetic factors: They are the genetic
control of the skeletal units themselves.
Local epigenetic factors: Bone growth is
determined by genetic control originating from
adjacent structures like brain, eyes, etc.
General epigenetic factors: They are genetic
factors determining growth from distant
26 Essentials of Orthodontics

structures, e.g. Sex hormone, growth hormone,

etc.
Local environmental factors: They are non­­
genetic factors from local external environment,
e.g. Habits, muscle force, etc.
General environmental factors: They are gen­
eral nongenetic influences such as nutrition,
oxygen, etc.
The views expressed by van Limbourgh can
be summarized as following:
Chondrocranial growth is controlled
mainly by the intrinsic genetic factors.
Desmochondral growth is controlled by
any few intrinsic genetic factors.
The cartilaginous parts of the skull must be
considered as growth centers.
Sutural growth is controlled mainly by
influences originating from the skull cartilages
and from other adjacent skull structures. Figure 2.10: ‘V’ principle of growth

Periosteal growth largely depends upon

growth of adjacent structures.
Sutural and periosteal growths are add­
iti­o nally governed by local nongenetic
environmental influence.

Enlow and Bang’s Expanding ‘V’

Principle (Fig. 2.10)
Many facial bones or parts of bone have a
‘V’ shaped pattern 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
(Fig. 2.11).
Deposition also takes place at the ends
Figure 2.11: ‘V’ principles—deposition and resorption
of the two arms of the ‘V’ resulting in growth
movement towards the ends.
The ‘V’ pattern of the growth occurs in Neurotrophic Process in Orofacial
a number of regions such as the base of the Growth (Neurotrophism)
mandible, ends of long bones, mandibular Neurotrophism is a nonimpulse transmitting
body, palate, etc. neural function that involves axoplasmic

transport and provides for long-term inter­
action between neurons and innervated
tissues that homeostatically regulates the
mor­phological, compositional and functional
integrity of those tissues. The nature of neuro­
trophic substances and the process of their
introduction into the target tissue are unknown
at present.
The different types of neurotrophic mech­
anisms are:
Neuroepithelial trophism: Epithelial mitosis
and synthesis are neurotrophically controlled.
The normal epithelial growth is controlled by
release of certain neurotrophic substances
by the nerve synapses. If this neurotrophic
process is lacking or is deficient, abnormal
epithelial growth, orofacial hypoplasia and
malformations, etc. occur. For example, the
presence of taste buds is dependent upon
an intact innervation. The nerves are not
only important for the sensation of taste
but they also have a neurotrophic effect in
sustaining healthy growth of the taste buds
and nearby epithelial tissue. If the taste buds
are deinnervated, they become atrophic and
so also the nearby epithelial cells.
Neuromuscular trophism: Embryonic myog­
enesis is independent of neural innervation
and trophic control. Approximately at the
myoblast stage of differentiation, neural inner­
vation is established without which further
myogenesis usually cannot continue.
Neurovisceral trophism: The salivary glands,
fat tissue and other organs are trophically
regulated, at least in part.
Hunter-Enlow Growth Equivalents
Concept (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
Growth and Development 27
structural and geometric counterparts 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 regional relationships
are produced by differences in, amounts of
growth between the counterparts, directions
of growth between the counterparts, and time
of growth between the counterparts.
The different parts and their counterparts
are:
Nasomaxillary complex relates to the
anterior cranial fossa.
Horizontal dimension of the pharyngeal
space relates to the middle cranial fossa.
Middle cranial fossa and breadth of ramus
are counterparts.
Bony maxilla and corpus of mandible are
mutual counterparts.
Maxillary tuberosity and lingual tuberosity
are counterparts.
Petrovic’s Servosystem Theory
(Flow chart 2.3)
Through the language of cybernetics, inter­
action of a series of causal change and
feedback mechanics which determines the
growth of the various craniofacial regions, were
Flow chart 2.3: Components of servosystem
28 Essentials of Orthodontics

explained. Control of primary cartilages takes PERIOD OF EMBRYO

a cybernetic form of command, whereas the
secondary cartilage (e.g. Mandibular condyle)
has a direct effect of cell multiplication and
indirect effects. No genetically predetermined
length of the mandible was observed. Direction
and magnitude of growth are quantitative
responses to the lengthening of the maxilla.
This theory is useful in studying the role of
functional appliances in mandibular growth.
PRENATAL GROWTH AND
DEVELOPMENT
Growth and development of an individual
can be divided into prenatal and postnatal
periods. The prenatal period of development
is a dynamic phase in the development of
human beings. During this period, the height
increases by almost 5000 times as compared
to only three-fold increase during postnatal
period.
The prenatal life can be arbitrarily divided
into three periods:
• Period of ovum: Fertilization to 14 days.
• Period of embryo: 14th day to 56th day.
• Period of fetus: 56th day till birth.
This period extends from the fourteenth day
to the fifty-sixth day (second to eighth week)
of the intrauterine life. During this period the
major part of the development of the facial and
the cranial region occurs.
The following events occur during the
embryonic period:
Development of Branchial Arches
(Fig. 2.12)
In the fourth week after conception, the
future face and neck region located under
the forebrain of the human embryo becomes
segmented they are called branchial arches.
Six branchial arches are formed, appearing
as rounded tubular enlargements and are
bounded by clefts and groove that help define
each arch. They are numbered beginning
anteriorly. Only the first two arches are
named, namely mandibular or first arch,
hyoid or second arch, rest are just called as

PERIOD OF OVUM

This period extends for a period of approxim­

ately two weeks from the time of fertilization.
During this period the cleavage of the ovum
and the attachment of the ovum to the
intrauterine wall occur. At the end of this
period the ovum is only 1.5 mm in length and
cephalic differentiation has not begun. Figure 2.12: Branchial arches

Figure 2.13: Face at four weeks
3rd, 4th, 5th and 6th arches, of which 5th arch
is rudimentary.
During 4th week, posterior boundary of the
oral pit comes into contact with the developing
foregut. As the ectodermal oral plate meets the
endodermal lining of the gut, the membrane
disintegrates and continuity between the oral
cavity and the gastrointestinal tract is first
gained (Fig. 2.13).
Development of Perioral Region
The face at the 5th week is about as thick as
the sheet of paper and the whole face is about
1.5 mm. At this time oral pit is bounded
above by frontonasal process, below by mandi­
bular arch and rudimentary maxillary process
laterally.
Development of Nasal Pits
At 5th week two small oval raised areas appear
just above the lateral aspects of future mouth.
In about 2 days centers of these raised areas
become depressions, which deepen to form
the nasal pits. Tissue masses around the nasal
pits forms the bridge and sides of the external
nose. The tissue between the nasal pits is called
Growth and Development 29
Figure 2.14: Face at five weeks
medial nasal process and those lateral to the
pit are called lateral nasal process (Fig. 2.14).
Development of Cranial Structures
The earliest evidence of formation of cranial
base is seen in the post or late somatic period
(4th-8th week of intrauterine life). During
this late somatic period mesenchymal tissue
derived from the primitive streak, neural
crest and occipital sclerotomes condense
around the developing brain. Thus a capsule
is formed around the brain called ectomenix
or ectomeningeal capsule. The basal portion
of this capsule gives rise to the future cranial
base (Fig. 2.15).
The development of the skull and formation
of the cartilages of the cranial base is dependent
upon the presence of many other cranial
struc­tures like brain, cranial nerves and eyes.
Thus evidence of skull formation is seen
30 Essentials of Orthodontics
Figure 2.15: Face at six weeks
comparatively late after the primordial of many
other cranial structures have developed.
From around the fortieth day onwards, this
ectomeningeal capsule is slowly converted into
cartilage. This heralds the onset of cranial base
formation. The conversion of mesenchymal
cells into cartilage or chondrification occurs
in 4 regions namely parachordal, hypophyseal,
nasal and otic.
Parachordal: The chondrification centers
forming around the cranial end of the
notochord are called parachordal cartilages.
Hypophyseal: Cranial to the termination of
notochord, (which is at the level of the oro-
pharyngeal membrane) the hypophyseal
pouch develops which gives rise to the anterior
lobe of the pituitary gland.
On either side of the hypophyseal stem
two hypophyseal or postsphenoid cartilages
develop. These cartilages fuse together and
form the posterior part of the body of sphenoid.
Cranial to the pituitary gland, two pres­
phenoid or trabacular cartilages develop which
fuse together and form the anterior part of
body of sphenoid. Anteriorly, the presphenoid
car­tilage forms a vertical cartilaginous plate
called mesethmoid cartilage which gives rise to
the perpendicular plate of ethmoid and crista
galli.
Lateral to the pituitary gland chondri­
fication centers are seen which form the lesser
wing (orbitosphenoid) and greater wing (ali
sphenoid) of sphenoid bone.
Nasal: Initially during development, a
capsule is seen around the nasal sense organ.
This capsule chondrifies and forms the
cartilages of the nostrils, which fuse, with the
cartilages of the cranial bone.
Otic: A capsule is seen around the vestibulo­
cochlear sense organs. This capsule chondrifies
and later ossifies to give rise to the mastoid and
petrous portions of the temporal bone. The
otic cartilages also fuse with the cartilages of
the cranial base.
The initially separate centers of cartilage
formation in the cranial base fuse together
into a single irregular and greatly perforated
cranial base. The early establishment of the
various nerves, blood vessels, etc. from and to
the brain results in numerous perforations or
foramina in the developing cranial base. The
ossifying chondro-cranium meets the ossifying
desmo-cranium (cranial vault) to form the
neurocranium.
Chondrocranial ossification: The cranial
base, which is now in a cartilaginous form,
undergoes ossification. The bones of the
cranial base undergo both endochondral as
well as intramembranous ossification.
Occipital bone: The occipital bone shows
both endochondral and intramembranous
ossi-fication. Seven ossification centers are
seen in occipital bone, two intramembranous
and five endochondral.

The supranuchal squamous part ossifies
intramembranously from one pair of
ossification centers which appear in the 8th
week of intrauterine life.
The infranuchal squamous part ossifies
endochondrally from two centers, which
appear at the 10th week of intrauterine life.
The basilar part ossifies endochondrally
from a single median ossification center
appearing in the 11th week of intrauterine life.
This gives rise to the anterior portion of the
occipital condyles and the anterior boundary
of foramen magnum.
A pair of endochondral ossification centers
appears in the 12th week forming the lateral
boundary of foramen magnum and the
posterior portion of occipital condyles.
Temporal bone: The temporal bone ossifies
both endochondrally and intramembranously
from 11 centers.
Squamous part of the temporal bone
ossifies from a single intramembranous center
that appears in the 8th week of intrauterine life.
The tympanic ring ossifies from four
intramembranous centers that appear in the
12th week of intrauterine life.
The petrous part of temporal bone ossifies
from 4 endochondral centers that appear in
the 5th month of intrauterine life.
The styloid process ossifies from 2 endo-
chondral centers.
Ethmoid bone: This bone shows only endo-
chondral ossification. It ossifies from three
centers.
One center located centrally that forms the
median floor of the anterior cranial fossa.
Two lateral centers in the nasal capsule.
Sphenoid bone: This bone ossifies both intra­
membranously and endochondrally. There are
at least 15 ossification centers.
Lesser wing: Endochondral ossification
occurs; the ossification center is seen in the
orbitosphenoid cartilage.
Growth and Development 31
Greater wing and lateral pterygoid plate: Two
intramembranous ossification centers are
seen in the alisphenoid cartilage. A part of the
greater wing ossifies endochondrally.
Medial pterygoid plate: Ossifies endochon­
drally from a secondary cartilage in the
hamular process.
Anterior part of body of sphenoid: Ossifies
endochondrally from five centers (two
paired and one in the midline). The center of
ossification is seen in presphenoid cartilage.
Posterior part of body of sphenoid: Ossifies
endochondrally from four centers. The center
of ossification is the postsphenoid cartilage.
The cranial base or chondrocranium is
important as a junction between the cranial
vault and the facial skeleton, being shared
by both. The cranial base is relatively stable
during growth compared to the cranial vault
and the face. Thus the cranial base can be
taken as a basis against which the cranial
vault and facial skeleton can be compared.
The chondrocranium is relatively stable. This
aids in maintaining the early eatablished
relationship of blood vessels and nerves
running to and from the brain. The cranial
base of a newborn is small when compared to
the cranial vault that extends beyond the base
laterally and posteriorly.
Flexure of the Cranial Base
During the embryonic and early fetal period,
the cranial base becomes flexed in the
region between the pituitary fossa and the
sphenooccipital junction. The face is hence
tucked under the cranium. This flexure of the
cranial base is accompanied by a corresponding
flexure of the developing brainstem. Thus the
spinal cord and the foramen magnum that
during the early stages of development were
directed backwards now become directed
downwards. This downward directed foramen
magnum is an adaptation seen man who,
32 Essentials of Orthodontics
unlike animals, stand erect. This flexure of the
cranial base aids in increasing the neurocranial
capacity. Another consequence of the flexure
is the predominant downward rather than
forward displacement of the face during its
growth from the cranial base.
At around the 10th week of intrauterine life
the flexion of the base is about 65o, this flattens
out a bit at the time of birth.
Uneven Nature of Growth of
Cranial Base
The growth of the cranial base is highly uneven;
this is attributed to the uneven nature of growth
seen in the different regions of the brain. Thus
the cranial base growth resembles the growth
of the ventral surface of the overlying brain.
The anterior and posterior parts of the
cranial base grow at different rates. Between
the 10th and the 40th weeks of intrauterine life,
the anterior cranial base increases in length
and width by 7 times while, during the same
period the posterior cranial base increases only
five fold.
PRENATAL DEVELOPMENT OF
MAXILLA
Around the fourth week of intrauterine life, a
prominent bulge appears on the ventral aspect
of the embryo corresponding to the developing
brain. Below the bulge a shallow depression,
which corresponds to the primitive mouth,
appears called stomodeum. The floor of the
stomodeum is formed by the buccopharyngeal
membrane, which separates the stomodeum
from the foregut.
The mesoderm covering the developing
forebrain proliferates and forms a downward
projection that overlaps the upper part of
stomodeum. This downward projection is
called frontonasal process.
The frontonasal process thus overlaps
the stomodeum superiorly. The mandibular
arches of both the sides form the lateral walls
of the stomodeum. The mandibular arch
gives off a bud from its dorsal end called
the maxillary process. The maxillary process
grows ventromediocranial to the main part
of the mandibular arch that is now called the
mandibular process. Thus at this stage the
primitive mouth or stomodeum is overlapped
from above by the frontal process, below by
the mandibular process and on either side by
maxillary process.
The ectoderm overlying the frontonasal
process shows bilateral localized thickenings
above the stomodeum. These are called the
nasal placodes. These placodes soon sink and
form the nasal pits. The formation of these
nasal pits divides the frontonasal process into
two parts, the medial nasal process and the
lateral nasal process.
The two mandibular processes grow
medially and fuse to form the lower lip and
lower jaw. As the maxillary process undergoes
growth, the frontonasal process becomes
narrow so that the two nasal pits come closer.
The line of fusion of the maxillary process and
the medial nasal process corresponds to the
nasolacrimal duct.
DEVELOPMENT OF PALATE
The palate is formed by contributions of the
maxillary process, palatal shelves of maxillary
process and frontonasal process.
The frontonasal process gives rise to the
premaxillary region while the palatal shelves
form the rest of the palate. As the palatal shelves
grow medially, their union is prevented by
the presence of the tongue. Thus initially the
developing palatal shelves grow vertically
downwards towards the floor of the mouth.

Sometime during the 7th week of intrauterine
life, a transformation in the position of the palatal
shelves occurs. They change from a vertical to a
horizontal position. This transformation is
believed to take place within hours. Various
reasons are given to explain how this trans­
formation occurs. They are:
i. Alteration in biochemical and physical
consistency of the connective tissue of
the palatal shelves.
ii. Alteration in vasculature and blood
supply to the palatal shelves.
iii. Appearance of an intrinsic shelf force.
iv. Rapid differential mitotic activity.
Muscular movements and withdrawal of
the embryonic face form against the heart
pro­minence results in slight jaw opening.
This results in withdrawal of the tongue from
between the palatal shelves and aids in the
elevation of the palatal shelves from a vertical
to a horizontal position.
The two palatal shelves, by 81/2 weeks of
intrauterine life, are in close approximation
with each other. Initially the two palatal
shelves are covered by an epithelial lining.
As they join, the epithelial cells degenerate.
The connective tissue from the palatal shelves
intermingles with each other resulting in their
fusion.
The entire palate does not contact and
fuse at the same time. Initially contact occurs
in the central region of the secondary palate
posterior to the premaxilla. From this point,
closure occurs both anteriorly and posteriorly.
The mesial edge of the palatal processes fuses
with the free lower end of nasal septum and
thus separates the two nasal cavities from each
other and from the oral cavity.
Ossification of Palate
Ossification of the palate occurs from the
8th week of intrauterine life. This is an intra-
membranous type of ossification. The palate
Growth and Development 33
ossifies from a single center derived from the
maxilla. The most posterior part of the palate
does not ossify. This forms the soft palate. The
midpalatal suture ossifies by 12–14 years.
DEVELOPMENT OF MAXILLARY
SINUS
The maxillary sinus forms sometimes around
the 3rd month of intrauterine life. It develops
by expansion of the nasal mucous membrane
into the maxillary bone. Later the sinus
enlarges by resorption of the internal wall of
maxilla.
DEVELOPMENT OF TONGUE
Because of its role in functional matrix and
its role in epigenetic and environmental
influences on osseous skeleton as well as
possible role in dental malocclusion the
development of tongue is of considerable
interest.
During 5th week of intrauterine life rapidly
proliferating mesenchymal swellings, covered
with a layer of epithelium appear on the
internal aspect of mandibular arch. These are
referred to as the lateral lingual swellings. A
small medial projection rises between them,
the tuberculum impar. Caudal to this is the
copula which unites the second and third
branchial arches. Mesodermal tissue from 2nd,
3rd and 4th arches out grows over the copula
and contributes to the tongue structure. The
point at which 1st and 2nd arches merges is
marked by formation of foramen caecum just
behind sulcus terminalis. Foramen caecum
gives rise to thyroid, lingual swellings gives
rise to anterior 2/3rds of tongue and copula
gives rise to posterior 1/3rd of tongue. Papillas
of tongue are seen as early as 11 weeks of fetal
34 Essentials of Orthodontics
age. By 14 weeks taste buds can be observed in
fungiform papilla. By 12 weeks taste buds are
seen in circumvallate papilla.
PRENATAL DEVELOPMENT OF
MANDIBLE
During the 4th week of intrauterine 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 cranial most
part of the foregut which lies in close approxi­
mation with the stomodeum. Initially there are
six pharyngeal 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.
The mandibular arch forms the lateral wall
of the stomodeum. It gives off a bud from its
dorsal end. This bud is called the maxillary
process. It grows ventromedially, 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.
MECKEL’S CARTILAGE
The Meckel’s cartilage is derived from the
first branchial arch around the 41st–45th
day of intrauterine life. It extends from the
cartilaginous otic capsule to the midline or
symphysis and provides a template for guiding
the growth of the mandible. A major portion
of the Meckel’s cartilage disappears during
growth and the remaining part develops into
the following structures, mental ossicles,
Malleus and Incus, Spine of sphenoid liga­
ment, anterior ligament of malleus, and
Spheno­mandibular ligament.
The first structure to develop in the primor­
dium 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
produced by the nerve induce osteogenesis in
the ossification centers. A single ossification
center for each half of the mandible arises in
the 6th week of intrauterine life in the region
of the bifurcation of the inferior alveolar nerve
into mental and incisive branches.
The ossifying membrane is located lateral
to the Meckel’s cartilage and its accompanying
neurovascular bundle. From this primary
center, ossification spreads below and around
the inferior alveolar nerve and its incisive
branch and upwards to form a tough for
accommodating the developing tooth buds.
Spread of the intramembranous ossification
dorsally and ventrally forms the body and
ramus of the mandible.
As ossification continues, the Meckel’s
cartilage becomes surrounded and invaded
by bone. Ossification stops at the site that
will later become the mandibular lingual
from where the Meckel’s cartilage continues
into the middle ear and develops into the
auditory ossicles, i.e. malleus and incus. The
sphenomandibular ligament, which extends
from the lingual of mandible to the sphenoid
bone, forms a remnant of the Meckel’s car­
tilage.

ENDOCHONDRAL BONE
FORMATION
Endochondral bone formation is seen only in
three areas of the mandible, the condylar pro­
cess, the coronoid process, and mental region.
Condylar process: At about the 5th week
of intrauterine life, an area of mesenchymal
condensation can be seen above the ventral
part of the developing mandible. This
develops into a cone-shaped cartilage by
about 10th week and starts ossification by
14th week. It then migrates inferiorly and
fuses with the mandibular ramus by about 4
months. Much of the cone-shaped cartilage
is replaced by bone by the middle of fetal
life but its upper end persists into adulthood
acting both as a growth cartilage and an
articular cartilage.
Coronoid process: Secondary accessory cartil­
age appears in the region of the coronoid
process by about the 10–14th week of intrau­
terine life. This secondary cartilage of coronoid
process is believed to grow as a response to the
developing temporalis muscle. The coronoid
accessory cartilage becomes incorporated into
the expand­ing intramem­branous bone of the
ramus and disappears before birth.
Mental region: In the mental region, on
either side of the symphysis, one or two small
cartilages appear and ossify in the 7th month
of intrauterine life to form variable numbers
of mental ossicles in the fibrous tissue of the
symphysis. These ossicles become incorporated
into the intramem­branous bone when the
symphysis ossifies completely during the first
year of postnatal life.
Growth and Development 35
PRENATAL GROWTH OF
TEMPORO­MANDIBULAR JOINT
Prenatally, condylar secondary cartilages
grow out from the intramembranous body
of the mandible bilaterally. These primary
growth centers grow against the pressure
gradient generated by the developing
pterygoid-masseteric sling of masticatory
muscles. Periodic contraction and relaxation
of the masticatory and suprahyoid muscles
rotates the developing condyle and moves it
anteriorly and posteriorly. Pressure against
the temporal bone and the wide range of
repetitive motion induces the formation of the
temporal fossa. The interarticular meniscus is
formed from interposed connective tissue. As
the temporomandibular joint (TMJ) develops
into a functioning joint, the meniscus and the
articulating surfaces of the condyle and fossa
are composed of dense fibrous connective
tissue. Similar to other joints, the TMJ is
enclosed in a capsule that is lubricated with
synovial fluid.
POSTNATAL GROWTH AND
DEVELOPMENT
A large majority of the patients who seek
treatment are of the growing age. The cranium
and orofacial regions are in an active phase
of growth and hence this has a direct effect
on treatment. Treatment modalities initiated
during the growth period can modify abnormal
growth. A sound knowledge of the processes
involved in the postnatal growth of the skull
and the jaws is thus very essential.
36 Essentials of Orthodontics
NEONATAL SKELETON
The neonate has 270 bones as compared to
adult who has 206 bones. Skull bones in the
neonate are 45 and in adult it is reduced to
22. The ratio between the calvarial and facial
proportion is 8:1 at birth whereas it is 2.5:1
in an adult female and 2:1 in adult male. The
newborn is usually kept in a supine posture but
can be literally folded to its most comfortable
posture, the posture simulating the fetal
posture of partial flexion.
From third month to birth the entire
cranium becomes longer and wider in its
relation to height. While the size of cerebral
cranium will increase by about 50% the
facial skeleton will grow to more than twice
the original size. Cranial circumference is
an indicator of cranial volume and therefore
is often used in young infants for a rough
measure of brain develop­ment. After four years
the growth is minimal, facial skeleton increases
in all dimensions during this period, the
increase in height being the greatest, in depth
the increase is somewhat smaller, Increase in
width is the smallest. The heights of upper and
lower face are highly independent. The upper
anterior face height seems to be primarily
correlated with cranial base changes. The
lower face height seems to be more dependant
on muscular function, environmental factors
interfering with the airway and the posture of
the head. Because of the above changes in the
craniofacial complex, general features of the
head and the face are observed to be different
at different ages.
POSTNATAL GROWTH OF THE
CRANIAL VAULT
Cranium grows because brain grows. This
growth is accelerated during infancy. By
the end of 5th year of life about 90% of
cranial vault growth is complete. The vault of
cranium is divided into segments by sutures
which are sufficiently wide to be palpable at
birth. The edges of the bone adjoining the
sutures become approximated during the
first two years of postnatal life. Concurrently
with growth in the sutures, opposition and
absorption adjust the shape of each bone to the
lessening curvature of the skull as the cranium
is enlarging. Apposition of bone on external
surface also increases thickness of these bones.
The development and extension of frontal
sinuses particularly about the age of puberty
accompany rapid addition of bone to facial
surface of frontal bone in superciliary region.
POSTNATAL GROWTH OF THE
CRANIAL BASE
The maxilla is attached to the cranial base by
means of a number of sutures. The mandible too
is attached to the cranial base at the temporo­
man­d i­b ular joint. Thus growth processes
occurring at the cranial base can affect the
placement of maxilla and the mandible.
The cranial base growth postnatally by
complex interaction between the following
three growth processes, extensive cortical drift
and remodeling elongation at synchondrosis
and sutural growth.
Cortical Drift and Remodeling
Remodeling refers to a process where bone
deposition and resorption occur so as to bring
about change in size, shape and relationship
of bone. The cranium is divided into a number
of compartments by bony elevations and
ridges present in the cranial base. These
elevated ridges and bony partitions show bone
deposition, while the predominant part of the
floor shows bone resorption. This intracranial
 Growth and Development 37

bone resorption helps in increasing the intra­

cranial space to accommodate the growing
brain.
The cranial base is perforated by the
passage of a number of blood vessels and
verves communicating with the brain. The
foramina that allow the passage of these nerves
and blood vessels undergo drifting by bone
deposition and resorption so as to constantly
maintain their proper relationship with the
growing brain.

Elongation of Synchondrosis
Most of the bones of the cranial base are
formed by a cartilaginous process. Later
the cartilage is replaced by bone. However
certain bands of cartilage remain at the
junction of various bones. These areas are
called synchondrosis. They are important
growth sites of the cranial base. They are
primary cartilages. The important synchond­
roses found in the cranial base are, Spheno­
occipital, Sphenoethmoid, Intersphenoid, and
Intraoccipital (Fig. 2.16).
Sphenooccipital synchondrosis: It is the
cartilagi­nous junction between the sphenoid
and the occipital bones. The sphenooccipital
synchond­rosis is believed to be the principal
growth cartilage of the cranial base during
childhood. It is considered to be the most
important growth site of the cranial base. The
sphenooccipital 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 sphenooccipital synchondrosis
provides a pressure or compression adapted
bone growth, in contrast to the tension
adapted growth seen in sutures. This is because
the cranial base supports the weight of the
brain and face, which bears down on the
Figure 2.16: Synchondroses
synchondrosis in the midline of the cranial
base. As endochondral bone growth occurs
at the sphenooccipital synchondrosis, the
sphenoid and the occipital bones are moved
apart. At the same time new endochondral
bone is laid down in the medullary region,
and cortical bone is formed in the endosteal
and periosteal regions. Thus the sphenoid and
occipital bones increase in length and width.
The structure of a synchondrosis is like
two epiphyseal plates positioned back-to-
back and separated by a common zone of
reserve cartilage. The direction of growth of
the sphenooccipital synchondrosis is upwards.
It therefore carries the anterior part of the
cranium bodily forwards. The growth at the
synchondrosis continues till the obliteration
of the same by formation of bone. Studies by
various scientists have shown that the closure
of the synchondrosis occurs on an average at
13–15 years.
38 Essentials of Orthodontics
Sphenoethmoidal synchondrosis: This is a
cartilaginous band between the sphenoid
and ethmoid bones. Cartilage between
mesethmoid and frontal are equally important.
In addition, there is the growth of the frontal
bone itself increasing in thickness through
pneumatization and creation of the frontal
sinus. All except the frontal bone develops
in chondrocranium. When exactly this
synchondrosis closes is not known, it is
believed to ossify by 5–25 years of age. It is
likely however that its major contribution
has been made by the time first permanent
molar erupts. Recent research indicates
that growth or lack of growth at the spheno­
ethmoidal synchondrosis may have important
ramification in cleft palate rehabilitation.
Intersphenoidal synchondrosis: It is the carti-
laginous band between the two parts of the
sphenoid bone. It is believed to ossify at birth.
Intraoccipital synchondrosis: This ossifies by
3–5 years of age.
Sutural Growth
The cranial base has a number of bones that
are joined to one another by means of sutures.
Some of the sutures that are present include
spheno­frontal, frontotemporal, spheno­
ethmoid, frontoe­thmoid and frontozy­gomatic.
As the brain enlarges during growth, bone
formation occurs at the ends of the bone.
Timing of Cranial Base Growth
By birth, 55–60% of adult size is attained
By 4–7 years, 94% of adult size is attained
By 8–13 years, 98% of adult size is attained
POSTNATAL GROWTH OF
MAXILLA
The growth of the nasomaxillary complex is
produced by the following mechanisms:
• Displacement
• Growth at sutures
• Surface remodeling.
Displacement
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
maxillary growth.
A passive or secondary displacement of the
maxillary complex occurs in a downward and
forward direction as the cranial base grows.
This is a secondary type of displacement,
as the actual enlargement of these parts is
not directly involved. The nasomaxillary
complex is simply moved anteriorly as the
middle cranial fossa grows in that direction.
The passive displacement of the maxilla is
an important growth mechanism during the
primary dentition years but becomes less
important as growth of cranial base slows.
In addition, a primary type of displacement
is also seen in a forward direction. This occurs
by growth of the maxillary tuberosity in a
posterior direction. This results in the whole
maxilla being carried anteriorly. The amount of
this forward displacement equals the amount
of posterior lengthening. This is a primary
type of displacement as its own enlargement
displaces the bone.
Growth at Sutures
The maxilla is connected to the cranium and
cranial base by a number of sutures, these
sutures are, frontonasal, frontomaxillary,
zygomatico-temporal, zygomaticomaxillary
and pterygo-palatine sutures.
According to Weinmann and Sicher,
these sutures are all oblique and more or
less parallel to each other. This allows the
downward and forward repositioning of the
maxilla as growth occurs at these sutures. As
growth of the surrounding soft tissue occurs,

Figure 2.17: Surface remodeling
the maxilla is carried downwards and forward.
This leads to opening up of space at the sutural
attachments. New bone is formed on either
side of the suture. Thus the overall size of
the bones on either side increases. Hence a
tension related bone formation occurs at the
sutures.
Surface Remodeling (Fig. 2.17)
In addition to the growth occurring at
the sutures, massive remodeling by bone
deposition and resorption occurs to bring
about, increase in size, change in shape of
bone and change in functional relationship.
The following are the bone remodeling
changes that are seen in the nasomaxillary
complex:
i. Resorption occurs on the lateral sur­
face of the orbital rim leading to lateral
movement of the eyeball. To compensate,
there is bone deposition on the medial
rim of the orbit and on the external
surface of the lateral rim.
ii. The floor of the orbit faces superiorly,
laterally and anteriorly. Surface deposi­
tion occurs here and results in growth in
a superior, lateral and anterior dire­ction.
iii. Bone deposition occurs along the
posterior margin of the maxillary
tuberosity. This causes lengthening of
the dental arch and enlargement of
the anteroposterior dimension of the
entire maxillary body. This helps to
accommodate the erupting molars.
Growth and Development 39
iv. Bone resorption occurs on the lateral
wall of the nose leading to an increase
in size of the nasal cavity.
v. Bone resorption is seen on the floor of
the nasal cavity. To compensate there
is bone deposition on the palatal side.
Thus a net downward shift occurs,
leading to increase in maxillary height.
vi. The zygomatic bone moves in a posterior
direction. This is achieved by resorption
on the anterior surface and deposition
on the posterior surface.
vii. The face enlarges in width by bone
for­mation on the lateral surface of the
zygomatic arch and resorption on its
medial surface.
viii. Anterior nasal spine prominence
increases due to bone deposition. In
addition there is resorption from the
periosteal surface of labial cortex. As
a compensatory mech­a nism, bone
deposition occurs on the endosteal
surface of the labial cortex and periosteal
surface of the lingual cortex.
ix. As the teeth start erupting, bone depos­
ition occurs at the alveolar margins. This
increases the maxillary height and the
depth of the palate.
x. The entire wall of the sinus except the
mesial wall undergoes resorption.
This results in increase in size of the
maxillary antrum.
Growth sites in maxilla are maxillary tuber­
osity, sutures, alveolar border, nasal septum
and surfaces (Figs 2.18A and B).
To summarize maxillary growth:
Length increases by sutural growth and
surface apposition at maxillary tuberosity.
Width of maxilla increases by the midpalatal
suture and apposition at zygomatic bones.
Height increases by sutural growth, surface
apposition and alveolar growth.
40 Essentials of Orthodontics
A B
Figures 2.18A and B: Surface remodeling of
mandible and maxilla
POSTNATAL GROWTH OF
MANDIBLE
Of the facial bones, the mandible undergoes
the largest amount of growth postnatally
and also exhibits the largest variability in
morphology. While the mandible appears in
the adult as a single bone, it is developmentally
and func­tionally divided into several skeletal
subunits. The basal bone or the body of the
mandible form a one unit, to which is attached
the alveolar process, the coronoid process,
the condylar process, the angular process,
the ramus, the lingual tuberosity and the
chin. Thus the study of postnatal growth of
the mandible is easy to study as separate units
(Fig. 2.19).
Ramus
The ramus moves progressively posterior by
a combination of deposition and resorption.
Figure 2.19: Growth sites in mandible
Resorption occurs on the anterior part of the
ramus while bone deposition occurs on the
posterior region. This results in a ‘drift’ of the
ramus in a posterior direction. The functions
of remodeling of ramus are, to accommodate
the increasing mass of masticatory muscles
inserted to it, to accommodate the enlarged
breath of pharyngeal space and to facilitate the
length­ening of the mandibular body, which in
turn accommodates the erupting molars.
Body of Mandible
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 of former ramal bone into the
posterior part of the body of mandible. In this
manner the body of the mandible lengthens.
Thus additional space made available by
means of resorption of the anterior border of
the ramus is made use of to accommodate the
erupting permanent molars.
Angle of the Mandible
On the lingual side of the angle of mandible,
resorption takes place on the posteroinferior
aspect while deposition occurs on the antero­
superior aspect. On the buccal side, resor­
ption occurs on the anterosuperior part while
deposition takes place on the posterosu­perior
part, this result in flaring of the angle of the
mandible as age advances.
Lingual 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 and
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 sizeable depre­ssion, the lingual
fossa. The combination of resorption in
the fossa and deposition on the medial
surface of the tuberosity itself accentuates the
prominence of the lingual tuberosity.
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 the 3rd molars.
In case of absence of teeth, the alveolar bone
fails to develop and it resorbs in the event of
tooth extraction.
Chin
The chin is a specific human characteristic and
is found in its fully developed form in recent
man only. In infancy, the chin is usually under-
developed. As age advances the growth of chin
becomes significant. It is influenced by sexual
and specific genetic factors. Usually males
are seen to have prominent chins compared
to females. The mental protuberance forms
by bone deposition during childhood. Its
prominence is accentuated by bone resorption
that occurs in the alveolar region above it,
creating a concavity. The deepest point in this
concavity is known as point B in cephalometrics.
Condyle
The mandibular condyle has been recognized
as an important growth center. A thin layer
Growth and Development 41
of cartilage called the condylar cartilage
covers the head of the condyle. The presence
of the condylar cartilage is an adaptation to
withstand the compression that occurs at the
joint. The role of the condyle in the growth of
mandible has remained a controversy. There
are two schools of thought regarding the role
of the condyle.
It is earlier believed that growth occurs at
the surface of the condylar cartilage by means
½ of bone deposition. Thus the condyle grows
towards the cranial base. As the condyle pushes
against the cranial base, the entire mandible
gets displaced forwards and downwards.
It is now believed that the growth of soft
tissues including the muscles and connective
tissues carries the mandible forwards away
from the cranial base. Bone growth follows
secondarily at the condyle to maintain
constant contact with the cranial base.
The condylar growth rate increases at
puberty reaching a peak between 12½–14
years. The growth ceases around 20 years of
age.
Coronoid Process
The growth of the coronoid process follows
the enlarging ‘V’ principle. Viewing the
longitudinal section of the coronoid process
from the posterior aspect, it can be seen that
deposition occurs on the lingual surfaces of
the left and right coronoid process. Although
additions take place on the lingual side, the
vertical dimension of the coro­noid process
also increases. This follows the ‘V’ principle.
Viewing it from the occlusal aspect, the
deposition on the lingual of the coronoid
process brings about a posterior growth
movement in the ‘V’ pattern. Briefly the
coronoid process has a propeller-like twist,
so that it lingual side faces three general
directions all at once.
42 Essentials of Orthodontics
Growth sites in mandible are mandibular
condyle, posterior border of ramus, lingual
tuberosity and alveolar process.
To summarize mandibular growth:
Lengthens by surface apposition at
posterior border of ramus and resorption at
anterior border, deposition at bony chin and
growth at condylar cartilage.
Height increases by surface apposition at
alveolar border, lower border of mandible and
condylar cartilage.
Width increase by surface apposition at
outer surfaces.
MANDIBULAR ROTATION
Clockwise rotation (Backward
rotation, Posterior rotation)
(Fig. 2.20).
Displacement of the mandible in the direction
of mouth opening (clockwise, with the patient
facing to the right), due to increased posterior
vertical growth. Clockwise mandibular rotation
also can occur as a consequence of orthodontic
treatment, when posterior teeth are extruded
in a nongrowing patient. Clockwise rotation
of the mandible usually is accompanied by an
Figure 2.20: Clockwise rotation
increase of the anterior lower face height and
a reduction of the overbite.
Counterclockwise Rotation
(For­ward Rotation, Anterior Rotation)
Rotation of the mandible in the direction of
mouth closing (counterclockwise, with the
patient facing to the right), due to increased
posterior, compared to anterior growth.
Counter­clockwise rotation of the mandible
would tend to cause a relative reduction in the
anterior lower face height and a deepening of
the overbite.
Intramatrix Rotation (External
Rotation) (Fig. 2.21)
Rotation within the body of the mandible,
due to angular remodeling of the inferior
border rela­­tive to the core of the mandible
is called intra­matrix rotation (which affects
the orientation of the mandibular plane with
regard to the cranial base).
Matrix Rotation (Apparent Rotation)
Rotation of the entire mandible around its
condylar axis is known as Matrix rotation.
(This affects the orientation of the mandible
as a whole relative to the cranial base).
Figure 2.21: Intramatrix rotation

Total Rotation (True Rotation,
Internal Rotation)
The actual rotation of the core of the mandible
(the part of the bone that surrounds the inferior
alve­olar nerve) relative to the cranial base,
which is a com­bination of the intramatrix and
matrix rotation.
POSTNATAL GROWTH OF TMJ
(FLOW CHART 2.4)
Postnatally, the TMJ becomes a secondary
growth site with two articular surfaces
that can adapt to changing environmental
conditions. The temporal fossa can change
position by apposition of cortical bone,
which is an example of anabolic modeling.
The mandibular condyle changes its shape
and length by subarticular proliferation of
connective tissue cells that differentiate into
fibrocartilage. The fibrocartilage is eroded
by osteoclasts at the metaphyseal surface
and replaced by lamellar trabecular bone.
This process is similar to the ossification that
occurs beneath the articulating cartilage of
Flow chart 2.4: Postnatal growth of TMJ
Growth and Development 43
the epiphysis of long bones. There are no
primary and secondary spongiosa in contrast
to metaphyseal growth plates in long bones.
Both articulating surfaces of the TMJ can
adapt but it is by different mechanisms. In the
temporal fossa, the subarticular proliferative
zone is the cambium layer of the periosteum.
It can support both anabolic and catabolic
bone modeling to change the shape and
position of the temporal fossa in response to
environmental demands. On the other hand,
subarticular proliferation of the mandibular
condyle produces fibrocartilage, which is
eroded at the endosteal surface and replaced
with lamellar trabecular bone. Fibrocartilage
has been reported on the articulating surface
of the mandibular condyle of aging cadavers.
However, this is not the normal anatomy
of the TMJ. Because of TMJ development
and its documented ability to adapt over
a lifetime, a mandibular condyle covered
with fibrocartilage is probably a joint that
has diminished or lost its ability to skeletally
adapt to environmental challenges. What
distinguishes the TMJ from other joints of the
body is the articular layer of dense fibrous
connective tissue with a subcondylar zone
of proliferating connective tissue cells. In the
fossa, the articular surface is analogous to the
fibrous and cambium layer of the periosteum,
which has a full range of bone modeling
capabilities. Beneath the proliferative zone
of the condyle is a layer of fibrocartilage that
can be eroded internally and replaced with
bone. Since the articulating surfaces of the
long bones are covered with hyaline cartilage,
which has no proliferative zone, there is limited
capacity for growth, adaptation, or healing. On
the other hand, animal and clinical studies
have demonstrated that normal TMJs have a
remarkable ability to heal and adapt over a
lifetime.
44 Essentials of Orthodontics
SUMMARY OF FACIAL GROWTH
CHANGES
The growth changes in the face are both
complex and highly variable as has been
demonstrated from the low correlations
between the changes in the various facial
parameters. The same can be said about the
relationship between the changes in the facial
parameters to the various indices of skeletal
maturation such as standing height and wrist
X-rays. Contemporary methods are generally
incapable of providing an efficient estimate
of individual changes attributable to growth.
The adolescent growth spurt in the mandible
occurs in less than 25% of the cases, but the
presence, onset, duration and magnitude of
the pubertal growth spurt in facial dimensions
cannot be accurately predicted for any one
individual. Substantial mandibular growth
occurs during adolescence over a number of
years. Therefore in the presence of significant
skeletal discrepancies, treatment should not
be postponed in anticipation of the elusive
spurt, particularly if treatment is indicated at
an earlier age.
At the present time the simplest method
of predicting changes in facial dimensions is
to start with the facial types presented by the
patient and add the average growth changes
expected for that face type. Obviously this
method has its limitations regarding the
prediction of individual changes, but it is is
as good, or as bad as any other more complex
method.
In regards to the future changes in facial
relationships, treatment planning should be
based on a worst case scenario. In other words,
for individuals with unfavorable skeletal
relationships, it is wiser to design a treatment
plan with the assumption that the same facial
growth pattern will be maintained during the
treatment period. Favorable growth changes,
if they occur, make the treatment objectives
easier to accomplish.
Orthodontists should be familiar with the
effects of the mechanics used on the facial
and dental structures. Therefore growth
projections require careful attention to the
mechanics used.
DEVELOPMENT OF DENTITION
AND OCCLUSION
Dentition is defined as a type, number and
arrangement of teeth. Dental formula for
humans is 2 incisors, 1 canine, 2 molars (Total 20)
in deciduous dentition and 2 incisors, 1 canine,
2 premolars and 3 molars (Total 32) in
permanent dentition.
The embryonic oral cavity is lined by
stratified squamous epithelium known as
the oral ectoderm. Around the 6th week of
intrauterine life, the inferolateral border
of the maxillary arch and the superolateral
border of the mandibular arch show localized
proliferation of the oral ectoderm resulting
in formation of a horseshoe- shaped band
of tissue called the dental lamina. The
dental lamina plays an important role in the
development of the dentition. The deciduous
teeth are formed by direct proliferation of the
dental lamina. The permanent molars develop
as a result of its distal proliferation while the
permanent teeth that replace deciduous teeth
develop from a lingual extension of the dental
lamina. Thus all teeth originate from the dental
lamina.
The ectoderm in certain areas of the
dental lamina proliferates and forms knob-
like structures that grow into the underlying
mesenchyme. Each of these knobs represents a
future deciduous tooth and is called the enamel
organ. The enamel organ passes through a

number of stages ultimately forming the teeth.
Based on the shape of the enamel organ the
development of teeth can be divided into three
stags. They are the bud, cap and bell stage.
BUD STAGE
This is the initial stage of tooth formation
where the enamel organ resembles a small
bud. During the bud stage the enamel organ
consists of peripherally located low columnar
cells and centrally located polygonal cells. The
surrounding mesenchymal cells proliferate,
which result in their condensation in two
areas. The area of condensation immediately
below the enamel organ is the dental papilla.
The ectomesenchymal condensation that
surrounds the tooth bud and the dental papilla
is the dental sac. The dental papillas as well as
the dental sac are not well-defined during the
bud stage. They become more defined during
the subsequent cap and bell stages. The cells
of the dental papilla form the dentin and pulp
while the dental sac forms cementum and
periodontal ligament.
CAP STAGE
The tooth bud continues to proliferate resulting
in a cap shaped enamel organ. This is chara­
cterized by a shallow invagination on the under
surface of the bud.
The outer cells of the cap covering the
convexity 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 and inner enamel epithelium, which
initially consisted of polygonal cells, acquire
Growth and Development 45
more intercellular 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 dental papilla and dental sac are
pronounced during this stage.
BELL STAGE
Due to continued uneven growth of the enamel
organ it acquires a bell shape. The cells 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 epithelium
and the stellate reticulum. This layer is called
the stratum intermedium. It is believed to be
essential for enamel formation. The stellate
reticulum expands further due to continued
accumulation of intra-cellular fluid. The
cells of this area are star-shaped; having
large processes that anastomose with those
of adjacent cells. As the enamel formation
starts, the stratum reticulum collapses to a
narrow zone thereby reducing the distance
between the outer enamel and inner enamel
epithelium.
The cells of the outer enamel epithelium
flatten to form low cuboidal cells. The outer
enamel epithelium is thrown into folds, which
are rich in capillary network. This provides a
source of nutrition for the enamel organ.
Before the inner enamel epithelium begins
to produce enamel, the peripheral cells of the
dental papilla differentiate into odontoblasts.
They are cuboidal cells that later assume a
columnar form and produce dentin.
46 Essentials of Orthodontics
The dental sac exhibits a circular arrange­
ment of its fibers and resembles a capsule
around the enamel organ. The fiber of the
dental sac forms the periodontal fibers that
span between the root and bone.
The junction between the inner enamel
epithelium and odontoblasts outlines the
future dentinoenamel junction.
Root Formation
Root development begins after the dentin and
enamel formation reaches the future cemento-
enamel junction. The outer and inner enamel
epithelium joins and forms a sheath that helps
in molding the shape of the root. This sheath
is called the Hertwig’s epithelial root sheath.
PERIODS OF OCCLUSAL
DEVELOPMENT
Occlusal development can be divided into the
following developmental periods:
Predental Period
• Deciduous dentition period
• Mixed dentition period
• Permanent dentition period.
PREDENTAL PERIOD
This is the period after birth during which the
neonate does not have any teeth. It usually
lasts for 6 months after birth.
Gum Pads
The alveolar processes at the time of birth are
known as the gum pads. The gum pads are
pink, firm and are covered by a dense layer
of fibrous periosteum. They are horseshoe-
shaped and develop in two parts. They are the
labiobuccal portion and the lingual portion.
The two portions of the gum pads are separated
from each other by a groove called the dental
groove (Table 2.1).
The gum pads are divided into ten segments
by certain grooves called transverse grooves.
Each of these segments consists of one
developing deciduous tooth sac.
The original groove separates gum pad
from the palate and floor of the mouth. The
transverse groove between the canine and first
deciduous molar segment is called the lateral
sulcus. The lateral sulci are useful in judging the
interarch relationship at a very early stage. The
lateral sulcus of the mandibular arch is normally
more distal to that of the maxillary arch.
At rest the tongue separates gum pads.
Vertical space exists between upper and
lower gum pads, which are occupied by the
tongue.
The upper and lower gum pads are
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, there is
a complete overjet all around. Contact occurs
between the upper and lower gum pads in the
first molar region and a space exists between
them in the anterior region. The infantile
openbite is considered normal and it helps in
suckling.
This posture is not necessarily a precursor
to an anterior openbite. At birth gum pads
are not wide enough to accommodate the
developing incisors which are crowded
and rotated in their crypts. Later during the
first year of life gum pads increase in width
sufficient enough to accommo­date developing
incisors. Later the labio-lingual width and
length of the gum pads increase moderately
and the second molar segment becomes
clearly defined.
 Growth and Development 47

Table 2.1: Development of dentition

Tooth Tooth germ Dentin Calcification Crown Eruption Root complete

fully developed formation begins formation in oral cavity
begins complete
Deciduous 3–4 month IUL 4–6 month IUL 2–3 month 6–9 month 1–1½ year
incisors after eruption
Canines 9 month 16–18 month
First molars 6 month 12–14 month
Second molars 12 month 20–30 month
Permanent 30th week IUL 3–4 month 3–4 month 4–5 year 7–9 year 2–3 year after
maxillary eruption
centrals
Mandibular 3–4 month 6–8 year
centrals
Maxillary 10–12 month 10–12 month 7–9 year
laterals
Mandibular 3–4 month 3–4 month 6–8 year
laterals
Maxillary 4–5 month 4–5 month 6–7 year 11–12 year 2–3 year after
canines eruption
Mandibular 9–10 year
canines
Maxillary first 1.5–2.5 year 1.5–1.75 year 5–6 year 10–11 year 2–3 year after
premolars eruption
Mandibular 1.75–2 year 10–12 year
first premolars
Maxillary 2–2.25 year 6–7 year 10–12 year
second
premolars
Mandibular 2.25–2.5 year 11–12 year
second pre­
molars
First molars 24th week IUL Before birth At birth 2.5–3 year 6–7 year 2–3 year after
eruption
Second molars 2.5–3 year 2.5–3 year 7–8 year 11–13 year
6th month
Third molars 7–10 year 7–9 year 12–16 year 17–21 year
6th year

Status of Dentition grow rapidly per­mitting the incisors to erupt

The neonate is without teeth for about 6
months of life. At birth the gum pads are
not sufficiently wide to accommodate the
developing incisors which are crowded in their
crypts. During the first year of life the gum pad
in good alignment.
Very rarely teeth are found to have erupted
at the time of birth. Such teeth that are present
at the time of birth are called natal teeth.
Sometimes teeth erupt during the first month
48 Essentials of Orthodontics
of age are called neonatal teeth. The natal
and neonatal teeth are mostly located in the
mandibular incisor region and show a familial
tendency.
DECIDUOUS DENTITION PERIOD
The initiation of primary tooth buds occurs
during the first six weeks of intrauterine life.
The primary teeth begin to erupt at the age of
about 6 months. The eruption of all primary
teeth is completed by 2–3 years, when the
second deciduous molars come into occlusion.
Eruption Age and Sequence of
Deciduous Dentition
The mandibular central incisors are the first
teeth to erupt into the oral cavity. They erupt
around 6–7 months of age. The timing of tooth
eruption is highly variable. A variation of 3
months from the mean age has been accepted
as normal. The sequence of eruption of the
deciduous dentition is A-B-D-C-E.
The primary dentition is usually established
by 3 years of age on eruption of the second
deciduous molars. Between 3-6 years of age,
the dental arch is relatively stable and very few
changes occur.
Spacing in Deciduous Dentition
(Physiologic Spaces)
Spacing usually exists between the deciduous
teeth. These spaces are called physiological
spaces or developmental spaces. The presence
of spaces in the primary dentition is important
for the normal development of permanent
dentition. Absence of spaces in the primary
dentition is an indication that crowding of
teeth may occur when the larger permanent
teeth erupt.
According to Leighton, it is possible to
predict the degree of crowding in permanent
teeth on the bases of spacing in lower
deciduous arches as follows.
Crowding in deciduous dentition 10 in 10
cases develop crowding in permanent teeth.
No spaces—7 in 10 cases develop crowding.
Below 3 mm of total spacing—5 in 10 cases
develop crowding.
3-6 mm of total spacing—2 in 10 cases
develop crowding.
Over 6 mm of total spacing—none develop
crowding.
Primate Spaces (Ape Space, Simian Space
and Anthropoid Space)
Spacing invariably is seen mesial to the
maxillary canines and distal to the mandibular
canines where the opposing canines
interdigitate, these physiological spaces are
called primate spaces, or simian spaces or
anthropoid spaces or ape spaces, as they are
seen commonly in primates. These spaces
help in placement of the canine cusps of the
opposing arch.
Flush Terminal Plane (Fig. 2.22)
The mesiodistal relation between the distal
surfaces of the upper and lower second
deciduous molars is called the terminal plane.
Figure 2.22: Flush terminal plane

A normal feature of deciduous dentition is a
flush terminal plane (FTP) where the distal
surfaces of the upper and lower second
deciduous molars are on same vertical plane.
The mandibular second deciduous molar is
usually wider mesiodistally than the maxillary
second deciduous molar giving rise to typical
flush terminal plane relationship. This flush
terminal plane develops into Class I molar
relationship following exfoliation of lower
second deciduous molar.
On the other hand in some cases upper
second deciduous molar is ahead of lower
which gives rise to distal step. This distal
step relationship can lead on to Class II
molar relationship in permanent dentition
(Fig. 2.23).
Mesial step is a relation where lower
second deciduous molar is ahead of upper
second deciduous molar. This mesial step
either can lead on to Class I molar or Class III
molar relationship (Fig. 2.24).
Thus flush terminal plane relationship is
normal indeciduous dentition, which will be
converted into end on molar relationship in
permanent dentition once the permanent first
Figure 2.23: Distal step
Growth and Development 49
molar develops. Following exfoliation of lower
deciduous second molar, whose mesiodistal
width is more than the upper deciduous
second molar allows for the mesial migration
of lower first permanent molar establishing
Class I molar relationship.
Early Mesial Shift: In human being the
forward movement of the lower posteriors
mainly utilizes the lower space. Such spaces
originally described by Lewis and Lehman
are a normal feature of the permanent
dentition in the higher apes and in the human
primary dentition are usually referred to as the
anthropoid spaces or primate spaces.
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
incisal edges often contact the cingulum area
of the maxillary incisors. This deep bite is later
reduced due to the following factors, eruption
of deciduous molars, attrition of incisors, and
forward movement of the mandible due to
growth.
Figure 2.24: Mesial step
50 Essentials of Orthodontics
Variations in the Occlusion of the
Primary Dentition
Only 33% of the children had spacing between
all the incisors. In 3% no spaces existed in the
incisor teeth; 3% had crowding of the incisor
teeth. Remaining had spacing between some
of the incisors.
The anthropoid space was absent in 13%
of the upper arches and 22% of lower arches
of the children. This is the most common
constant feature in the primary dentition.
The incisal overbite was normal only in 19%
of the cases. There was a reduced overbite in
37%, anterior openbite in 24% and an excessive
overbite in 20% of the cases.
Only 55% of the children had flush terminal
plane relationship, 26% had distal step and
4% of children had mesial step relation. In the
remaining cases there was varied relation on
the either side.
Excessive incisal overjet was present in 72%
of the children.
Changes in Incisor Relationship
during Deciduous Dentition
The mean changes include a reduction in
incisal overjet and overbite. Reduction in
overjet is due to the forward growth of the
mandible during this period, reduction in
overbite has been associated with the attrition
of teeth, the differential growth of the alveolar
processes of jaws. Changes in incisal overbite
were variable, i.e. 52% showing a decrease
44% showing an increase and 4% no change.
Primary teeth undergo marked attrition; as
a result dental arches are relatively free to
move because of lack of cuspal interdigitation.
This leads to an edge-to-edge occlusion,
while the buccal teeth are still in complete
occlusal contact such a situation has led
to the misconception that an edge-to-edge
incisor relationship is a normal feature of the
occlusion at this age.
MIXED DENTITION PERIOD
The mixed dentition period begins at
approximately 6 years of age with the eruption
of 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 can be classified into
three phases:
First Transitional Period
The first transitional period is characterized by
the emergence of the first permanent molars
and the exchange of the deciduous incisors
with the permanent incisors.
Emergence of First Permanent Molar
The mandibular first molar is the first
permanent tooth to erupt at around 6 years
of age. The location and relationship of the
first permanent molar depends much upon
the distal surface relationship between the
upper and lower second deciduous molars.
The first permanent molars are guided into the
dental arch by the distal surface of the second
deciduous molars. The mesiodistal relation
between the distal surfaces of the upper and
lower second deciduous molars can be of
three types.
Flush terminal plane: The distal surface of the
upper and lower second deciduous molars
are in one vertical plane, called flush terminal
plane. Thus the erupting first permanent
molar may also be in a flush or end-to-end
relationship. For the transition of such an end
on molar-molar relation to a Class I molar

relation, the lower molar has to move forward
by about 3–5 mm, relative to the upper molar.
This occurs by utilization of the physiological
spaces and leeway space in the lower arch and
by differential forward growth of the mandible.
The shift in lower molar from a flush
terminal plane to a Class I relation can occur
in two ways. They are designated as the early
and late shift.
Early shift occurs during the 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 primate space and thereby
establish a Class I molar relationship. Since
this occurs early in mixed dentition period it
is called early mesial shift.
Many children lack 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 leeway space. This occurs
in the late mixed dentition period and is thus
called late mesial shift.
Mesial step terminal plane: In this type of
relationship the distal surface of the lower
second deciduous molar is more mesial than
that of upper. Thus the permanent molars
erupt directly into Angle’s Class I occlusion.
This type of mesial step terminal plane most
commonly occurs due to early forward growth
of the mandible. If the differential growth of the
mandible is in a forward direction persists, it
can lead to an Angle’s Class III molar relation.
If the forward mandibular growth is minimal,
it can establish a Class I molar relationship.
Distal step terminal plane: This is characterized
by the distal surface of the lower second
deciduous molar being more distal to that
of the upper. Thus the erupting permanent
molars may be in Angle’s Class II occlusion.
Growth and Development 51
Exchange of Incisors (Incisor Liability)
During the first transitional period the per­
m­a nent incisors replace the deciduous
incisors. The mandibular central incisors
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 needed for
the accommodation of the incisors and the
amount of space available for this is called
incisal liability. The incisal liability is roughly
about 7 mm in the maxillary arch and about 5
mm in mandibular arch. The incisal liability is
overcome by the following factors:
Utilization of Interdental Spaces Seen in
Primary Dentition
The physiologic or the developmental spaces
that exist in the primary dentition are utilized
to partly account for the incisal liability. The
permanent incisors are much more easily
accommodated in normal alignment in cases
exhibiting adequate interdental spaces than
in an arch that has no space.
Increase in Intercanine Width
During the transition from the primary
incisors to the permanent incisors an increase
in intercanine width of both the maxillary
as well as the mandibular arches has been
observed. This is an important factor that
allows the much larger permanent incisors
to be accommodated in the arch previously
occupied by the deciduous incisors.
Change in Incisor Inclination
One of the differences between deciduous
and permanent incisors is their inclination.
The primary incisors are more upright than
the permanent incisors. Since the permanent
incisors erupt more labially inclined they tend
to increase the dental arch perimeter. This is
52 Essentials of Orthodontics

another factor that helps in accommodating

the larger permanent incisors.

Intertransitional Period
In this period the maxillary and mandibular
arches consists of sets of deciduous and
permanent teeth. Between the permanent
incisors and the first permanent molar are
the deciduous molars and canines. This phase
during the mixed dentition period is relatively
stable and no major change occurs.

Second Transitional Period

The second transitional period is characterized
by the replacement of the deciduous molars
and canines by the premolars and permanent
canines respectively.

Leeway Space of Nance (Fig. 2.25)

The combined mesiodistal width of the
permanent canines and premolars are usually
less than that of the deciduous canines and
molars. The surplus space is called leeway
space of Nance. The amount of leeway space Figure 2.25: Leeway space
is greater in the mandibular arch than in the
maxillary arch. It is about 1.8 mm (0.9 mm on
each side of arch) in the maxillary arch and
about 3.4 mm (1.7 mm on each side of the arch)
in the mandibular arch. This excess space is
available after the exchange of the deciduous
molars and canines is utilized for mesial drift
of the mandibular molars to establish Class I
molar relation.

Ugly Duckling Stage (Fig. 2.26) Broadbent’s

Phenomenon
Sometimes, a transient or self-correcting
malocclusion is seen in the maxillay incisor
region between 8–9 years of age. This is a
particular situation seen during the eruption
of the permanent canines. As the developing
permanent canines erupt, they displace the Figure 2.26: Ugly duckling stage

roots of the lateral incisors mesially. This
results in transmitting of the force on to
the roots of the central incisors which also
get displaced mesially. A resultant distal
divergence of the crowns of the two central
incisors causes midline spacing. This situation
has been described by Broadbent as the ugly
duckling stage as children tend to look ugly
during this phase of development. Parents
are often apprehensive during this stage and
consult the dentist. This condition usually
corrects by itself when canines erupt and the
pressure is transferred from the roots to the
coronal area of the incisors.
PERMANENT DENTITION PERIOD
The permanent dentition forms within the
jaws soon after birth, except for the cusps of
the permanent molars which forms before
birth. The permanent incisors develop lingual
or palatal to the deciduous incisors and move
labially as they erupt. The premolars develop
below the diverging roots of the deciduous
molars.
The eruption sequence of the permanent
dentition may exhibit variation. The frequently
seen sequences in the maxillary arch are:
6-1-2-4-3-5-7 or
6-1-2-4-3-5-7
In case of mandibular arch the sequence is,
6-1-2-3-4-5-7 or
6-1-2-4-3-5-7
Dimensional Changes
Dental arch length decreases a surprising
amount during the late adolescent period.
Fisk found that mandibular arch perimeter
decreased by 5 mm between 9–16 years
whereas maxillary arch perimeter decreased
by about 2.5 mm.
Growth and Development 53
Both overjet and overbite decrease thro­
ugh­out the second decade of life probably
due to relatively greater forward growth of the
mandible.
Factors Affecting the Development
of the Occlusion
General Factors
1. Skeletal factors: The position, size and
relationship of the bone in which tooth
develops. The relationship of maxilla
or mandible to other bones and to
each other is probably determined by
hereditary, but may also be influenced by
number of other factors namely hormonal
imbalance, traumatic and pathological
conditions which interfere with growth.
The relationship of maxilla to mandible
is important in all the three dimensions,
as this bone relationship will have a
marked effect upon the nature of ultimate
occlusion. Alveolar bone and tooth
relationship may be different from skeletal
relationship.
2. Muscle factors: The form and function of
the muscle which surrounds the teeth. The
muscles of tongue, lips, and cheeks are of
particular importance in guiding the teeth
into their final position and variation in
muscle form and function can affect the
position and occlusion of the teeth. The
effect of these muscles is modified by the
position of their bony attachments.
3. Dental factors: The size of the dentition
in relation to the size of the jaws. The
disproportion in size between the jaws and
teeth is a feature of many dentitions, but
the main problem affecting the occlusal
development in this respect appears
when the dentition is too large for the
jaws. This can lead on to overlapping and
54 Essentials of Orthodontics
displacement of teeth, impaction of teeth
or mesial movement of teeth. On the other
hand dentition too small for the jaw size
rarely poses a problem.
4. The position and relationship of the teeth
within that bone: During eruption tooth
passes through four distinct stages namely,
preeruptive, intraalveolar, intraoral, and
occlusal. At the onset the position of the
tooth germ is thought to be determined
by genetic mechanism. During, intra-
alveolar eruption, the tooth’s position is
affected by presence or absence of adjacent
teeth, rate of resorption of primary teeth,
early loss of primary teeth and localized
pathologic conditions. During intraoral
or preocclusion stages the tooth can be
moved by lips, cheek, and tongue muscles,
by extraneous objects brought into the
mouth, for example thumb, finger, etc.
once the teeth occlude, i.e. occlusal stage
a most complicated system of forces come
into play.
5. The path which the tooth follow to reach
the mucous membrane before eruption:
Several theories have been propounded to
explain the mechanism whereby eruption
is achieved namely:
i. Vascular pressure
ii. Growth of the root
iii. Epithelial coils
iv. Hammock ligament
v. Pulp growth theory
vi. Bone remodeling theory
vii. Periodontal ligament, etc.
  It is probable that the eruption is a
combination of all these factors.
  The permanent incisors erupt occlu­
sally and outward from position lingual
to their deciduous counterparts. The
canines erupt a little mesially as well
as downwards and outwards. The
premolars erupt vertically. But often
emerge in a position more buccal than
deciduous molars. The permanent
molars follow a curved path of eruption.
6. The forces which guide its course after
eruption: At the time tooth erupts into
the mouth, its roots are separated by
a considerable margin from the walls
of its socket. This permits plenty of
latitude for its guidance by other forces
to its final position it is at this stage
that physical forces are most likely to
influence the position of the tooth, e.g.
thumb, finger pressure. These forces
which are continued by the tooth may be
divided into buccolingual forces which
arise largely from the musculature of
the lips, cheeks bucally constituting the
buccinator mechanism and the tongue
on the lingual side; mesiodistal forces
are exerted through adjacent teeth.
Forces generated by the muscles may
be either passive which is continuous
but very light or active forces associated
with muscle activity which are always
intermittent.
  Buccinator mechanism: Buccinator
mechanism is like a continuous band of
muscles that encircles the dentition and
is anchored at the pharyngeal tubercle.
Opposing this mechanism is a very
powerful muscle, the tongue. These two
muscles act in opposite direction and
maintain the position of teeth.
  This buccinator mechanism is like
a curtain starting with the decussating
fibers of the orbicularis oris muscle,
runs laterally joining the fibers of the
buccinator muscle which are inserted
into pterygomandibular raphe just
behind the dentition. At this point it
intermingles with fibers of superior

constrictor muscle and continues
posteriorly and medially to anchor at
the origin of the superior constrictor
muscle, i.e. the pharyngeal tubercle of
the occipital bone.
7. The forces which start to operate when the
tooth makes contact with its opponent.
When the tooth makes contact with its
opponent a most complicated of forces
determines the position of the tooth. For the
first time, the muscles of mastication exert
an influence through the interdigitation of
the cusps. The upward forces of eruption
and alveolar growth are countered by the
opposition of the apically directed force of
occlusion; the periodontal membrane is
designed to disseminate the strong forces
of chewing to the alveolar bone.
The axial inclination of the permanent
teeth is such that some of the forces of
chewing produce a mesial result through
the contact points of the teeth, the anterior
component of force. The anterior component
of force often is confused with the mesial drift
tendency. The anterior component of force
is the result of muscle forces acting through
the intercuspation of the occlusal surfaces;
while the mesial drifting tendency is an
inherent disposition of most teeth to drift
mesially even before they are in occlusion. This
anterior component of force is countered by
the proximal contacts of the teeth and by the
musculature of lips and cheecks from moving
labially; mesially by the teeth of opposite
side. The lower incisors are also limited from
moving labially by the overbite of the upper
incisors.
Forces of Mastication
The forces of mastication exerted upon the
teeth can be divided as follows for the ease of
description, namely, vertical, anteroposterior
and transverse.
Growth and Development 55
Vertical: The mandible moves from rest
position into occlusion and applies direct
vertical pressure to the upper teeth. In the
mesial direction there is a forward resultant
force. The forward resultant of occlusal
pressure is absorbed partly by the lips and
partly by the palatal curvature of the upper
incisor roots. The roots of lower incisors resist
lingual pressure because they are flattened
mesiodistally.
Anteroposterior: Movement of the mandible
in this direction is not used frequently in
mastication because the overbite of the
incisors causes the molars and premolars to be
disengaged if any but the smallest excursions
are made.
Transverse: In the molar region, lateral
excursions of the mandible at first cause the
large mesiopalatal cusps of the upper molars
to guide up the buccal cusps of the lower
molars and if movement is continued, the
cusp-to-cusp contact of the buccal cusps of the
opposite side disengages the molars. Shearing
action may be performed by premolars and
canines.
Safety Valve Mechanism
A theoretical explanation of the formation
and maintenance of the maxillary intercanine
width which inturn will determine the
intercanine with of the mandibular canines is
called safety valve mechanism. Thus maxillary
intercanine width acts as a safety valve in
determining and maintaining the intercanine
width of mandibular canines.
‘Rail’ Mechanism (Fig. 2.27)
A theoretical explanation of the transverse
expansion of the maxillary dental arch as an
adaptation to advancement of the mandibular
arch during physiological development or
appliance treatment is called ‘rail’ mechanism.
The mandibular dental arch acts as a rail that
56 Essentials of Orthodontics
Figure 2.27: ‘Rail’ mechanism
through occlusal contacts dictates the buccal
movement of the maxillary posterior teeth.
Local Factors
Aberrant developmental position of teeth:
The teeth most commonly affected are upper
canines, lower third molars, upper central
incisors and lower lateral incisors. Aberrant
developmental position is either due to trauma
or unknown etiology.
The persistence of supernumerary teeth: They
can occur in primary or permanent dentition.
But only those occurring in permanent
dentition have marked effect on occlusal
development.
Hypodontia: The congenital absence of certain
teeth. Hypodontia can modify the occlusion
and position of the teeth by virtue of its
effects on form of teeth, position of the teeth
and growth of the jaws. Noticeable effects
on jaw growth only occur in the more severe
types of hypodontia, when a large number of
permanent teeth are missing. The growth of
the basal parts of the jaws is not affected, but
the absence of much of the dentition causes
reduction in growth of the alveolar bone.
The effects of certain habit activities: Abnormal
habits disturb the normal balance of mus­cul­
ature thereby interfere with the development
of occlusion.
Localized soft tissue anomalies, the labial
frenum: In the primary dentition the labial
frenum can frequently be seen to be attached
to the alveolar process between upper central
incisors. With normal dentoalveolar growth,
the upper alveolar process grows down
and the labial frenum attachment becomes
progressively higher on the jaw, occasionally,
however the low attachment persists and the
frenum apparently causes a midline space
between upper central incisors.
Dental Arch Form
Dental arch form is formed by the buccal and
facial surfaces of teeth when viewed from
their occlusal surfaces. The importance of
arch form particularly mandibular arch form
has been stressed by Richard Riedel and
Donald Joondeph in their theorms for stability
of retention. In addition to improving the
occlusion when aligned in a proper arch form
it also contributes significantly to the esthetic
value of the face.
In 1885, Bonwill noted the tripod shape of
the lower jaw and declared that it formed an
equilateral triangle with the base extending
from condyle-to-condyle and the sides
extending from each condyle to the midline of
the central incisors. He stated that this triangle
existed for the proper functioning of the teeth.
Importantly, he noted that the bicuspids and
molars formed a straight line from the cuspids
to the condyles.
In 1905, Hawley employed some of
Bonwill’s principles in proposing a geometric
method for constructing the ideal arch form.
Hawley suggested that the six anterior teeth
be made to lie along a circle whose radius
equaled their combined widths. From this
circle he created an equilateral triangle, the
base of which represented the intercondylar
width. It was proposed that the bicuspids
and molars should be aligned along these
 Growth and Development 57

extended straight lines. Hawley did, however,

advised against the strict use of this method for
determining arch form and that it is used only
as a guide in establishing arch form. Numerous
authors described other shapes for the dental
arches.
In 1902, Black stated that the upper teeth
are arranged in a semiellipse and that the lower
teeth were arranged similarly on a smaller
curve.
Broomell, in the same year, said that “the
teeth are arranged in the jaws in the form
Figure 2.28: Catenary’s curve
of two parabolic curves, the superior arch
describing the segment of a larger circle than
the inferior, as a result of which the upper teeth
slightly overhang the lower”.
Angle developed the concept of Line of
Occlusion in 1890. According to him the line
of occlusion is a smooth Catenary’s curve (Fig.
2.29) passing through the central fossa of each
upper molar and across the cingulum of the
upper canine and incisor teeth. The same line
runs along the buccal cusps and incisal edges
of the lower teeth thus specifying the occlusal
as well as interarch relationships once the
molar position is established.
In 1942, Gray’s Anatomy stated the
following about human arch form:
“The maxillary dental arch forms an
elliptical curve...The mandibular dental arch
forms a parabolic curve”. Figure 2.29: Brader arch form
The basic types of the dental arch form are
parabolic, hyperbolic, ellipsoidal, square and arch formed by the alveolar process and the
V-shaped (Figs 2.28 and 2.29). dental arch which is formed by the crowns
Factors that control the dental arch form of all the maxillary or mandibular arch (Figs
include, the dental development, forces 2.30A to C).
of occlusion, development of maxilla and
mandible and the surrounding soft tissues.
Factors that determine the dental arch FUNCTIONAL DEVELOPMENT
form include, the apical base arch which is the The orofacial region performs a wide range
arch formed by the roots of all the maxillary or of functions such as mastication, swallowing,
mandibular teeth, alveolar arch which is the respiration and speech. It is now an accepted
58 Essentials of Orthodontics
A B
C mirror.
Figures 2.30A to C: Dental arch
fact that form and function are interrelated.
Normal development of the orofacial region
is to a large extent dependent upon normal
function.
NORMAL MILESTONES OF
DEVELOPMENT
Infancy
1–4th week: In prone position child lies, flexed
turns head from side-to-side head sags on
ventral suspension. Motor response, gras
reflex are active. Baby shows visual preference
to human face. Face is round and mandible
small. Abdomen is prominent with relatively
short extremities.
4 weeks: Holds the chin up, head lifted
momentarily to the plane of the body on
ventral suspension, watches person, follows
moving object. The child begins to smile.
8 weeks: Head sustained in plane of body on
ventral suspension. Smiles on social contact,
listens to voice and coos.
12 weeks: Lifts the head and chest, lifts head
above plane of body on ventral suspension.
Early head control with bobbing motion.
Makes defensive movements and listen to
music.
16 weeks: Lifts head and chest, head in
approximately vertical axis. Symmetrical
posture predominates, hands in midline.
Enjoys sitting with ful truncal support. Laughs
out loud and excited at sight of food.
28 weeks: Rolls over, crawls, sits briefly, reaches
out for and grasps large objects. Transfers
objects from hand-to-hand polysyllabic vowels
sounds formed, prefers mother and enjoys
40 weeks: Sits up alone, without support. Pulls
to standing position, walks holding on to
furniture. Grasps objects with the thumb and
fore finger; pokes at things with forefinger.
Repetitive consonant sounds. The child
responds to sound of name.
52 weeks: Walks one hand held raises
independently takes several steps. Realises
object to other person on request or gesture.
Increase in vocabulary by a few words, makes
postural adjustments to dressing.
Preschool Period
15 months: Walks alone, crawls upstairs, inserts
pellet in bottle, follows simple commands, may
name a familiar object. Indicates some desires
or needs by pointing and hugs parents.
18 months: Runs stiffly, walks upstairs with one
hand held. Baby explores drawers and waste
baskets. Imitates scribbling, dumps pellet from
bottle. Vocabulary consists of about 10 words,
identifies one or more parts of the body. Feeds
self seeks help when in trouble.
24 months: Runs well, walks up and down the
stairs one step at a time. Opens doors, jumps,
circulating scribbling, imitates horizontal
strokes. Puts three words together, handles
spoon well, helps to undress and listens to
stories with pictures.
30 months: Goes upstairs with alternating feet.
Refers to self by pronoun ‘I’ knows full name.

Helps us to keep things away, pretends in play.
36 months: Rides tricycles, stands momentarily
on one foot, imitates a cross, copies a circle,
and knows age and sex, counts three objects
correctly.
48 months: Hops on one foot, uses scissors to
cut out pieces, tells a story, plays with several
children, goes to toilet alone.
60 months: Skips, dresses undress, asks
questions about meaning of words, domestic
role playing.
School Period (6–12 years)
6–10 years: Stedy growth until the prepubertal
growth spurts.
10–12 years: Usual peak height velocity in girls.
13–14 years: Usual peak height velocity in
boys. Lymphatic tissues are at their peak
development during these years. Girls reach
their peak height velocities earlier than boys on
an average and have a lower peak. Growth rate
declines after the peak height velocity period to
about the same as during the infantile period.
PUBERTY AND ADOLESCENCE
There exists a considerable variability in the
chronological ages in which this pubertal
period begins.
Puberty coincides with development of
secondary sexual characteristics like breasts
in female, pubic hair, voice changes in male.
It is also marked by menarche in females. The
sooner the puberty occurs the sooner the rater
of growth declines and finally stops. In females
maximum growth in height occurs the year
before the menarche. There is an increase
in the mass of muscles, and redistribution of
body fat. Increase in skeletal growth. Average
height gain from 5 years to puberty is 3 inches
and by 13 years in females is 63 inches while
62–65 inches in males.
Growth and Development 59
Predicting adult height and weight:
Adult height and weight are related as
follows:
Boys : 2 × height at 8 years = adult height
Girls : 2 × height at 7½ years = adult height
Adult weights are related as follows:
Boys : 5 × weight at 2 years = adult weight
Girls : 5 × weight at 1½ years = adult weight
MASTICATION
Mastication is a complex activity aimed at
breaking down and insalivations of the food,
preparatory to swallowing. In infants, the
food is taken in by suckling as their diet is
mostly confined to liquids. This is unlearned
or automatic reflex in Homo sapiens. It would
be seen from the analysis that at no time of
life are more muscles involved in the intake
of food than in newborn. Thus mastication
in true sense is not present in infants. As the
infants’ switches on to solid or semisolid food,
it quickly learns to use the lip to keep the food
from being forced out of the mouth. The bolus
of food is mixed with saliva by the action of the
tongue and is forced between the gum pads
or the occlusal surfaces of the erupting teeth.
Classic Pattern (Suckle-swallow) is
Outlined by Bosma in Infants
Head is extended, tongue elongated and
low in the floor of the mouth, jaws apart and
lips pursed around the nipple. Mandible
is somewhat protruded. During functions,
the rhythmic contraction of the tongue and
facial muscles aids in the stabilization of the
mandible.
Once the child starts taking solid foods,
the intensity of the act of satisfying hunger is
reduced, but most of the muscles of the cheeks,
tongue and floor of the mouth are involved.
Less activity of lips and mandibular thrust
60 Essentials of Orthodontics
occurs. Infant quickly learns to use his lips
primarily to keep the food from being forced
out of the mouth during the peristaltic action
of the tongue and cheeks as the bolus of food
is forced back towards the pharynx.
In infants, bolus is mixed with saliva by
tongue action. Rhythmic action of muscles of
the cheek serves to force the food back towards
the tongue; which mashes the food against
hard palate. To permit the food to interpose
between gumpads or teeth the mandible is
depressed by gravity and hyoid and lateral
pterygoid muscles with a simultaneous
deflection towards working side. Lateral shift
of mandible is more apparent in hard to chew
foods. Mandible closed primarily by temporal
and masseter muscle activity.
The mastication of food in an adult
summarized by Fletcher using the six phases
as outlined by Murphy:
Preparatory Phase
Food is ingested and positioned by the tongue
within the oral cavity and the mandible is
moved towards the chewing side. Murphy
observed a slight constant deviation of the
mandible to the nonfood side an instant before
the masticatory stroke began and used this
point as a precise beginning of the preparatory
phase.
Food Contact
This phase is characterized by a momentary
hesitation in movement. This pause is
triggered by sensory receptors concerning
the apparent viscosity of the food and probable
transarticular pressure incident of chewing.
The crushing phase: Starts with a high velocity
then slows as the food is crushed by a slight
change in direction but no delay.
Tooth contact: Tooth contact is accompanied
by a slight change in direction but not delay.
The grinding phase: It coincides with the
transgression of mandibular molars across
their maxillary counterparts and is highly
constant from one cycle-to-cycle.
Terminal phase: Messerman (1963) termed
this phase as terminal functional orbit. Ahlgern
(1961) noted that during this phase the
bilateral muscular discharge becomes unequal
and asynchronous, indicating that the person
is chewing unilaterally.
DEGLUTITION
Deglutition or swallowing is an important
function carried out by the stomatognathic
system. Two types of swallowing are
recognized. They are the infantile swallow
and the mature swallow.
Infantile Swallow
The ability to feed from the breast is present
in the newborn child. During the process of
suckling, the nipple is drawn into the mouth
by negative pressure from within. The tongue
lies over the lower gum pads and protrudes
between the nipple and lower lip.
The milk is directed continuously to the
pharynx by an automatic peristaltic movement
of the tongue and mylohyoid muscle. During
the process of swallowing, regular breathing
continues. The milk passes between the facial
pillars and the lateral channels of the pharynx.
Any excess milk in the mouth dribbles down
the chin.
The characteristic of an infantile swallow
as outlined by Moyers is as follows:
The jaws are apart with the tongue being
placed between the upper and lower gum pads.
The mandible is stabilized by the contr­
action of the muscles of the seventh cranial
nerve and the interposed tongue.
 Growth and Development 61

The swallow is guided and to a large extent

controlled by sensory interchange between the
lips and tongue.
As the infant begins to eat solid food,
there is a distinct change in the swallowing
pattern. The tongue is contained within the
dental arches and the mandible is no longer
protruded. This heralds the onset of the mature
swallow.
Change from semisolid to solid food and
eruption of teeth.
Tongue is no longer forced into space
between the gumpads or incisal surfaces of
the teeth which contact momentarily during
swallowing act. Mandibular thrust diminishes
during transitional period of 6–12 months.
Mandibular elevators stabilize the mandible.
Cheek and lip muscles reduce the strength of
Figures 2.31A and B: Mature swallow
their contractions. Tip of tongue is positioned
near the incisive foramen at the movement of
deglutition. nerve muscles. Tongue tip is held against the
Fletcher points out that infantile swallow palate, above and behind the incisors. There
are attributable to a significant difference in are minimal con­tractions of lips in mature
oral cavity morphology and to a large tongue swallow.
size, orientation and suspensory system.
Whereas general bodily dimension change in Phases of Deglutition or Swallowing
a neonate on a ratio of 5:1 the infant tongue Preparatory phase or oral phase: Soft palate
size only doubles in size. The expansion of moves upward and the tongue drops downward
peripheral attachments continues well into and backwards. At the same time larynx and
postnatal period. The change to the adult hyoid bone move upward. These combined
swallow pattern occurs gradually in what movements create a smooth path for bolus as
has been called the transitional period. it is pushed from oral cavity, liquid food flows
Neuromuscular maturation, changes in head ahead of lingual constrictions. The oral cavity,
posture gravitational effect on mandible are stabilized by muscles of mastication maintains
conditioning factors by 18 months. an anterior and lateral seal during this phase.
Pharyngeal phase: Starts as the bolus passes
Characters of Mature Swallow through the fauses. The pharyngeal tube is
(Figs 2.31A and B) raised upward enmasse; nasopharynx is sealed
Teeth are together from 18 months, mandible off by the closure of the soft palate against
is stabilized by contraction of mandibular the posterior pharyngeal wall (Passawant’s
elevators which are primarily 5th cranial ridge). The hyoid bone and the base of tongue
62 Essentials of Orthodontics
move forward as both the pharynx and the
tongue continue their peristaltic like activity
movements of bolus of food.
Esophageal phase: This commences as food
passes the cricopharyngeal spincter. While
peristaltic movement carries the food through
the esophagus the hyoid bone, palate and
tongue return to their original positions.
Theories of Deglutition
• Theory of constant proportions
• Theory of negative pressure
• Theory of expulsion
• Theory of integral function.
Average individual swallows once a minute
between meals and 9 times during eating.
There are various estimates of frequency of
deglutition, which ranges as high as 2400
somatic and visceral swallows per 24 hours
period.
Some observers feel that the patients with
certain types of malocclusion like Class II
div.1 and open bite problems swallow more
frequently. The level of nervous irritability
uses swallowing cycle as a tensional release
mechanism may also enhance deglutitional
frequency.
Triangular Force Concept
The three major groups of muscles affecting
occlusion during the swallowing act are:
Tongue: Which is the only muscle in the body
attached at only one end. The tongue muscles
functions during the act of swallowing as a
moving force, as an impeding force or as both.
Masseter and buccinator: These are activated
each time the patient swallows. Failure of the
activation of these muscles is caused either
by the placement of tongue between the
teeth during deglutition or by poor posterior
occlusion.
Orbicularis oris: Acts as stabilizing influence
on the dentition. The lips are the natural
anterior retainers for the teeth. Patients who
exhibit weak orbicularis oris muscles as a result
of functional or organic problems invariably
exhibit a poor occlusal relationship.
These are referred to as the triangular force
concept. It should be noted that the position
of tongue in relation to the upper and lower
incisors during swallowing act is contributory
to lip functions. If the tongue extends beyond
the upper and lower central incisors, the
tongue will prevent the lower lip from making
contact with the upper teeth, thus preventing
full utilization of the orbicularis oris muscle as
a restraining force. This inhibition of function
will eventually cause a weakening of this
particular muscle.
Tongue is certainly a potent force in mold­
ing the dentition. Together with finger sucking
habit and retained swallowing patt­erns, it
may alter the total function of stomato­gnathic
system.
RESPIRATION
Respiration is an inherent reflex activity. The
newborn infant is basically a nasal breather.
Breathing is evoked spontaneously at birth and
is aided by the posture of the mandible and
hyoid bone. Normal orofacial development is
to a large extent dependent upon presence of
normal respiration.
In patients having partial or total nasal
obstruction, nasal breathing may not be
possible. These patients breathe through the
mouth. The alteration in breathing pattern
brings about a lowered mandibular and tongue
position. Thus the orofacial muscular balance
is lost leading to abnormal development of the
dental arches.
The relationship of breathing patterns
and the form of dentofacial structures and
dental arches is a subject of investigation

and controversy among orthodontists. Much
of the confusion stems from the failure to
establish clear-cut correlations between the
functional problems and the supposedly
related morphologic characteristics.
Enlarged tonsils and adenoids, by com-
promising the airway space, have been
implicated in dentofacial abnormalities.
Orthod­ontists are thus referring patients to
physi­cians for tonsillectomy and/or adenoi-
dectomy to relieve respiratory obstruction.
But is the diagnosis of enlarged tonsils and
adenoids and mouth breathing based on
well-defined criteria? Also, is craniofacial
morphology undisputably influenced by
respiratory mode?
Tonsil size is, from a clinical standpoint, a
difficult assessment. There is no recognized
“normal” size for a tonsil. It is, therefore,
arguable whether tonsils can be described as
“enlarged.” The apparent size of the tonsil can
be altered considerably when the tongue is
protruded forcibly. A child whose oropharynx
looks normal with the tongue slightly protruded
can make the tonsils meet in the midline with
maximum protrusion of the tongue. The
tongue depressor also alters the apparent size
of the tonsils. If the tongue is firmly depressed,
the patient gags and the tonsils meet in the
midline. Grossly enlarged tonsils can create an
obstruction in the oropharyngeal space dorsal
to the root of the tongue. If obstruction is severe
enough, the tongue may be postured forward
to maintain an adequate oropharyngeal
space for respiration. A tongue that appears
protrusive, however, does not necessarily
indicate enlarged tonsils, since any condition
leading to nasorespiratory obstruction might
result in reposturing of the tongue to maintain
a patent oral airway. Macroglossia, while rare,
does occur, and the tongue in these cases also
appears protrusive.
Growth and Development 63
Adenoid size must be assessed relative
to the dimensions of the nasopharynx.
Adenoids are best assessed clinically by direct
naso-pharyngoscopy, a procedure usually
employed by otolaryngologists. Orthodontists
currently depend on lateral skull radiographs
in assessing adenoid size. Mouth breathing
is usually defined as “habitual respiration
through the mouth instead of the nose.” In
reality, however, oral respiration nearly always
implies a combination of nasal and oral
respiration. It does not seem to be a question
of either-or, as many authors have asserted.
The question is, rather: “At what point, if any,
does mouth breathing lead to dentofacial
deformity?”
In studies of airway obstruction, it has been
customary to express degrees of obstruction
in terms of nasal resistance. Watson, Warren,
and Fischer showed that the incidence of
clinically observable mouth breathing was
greater among subjects with a nasal resistance
above 4.5 cm. water per liter per second. It is
necessary, however, to consider each individual
in relation to his age-related norms, which are
not yet available. Furthermore, nasal airflow in
isolation, as opposed to the estimate of relative
oral/nasal flow, is less than satisfactory for the
diagnosis of respiratory dysfunction.
Clinically, then, unless sophisticated
measures are employed, it is currently
impossible to measure differentially and
adequately the relative amounts of nasal
and/or oral respiration. Estimating nasal
respiratory capacity, as many orthodontists do,
by having the patients breathe through each
nostril separately, placing a cold mirror under
the subject’s nose, or placing cotton/wool
under the subject’s nose is unreliable. Further,
it must be emphasized that nasal patency is
not at all constant and can vary considerably
within minutes in all subjects.
64 Essentials of Orthodontics
The evaluation of nasal airway patency is
complicated also by the fact that the airways
may clinically appear inadequate, but may be
quite functional physiologically. Lip separation,
or an open-mouth habit, is not a reliable
indicator of mouth breathing, because complete
nasal respiration often occurs in the presence
of dental conditions which cause an open-
mouth posture. Similarly, a narrow nose is not
necessarily characteristic of mouth breathers.
Holmberg and Linder-Aronson believe that
frontal cephalometric radiographs provide
a reasonable assessment of the nasal airflow
by subjective evaluation of airway capacity
and are valuable in diagnosing reduced nasal
respiratory function.
SPEECH (FIG. 2.32)
Speech is largely a learned activity. The first
sounds produced by a child are often the ‘baby
cry’. 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 phonation, and modification of these
sounds by changing the shape of the cavities
in the mouth, nose and throat, which is known
as articulation.
A large number of muscles are involved
in production of speech. They include the
muscles of the wall of the torso, respiratory
tract, the pharynx, the soft palate, the tongue,
lips and face. Speech does not make gross
demands on the peri-oral musculature and
hence speech defects are rarely a cause for
malocclusion.
Speech defects that arise in connection
with orofacial and dental abnormalities are
mainly those in which the articulation of
the vowels and consonants are distorted
by functional mala­d aptations of various
structures of the mouth during speech.
The effects on speech may be either direct
or indirect: The direct, through the mechanical
difficulties that they impose on a person
attempting to achieve the proper positioning
and movement of the articulators of speech;
and indirect, through the influence that the
deformities may have on the physical and
mental health of the person. The teeth, tongue,
lips, alveolar ridge, palate, and soft palate
are some of these articulators. Any osseous,
muscular, dental, or soft tissue deformity
that impairs the movement or appearance of
the organs of articulation may contribute to
defective speech. Besides, dental appliances
(orthodontic or prosthetic) can cause disorders
of articulation of linguodental, labiodental, or
linguoalveolar consonants.
Passive Muscle Function
A number of muscles exert force on the
developing jaws. There has been observed to be
a strong inter-dependence between the bone
and the muscles. Although the bone is one of
the hardest tissues in the body, it is most
responsive to environmental factors including
musculature.
The teeth and the supporting structures
are blanketed from all directions by muscles.
Thus the integrity of the dental arches and the
relationship of the teeth with each other and
with teeth of the opposing arch are to a large
extent influenced muscles.
The dentition is covered by a continuous
muscle band that encircles it starting with
the fibers of the lip, the muscles run laterally
and posteriorly around the corner of the
mouth, joining the fibers of buccinator which
insert into the pteryogomandibular raphe.
These fibers intermingle with the fibers of the
superior constrictor and continue posteriorly
and medially to anchor at the origin of the

Figure 2.32: Speech
superior constrictor, i.e. at the pharyngeal
tubercle. The dentoalveolar region is thus
encircled from the buccal aspect by this band
of muscle and this phenomenon is referred to
as the buccinator mechanism.
Opposing the buccinator mechanism from
within is a very powerful muscular organ, the
tongue.
Growth and Development 65
TRAJECTORIES OF FORCE
The trajectorial theory of force states that the
lines of orientation of the bony trabeculae
correspond to the pathways of maximal
pressure and tension and that bone trabeculae
are thicker in the region where the stress is
greater.
66 Essentials of Orthodontics
Benninghoff studied the natural lines
of stress in the skull by piercing small holes
into a fresh skull. Later as skulls were dried,
he observed assumed a linear form in the
direction of the bony trabeculae. These were
called Benninghoff’s lines or trajectories which
indicate the direction of the functional stresses.
Trajectories of Maxilla
The trajectories of the maxilla can be broadly
classified as vertical and horizontal trajectories.
The vertical trajectories include the frontonasal
buttress, the malar-zygomatic buttress and the
pterygoid buttress.
Frontonasal buttress: This trajectory originates
from the incisors, canines and the first maxillary
premolar and runs cranially along the sides of
the piriform aperture, the crest of the nasal
bone and terminates in the frontal bone.
Malar-zygomatic buttress: This trajectory
transmits the stress from the buccal group
of teeth in three pathways: Through the
zygomatic arch to the base of the skull, upward
to the frontal bone through the lateral walls of
the orbit, and along the lower orbital margin to
join the upper part of the frontonasal buttress.
Pterygoid buttress: This trajectory transmits the
stress from the second and third molars to the
base of the skull.
Horizontal trajectories of maxilla include
hard palate, orbital ridges, zygomatic arches,
palatal bones and lesser wings of sphenoid.
Trajectories of Mandible
A line of stress extends from one condyle to the
other passing along the symphysis. A number
of vertical trajectories radiate 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.
WOLFF’S LAW OF
TRANSFORMATION OF BONE
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 plastic than any other connective tissue.
It has been found that bone is formed in just
the quantity and shape that will enable it to
withstand the physical demands made upon
it, with the greatest amount of economy of
structure. This is the basis of Wolff’s law of
transformation of bone.
Thus, not only is the quantity of bone
tissue the minimum that would be needed for
function requirements, but also 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
of the cancellous bone within are arranged
in such a say that they support the cortical
bone along well-defined paths of stress and
strain.
PSYCHOLOGICAL
DEVELOPMENT
Study of Psychology of the child receiving
orthodontic treatment is one of most difficult
and essential part of the orthodontics.

PSYCHOLOGY (STUDY OF PSYCHE)
Psychology can be defined as a branch of
science dealing with behavior, acts or mental
processes and with the mind, self or person
who behaves or acts or has the mental pro­
cess.
Reduced to its essence the most typical
definition of psychology becomes the “Science
of Behavior”. But, psychology is not only a
science, it is also profession that is concerned
with studying behavior, predicting behavior
and helping the individuals to change their
behavior.
THEORIES OF PSYCHOLOGICAL
DEVELOPMENT
Psychoanalytical Theory (Sigmund
Freud 1856-1931)
The first formal theory of personality to have
marked impact of psychology and psychiatry
was that of Sigmund Freud. This concept
of personality was based on the interaction
between three systems within each individual;
he called these systems the Id, Ego and Super­
ego.
Id
The Id is the source of all gratifications and
pleasure; it represents the unconscious
instinctive urges that motivate behavior. The
Id operates on what Freud described as the
pleasure principle. But the inner urges of the
Id can find satisfaction only in external sources.
Hence, Id can be defined as the inherited
reservoir of unrecognized drives. It is mostly
unconscious, is governed by the pleasure-pain
principle, aims at immediate satisfaction of
libidinal urges is immoral, is illogical and lacks
unity of purpose.
Growth and Development 67
Ego
It is the ego that makes the necessary interaction
with the social work possible and permits the
needs of the Id to be satisfied. Although the
ego serves as a way of satisfying Id impulses, it
responds to the reality principle. If the Id were
left entirely to its own devices, the organism
would probably be destroyed. Thus the ego
serves to control the Id’s pleasure seeking.
Hence, the ego can be defined as the
integrating or mediating part of personality,
which develops out of interaction of Id
and environment and which controls the
tendencies of Id, excluding or modifying those
tendencies which are in conflict with reality. It
has perception both of the internal and of the
external world.
Superego
The Superego acts as a conscience; it is the
internal part of the individual that makes value
judgments. The superego is idealistic; it is not
necessarily composed of society’s standard
unless the individual has accepted and
internalized them. The child is born without a
superego. This element of personality structure
superego like the ego is developed under the
training and influence of the environment.
Superego makes value judgements about
the individual’s unges impulses and activities
can be defined as the latest development of
the mind embodying the code of society and
including concepts of right and wrong, the
value system and the ideals.
Freud believed that many personality
disorders come because of a conflict between
the ego and the superego. Whenever the ego
attempts to fulfill Id impulses directly, the
superego comes in conflict with the ego. The
ego also develops defence mechanisms to hide
from the superego the fact that Id impulses are
being satisfied.
68 Essentials of Orthodontics
Oedipus Complex
Young boys have a natural tendency to the
mother and they consider their father as their
enemy. Hence they strive to imitate their father
to gain the affection of the mother.
Electra Complex
Similarly the young girls develop an attraction
towards their father and they resent the mother
being close to the father. Freud has reported
that little girls have a comparable Electra
complex to resolve this.
Freud postulated several stages of develop­
ment, each involving special adjust­m ent
problems and each contributing to man’s
behavior.
Oral Stage
The oral stage is the earliest and is characterized
by the child seeking satisfaction of his needs
through the mouth, i.e. through sucking and
ingesting food or drink. The baby learns that
manipulation of the mouth, and especially
the lips and tongue, whether on the breast or
bottle, brings happiness and satisfaction. The
lesson is quickly learned and the child repeats
the action whenever possible. Problems
and tensions at this stage can result in some
oral behavior that may not be productive or
efficient, such as thumb sucking.
Anal Stage
The second stage proposed by Freud is the anal
stage, which corresponds to the period during
which toilet training takes place in western
societies. The pressures of accumulated waste
in the lower digestive tract lead the individual
to seek relief from the discomfort through
excretion.
Phallic Stage
During this stage the child focus attention
on the genitals. The child usually discovers
other erogenous zones of the body, which
may become sources of pleasure through
manipulation. These zones include the
nostrils, ears and eyes. Unresolved problems
or conflicts occurring during this stage can
lead to later problems of several adjustments.
Latent Stage
This stage arrives at about the sixth year,
lasts until puberty. It is a relatively dormant
stage from the standpoint of personality
development.
Genital Stage
At puberty, the endocrinal system functions
with renewed energy and intensity. No new
erogenous zones are discovered, but there is
a major integration of the three earliest stages.
Inner forces now become directed towards
members of the opposite sex, and the focus is
on reproduction or mutual pleasure between
partners.
According to Freud, the individual who
is unable to proceed through various stages
smoothly will develop some form of personality
maladjustment.
Classical Conditioning (Pavlov, 1927)
Ivan Petrovich Pavlov was one of the first to
study conditioned reflexed experimentally.
The crucial element of the conditioning is the
relation between the conditioned stimulus
and the unconditioned stimulus. The more
frequent the pairing of the conditioned and
unconditioned stimulus, the stronger is the
conditioning.
The principles involved in the process are:
1. Generalization: Wherein the process
of conditioning is evoked by a band of
stimuli centered on a specific conditioned
stimulus. Thus a test stimulus similar to
training stimulus results in a response, e.g.
a child who has a painful experience with

a doctor in a white coat always associates
any doctor in white coat with pain.
2. Extinction: Of the conditioned behavior
results if the association between the
conditioned and the unconditioned
response is not reinforced. For example, in
the above mentioned example subsequent
visits to the doctor without any unpleasant
experiences results in extinction of the fear.
3. Discrimination: It is the opposite of
generalization, if the child is exposed to
clinic settings which are different to those
associated with the painful experiences
the child learns to discriminate between
the two clinics and even the generalized
response to any office will be extinguished.
The principles of classical conditioning
can be used in the following areas of animal
and human behavior: Developing good habits,
breaking habits and elimination of conditioned
fear, psychotherapy, to decondition emotional
fear, developing positive attitudes, and
teaching alphabets.
Maher’s Theory (1933)
This theory categorises the early childhood
object relations to understand personality
development.
The period of childhood is thus divided into
three stages:
Normal autistic phase (0–1 yrs): It is a state
of half sleep, half wakefulness. This phase
involves achievement of equilibrium with the
environment.
Normal symbiotic phase (3–4 weeks to 4–5
months): The infant at this stage is slightly
aware of the caretaker but they both are still
undifferentiated.
Separation individualization process (5–36
months): This phase is divided into 4 subphases,
differentiation (5–10 months), practicing
period (10–16 months), rapproachment (16–24
Growth and Development 69
months), consolidation and object constancy
(24–36 months).
Psychosocial Theory (Erik Erikson)
Erik Erikson, a friend and student of Freud,
elaborated and modified Freud’s theory
by superimposition of psychosocial and
psychosexual factors simultaneously contri­
buting to the personality development of the
child. Erikson’s theory postulates that the
society responds to the child’s basic needs or
developmental tasks in each specific period of
life and states that in doing so, society assures
not only the child’s healthy growth but also the
passage and survival of society’s own culture
and conditions. His approach emphasizes the
dependent interaction of the individual and
the society.
Although chronologic ages are associated
with Erikson’s developmental stages, as in
physical development, the chronologic age
varies among individuals but the sequence of
the developmental stages is constant. Rather
differently from physical development, it is
possible and indeed probable that qualities
associated with earlier stages may be evident in
later stages because of incomplete resolution
of the earlier stages.
Erikson’s Eight Ages of Man
1. Development of basic trust (Birth-18
months): Thus Erikson describes the first
year of life (the oral stage) as a time of
achieving a sense of basic trust by the
child that his needs will be met. Failure to
achieve satisfaction will result in a sense of
“basic mistrust”.
2. Development of autonomy (18 months –3
years): The second year of life (the anal
stage) is viewed by Erikson as a time of
gaining mastery over issues of self control
for beyond bowel and bladder control. A
70 Essentials of Orthodontics
successfully outcome leads to a sense of
autonomy, whereas failure leads to a sense
of shame and doubt.
3. Development of initiative (3–6 years):
From three to seven years (the phallic or
oedipal stage) the child deals with issues
of curiosity about the anatomic differences
between the sexes, body integrity and
gender identity. The successful resolution
of gender identity problems, oedipal,
longings, leads to a sense of initiative
whereas failure to accomplish these tasks
leads to a sense of guilt.
4. Mastery of skills (7–11 years): During the
period from age 7–12 yrs (the latency stage),
the child moves out of the home into the
society of children in school. Mastery over
academic achievement and integration into
the world of children require the growing
child to develop a sense of industry. If this
is not accomplished, a sense of inferiority
may result.
5. Development of personal identity (12–17
years): The time of puberty and adolescence
(the genital stage) has been of particular
interest to Erikson. He has focuses less
upon the sexual aspects and more upon the
issues of “ego identity” during adolescence.
Unless a consolidation of a sense of self
is achieved, the teenager is faced with
a sense of identity confusion and the
inability to progress to adulthood as an
independent being apart from his parents.
It is extremely compels stage because of
the many new opportunities that arise.
Emerting sexuality complicates with
others. Establishing ones own identity
requires a partial withdrawal from the
family, and the peer group increases still
further in importance because it offers
a sense of drastic changes within the
individual. Most orthodontic treatment is
carried out during the adolescent years,
and behavioral management of adole­
scents can be extremely challenging.
Since parental authority is being rejected,
a poor psychologic situation is created by
orthodontic treatment if it is being carried
out primarily because the parents want
it, not the child. At this stage, orthodontic
treatment should be instituted only if the
patient wants it, not just to please the
parents.
Motivation for seeking treatment can be
defined as internal or external. External
motivation is from pressure from others
(friends, parents). Internal motivation
is provided by an individual own desire
for treatment to correct a defect that he
perceives in him, not some defect pointed
to by authority figures whose values are
being rejected anyway.
It is extremely important for an
adolescent to actively desire the treatment
as something being done for, not to him
or her. In this stage, abstract concepts
can be grasped readily, but appeals to
do something because of its impact on
personal health are not likely to be needed.
The typical adolescent feels that health
problems are concerns of somebody
else, and this attitude covers everything
from acci­dental death in reckless driving
to develop­ment of decalcified areas on
carelessly brushed teeth.
6. Development of intimacy (young adult):
The adult stages of development begin with
the attainment of intimate relationship
with others. Successful development
of intimacy depends on a willingness
to compromise and even to sacrifice to
maintain a relationship. Success leads
to the establishment of affiliations and
partnerships, both with a mate and with
others. Failure leads to isolation from
others and a set of attitudes that serve to

keep others away rather than bringing
them into closer contact. A growing
number of young adults are seeking
orthodontic care. Often these individuals
seek to correct a dental appearance they
perceive as flawed. They may feel that a
change in their appearance will facilitate
attainment of intimate relationships. On
the other hand, a new look resulting from
orthodontic treatment may interfere with
previously established relationships.
7. Guidance of the next generation (adult):
A major responsibility of a mature adult
is the establishment and guidance of the
next generation. Becoming a successful
and supportive parent is obviously a major
part of this, but another aspect of the same
responsibility is service to the groups,
community and nation.
8. Attainment of integrity (late adults): The
final stage in psychosocial development is
the attainment of integrity. At this stage, the
individual has adapted to the combination
of gratification and disappointment that
every adult experiences. The feeling of
integrity is best summed up as a feeling that
one has made the best of this lifes situation
and has made peace with it.
Operant Conditioning (Skinner, 1938)
The principle of operant conditioning arises
from the experimental work of Skinner.
It has been considered as an extension of
classical conditioning. Individuals response
is changes as a result of reinforcement or
extinction of previous responses. Hence,
satisfactory outcome will be repeated while
unsatisfactory outcomes will diminish in
frequency. According to this theory, the
consequence of behavior itself acts as a
stimulus and affects future behavior. Since the
behavior acts upon the environment it is called
an operant. Skinner described for basic types
Growth and Development 71
of operant conditioning distinguished by the
type of consequences.
Positive reinforcement: Occurs if a pleasant
consequence follows the response, e.g. a child
rewarded for good behavior following dental
treatment.
Negative reinforcement: Involves removal of
unpleasant stimuli following a response, e.g.
if the parent gives into the temper tantrums
thrown by the child, he reinforces ths behavior.
Omission refers to removal of the pleasant
response after a particular response, e.g. if the
child misbehaves during the dental procedure,
his favourte toy is taken away for a short time
resulting in the omission of the undesirable
behavior.
Punishment involves introduction of an aver­
sive stimulus into a situation to decrease the
undesirable behavior, e.g. use of palatal rake
in correction of tongue thrusting habit.
Cognitive Theory (Jean Piaget)
Jean Piaget is the world’s leading theoritist in
the field of cognitive development of children.
He has unremittingly studied virtually every
aspect of the acquisition of knowledge from
language skills, to concepts of time and
space, under­standing mathematical symbols,
to the develop­m ent of moral reasoning.
Although Piaget does not place much
emphasis on the influence of psychosocial
and psychosexual factors, he does hold that
child­hood development proceeds from an
egocentric position through a predictable step
like, consistant expansion and incorporation
of learned experiences. In this sense his theory
is consistent with those of Freud and Erikson
that the child is an active participant with the
environ­ment in the constant incor­poration
and reor­ganization of data.
Piaget has delineated four major periods
of cognitive growth, each characterized by
distinct types of thinking and in which the child
72 Essentials of Orthodontics

Table 2.2: Comparison of stages BEHAVIOR IN ORTHODONTICS

Chronological Freud Erikson Piaget age
Behavior: Any change observed in the functi­
Birth to 1 yr Oral Trust v/s Sensorimotor
mistrust oning of an organism. Behavioral science deals
1–2 yr Anal Autonomy with the observation of behavioral habits of
v/s shame man and lower animals in various physical and
and doubt social environments including orthodontics.
2–6 yr Phallic Initiative v/s Preoperational Classification of child’s behavior observed
guilt
in dental clinic:
6–12 yr Latent Industry v/s Concrete
infer­i­ority operations Wilson’s Classification (1933)
12–20 yr Genital Identity v/s Formal
role con­ operations
1. Normal or bold: The child is brave enough
fusion to face new situations, is cooperative, and
friendly with the dentist.
2. Tasteful or timid: The child is shy, but does
success­fully relies more upon internal stimuli not interfere with the dental procedures.
and symbolic thought and less upon external 3. Hysterical or rebellious: Child is influenced
stimul­ation. The stages are (Table 2.2): by home environment—throws temper
1. Sensorimotor period (birth–18 months) tan­trums and is rebellious.
2. The preoperational period: 4. Nervous or fearful: The child is tense and
a. Preconceptual period (18 months–4 anxious, fears dentistry.
years)
b. Intuitive period (4–7 years) Frankel’s Classification (1962)
3. The period of concrete operations (7–12 1. Definitely negative: Refuses treatment, cries
years) forcefully, extremely negative behavior
4. The formal operations period (12–18 years) associated with fear.
In the first period, the infant learns to 2. Negative: Reluctant to accept treatment
integrate the sensory modalities and is able to and displays evidence of slight negativism.
look forward to an object and make a sound, or 3. Positive: Accepts treatment, but if the child
reach forward and hold an object he desires. has a bad experience during treatment may
The preoperational period is a transitional become uncooperative.
period from the sensorimotor period to the 4. Definitely positive: Unique behavior
period of concrete operations where the looks forward to and understands the
concepts of time, space, number and logical importance of good preventive care.
ordering are acquired. The period of concrete
operations corresponds to the elementary Lampshire’s Classification (1970)
school years. During this time, the child 1. Cooperative: The child is physically and
undergoes an enormous surge in intellectual emotionally relaxed and cooperative
development guided by academic rigor. The throughout the entire procedure.
period of formal operations occurs during 2. Tense cooperative: The child is tensed and
adolescence. The major shift is the ability to cooperative at the same time.
utilize abstract thinking, logical operations 3. Outwardly apprehensive: Avoids treatment
and hypothetical reasoning. initially, usually hides behind the mother,

avoids looking or talking to the dentist.
Eventually accepts dental treatment.
4. Fearful: Requires considerable support so
as to overcome the fears of dental treat­
ment.
5. Stubborn/defiant: Passively resists treat­
ment by using techniques that have been
successfully in other situations.
6. Hypermotive: The child is acutely agitated
and resorts to screaming kicking.
7. Handicapped: Physically/mentally, emo­
tionally handicapped.
8. Emotionally immature.
Wright’s Classification (1975)
1. Cooperative (Positive Behavior):
a. Cooperative behavior: Child is coo­
per­ative, relaxed with minimal appre­
hension.
b. Lacking cooperative ability: Usually seen
in young child, (0–3 yrs), disabled child,
physical and mental handicap.
c. Potentially cooperative: Has the poten­
tial to cooperate, but because of the
inherent fears (subjective/objective) the
child does not cooperate.
2. Uncooperative (Negative behavior):
a. Uncontrolled/Hysterical/Incorrigible:
Usually seen in preschool children at
their first dental visit, temper tantrums,
loud crying and refuses to cooperate.
b. Defiant/Obstinate: This type can be seen
in any age group, usually in spoilt or
stubborn children. They can be made
cooperative.
c. Tense cooperative: These children are the
borderline between positive and neg­
ative behavior. Does not resist treatment
but the child is tensed at mind.
d. Timid/Shy: Usually seen in an over­pro­
tective child at the first visit, is shy but
cooperative.
Growth and Development 73
e. Whining type: Complaining type of
beha­v ior allows for treatment but
complains through-out the procedure.
f. Stoic: Seen in physically abused children.
They are cooperative and passively
accept all treatment without any facial
expression.
BEHAVIOR DEVELOPMENT
The basic mechanism of learning appears to
be essentially the same at all ages. As learning
proceeds, more complex skills and behaviors
appear, but it is difficult to define the process
in distinct stages—a continuous flow model
appears more appropriate.
BEHAVIOR MANAGEMENT
Behavior management is a continuum of
interaction with the child directed towards
communication and education in an endevor,
to allay anxiety and fear and to promote an
understanding of not only the need for good
dental health but also the process by which it
is achieved.
Behavior management is defined as the
means by which the dental team effectively
and efficiently perform dental treatment
and thereby instills a positive dental attitude
(Wright).
Behavior shaping is the procedure which
slowly develops behavior by reinforcing a
successive approximation of the desired
behavior until the desired behavior comes into
being.
Behavior modification is defined as the
attempt to alter human behavior and emotion
in a beneficial way and in accordance with the
lows of learning.
74 Essentials of Orthodontics
Figure 2.33: Psychologic influences on orthodontic
treatment demand
Behavior management is as much a clinical
skill as it is a science. It is not an application of
individual techniques created to “deal” with
children, but rather a comprehensive meth­o­
do­logy meant to develope relationship bet­ween
patient and doctor which ultimately builds trust
and allays fear and anxiety (Fig. 2.33).
Objectives of behavior management:
1. To render treatment effectively and effici­
ently.
2. To build a positive dental attitude in the
child.
Fundamentals of behavior management:
1. Positive approach.
2. Team attitude: The team should have
interest, friendly and caring attitude.
3. Organization: Effective planning without
delay or indecisiveness.
4. Truthfullness.
5. Tolerance: Rationally coping with child’s
behavior.
6. Flexibility: If necessary altering the treat­
ment plans wisely.
7. Try to explain the child in easy under­
standable language.
8. Before starting the treatment, let the
child be familiar with environment.
9. Talk about childs hobbies and interests
in the first visit.
10. Let the child talk to you, answer his
questions patiently.
Do not do the following:
1. Do not talk about childs siblings in first
appointment.
2. Do not expect a child to be troublesome
always.
3. Do not postpone treatment if child is not
cooperative. It may have negative rein­
forcement.
4. Do not use fear provoking words.
5. Do not be submissive or over sympathetic.
6. Do not go never below the level of child
such as baby talks.
Factors which affect child’s behavior in dental
office
1. Under the control of the dentist:
i. Dental clinic: Dental office should be
warm and simulate a homely environ­
ment. Healthy communication with
the child should be established. The
operating environment should be
made colorful and lively with posters,
TV and videogames and separate
wait­ing room for children, with kids
books, comics and magazines can be
made. Appointment time should be
short, early morning appointments are
preferable for younger children, they
should not be kept waiting for too long.
ii. Effect of dentist activity and attitudes: The
dentist should form a good impression
on the child. He should avoid jerky and
quick movements and should be fluent
in his works and actions.
iii. Presence or absence of parents in
the oper­a tory: This depends on the
behavior of the child, parent and dentist.
Mother presence is essential for a

preschool child, handi­capped child,
etc. An older child does not require
mothers’ presence because of emotional
independence of these children as they
grow older.
2. Out of control of the dentist:
i. Growth and development: If there is
deficiency in physical growth and
development or congenital malfor­
mations as awareness of the deformity
increases it leads to psycholo­g ical
trauma due to rejection by the society.
ii. Nutritional factors: Studies have shown
that an increased intake of sugar causes
irritable behavior, hypoglycemia causes
a criminal behavior, and skipping
breakfast can lead to impaired perfor­
mance.
iii. Past medical and dental experiences: Any
past unpleasant dental experience, prior
hospitalization, surgical intervention,
sickness, are associated with high
degree of uncooperative behavior.
iv. Genetics: Genes play important role in
psychological development.
v. School environment: In the school
teachers and peers help to influence
the behavior of the younger children.
Also seniors become rolemodels to the
juniors.
vi. Socioeconomic status: High socioeco­
nomic status child may show favorable
behavior, and lower socioeconomic
children are usually tensed and negle­
cted.
3. Under the control of parents:
i. Home environment: Home is the first
school child learns to behave.
ii. Family development and peer influence:
Position of the child, status of the child
in the family parental attitudes can
influence the childs behavior. Over
indulgence by parents can lead to a spoit
Growth and Development 75
behavior in the child who may show
sudden outbursts and temper tantrums.
Internal family conflicts affect children,
and can sense disharmony in the family
and this can emotionally frustrate the
child.
The main difference between treating an
adult patient and a child is treating a child
patient involves a 1:2 transaction as shown in
the orthodontic treatment triangle (Fig. 2.34).
The triangle indicates that:
1. The child is the focus of attention both for
dentist and parents.
2. The arrows show that the relationship
should be reciprocal.
3. The dentist has to communicate with the
child as well as the parents whereas in case
of adults, a direct communications (1:1) is
possible.
4. The corners cannot be observed to isolation,
hance the approach should be reciprocal.
Parental Influences on Child’s
Behavior
Both father and mother play an important
role in child’s psychological development; but
maternal influence is more important because,
i. Mother-child relationships are more
intimate.
ii. Maternal influence on child’s mental,
physical and emotional development
Figure 2.34: Orthodontic treatment triangle
76 Essentials of Orthodontics
begins even before birth. Mother’s nutri­
tional status, physical health, emotional
state may affect the fetus through
changes in mothers neurohumoral
systems.
Bell has termed parent-child relationship
as being “one tailed” where parent is an
independent variable and child is the depen­
dent one.
Parental influences on child’s behaviors are
effects of Parental attitudes: Parental attitudes
can be of the following nature:
Overprotection: Exaggeration of love and
affection. Factors responsible for overpro­
tection can be history of previous miscarriage,
period of sterility before the child’s birth.
Death of sibling, or if the mother cannot have
more children. Family’s financial condition.
Absence of either parent, and physical illness
or handicap in a child.
Overprotective parents take excess care
of their children past the usually. They do not
allow the children to any risks. They ‘infantize’
their children.
Overprotection can be of two types:
i. Dominating overprotection: The child
becomes submissive, timid and anxious;
however, they are usually cooperative
dental patient.
ii. Overindulgent overprotection: The chil­
dren become aggressive demanding
and produce temper tantrums. Such
children are difficult ones to manage in
dental office.
Overindulgence: Parents give children what­
ever they want without any restraint. The
child becomes spoiled and is accustomed by
getting his own way. The child’s emotional
development is impaired. In the dental clinic,
the children may show temper-burse when
they cannot control situations as they do at
home.
Underaffection: Underaffection may manifest
as mild detachment, indifference and neglect,
this can be due to other interests of parents
or if the parents are employed and have little
time and concern for the children, if child is
unwanted due to some reason. The children
are usually will behave; and indecisive. Though
they cry easily, they respond will when treated
with a little caution.
Rejection : The causes of rejection are
unwanted child, unstable, unhappy marriage,
birth of the child not anticipated, if child’s
presence interferes with parental careers or
ambitions and if mother herself is immature
or emotionally unstable. These children lack
the feeling of belonging. They are anxious,
aggressive, interactive, disobedient and
attention seekers.
Authoritarianism: Parents induce discipline
in the form of physical punishment or verbal
ridicule. They insist that the child should follow
a set of norms and extend much efforts and
train the child along their lines. The parents
are nonlove oriented.
The children are submissive with increased
avoidance gradient. They delay response and
exhibit evasive behavior.
Identification: Parents try to relive their lives
through their children. In doing so, they give
the children everything that had been denied to
them. If the children do not respond favorably,
parents display overt disappointment. The
children carry a sense of guilt which is mirrored
in shyness, retirement and unsurety. They are
generally good dental patients but need to be
handled with kindness and consideration.
Parental Anxiety
Children who respond with tension and fear
do so chiefely because of the way dental
experiences have been described at their
homes. The problem of dental fear is not

specific to dental situations or procedure.
The behavior of a child is found to be directly
proportional to the level of maternal anxiety.
Children of mothers with high anxiety levels
exhibit more negative and uncooperative
behavior.
BASIC APPROACHES TO CHILD
MANAGEMENT IN ORTHODONTICS
1.
Tender loving care and rapport
Consistently firm management
Positive reinforcement
↓
2.
Physical aids
Extra assistance
Tranquillizers and sedatives
↓ of puberty is paralleled by the development
3.
Combination of stronger premedications
General anesthesia
EPHEBODONTICS
Introduction
Ephebos is the Greek noun referring to a youth
entering manhood and from it is derived the
word ephebodontics, which encompasses
total dentistry for the individual undergoing
the transition from childhood to adulthood,
period of life known as adolescence.
The word adolescence is derived from the
Latin “adolescere”, which is composed of the
Latin words “ad” or to, and “olive” to grow, or
“olere” to nourish.
It is an inbetween age in our society
and needs to be understood as something
independent of either childhood/adulthood.
It is a time of enor­m ous transition and is
Growth and Development 77
certainly not of short duration. Hence, the term
teenager (13–19 yrs) has become synonymous
with the term adole­scence.
Ephebodontics/Adolescent dentistry is
the science of dentistry which deals with the
children who are in the process of growing up
from childhood to adulthood. Since most of the
orthodontic patients are of this age group their
psychological management forms an essential
part in clinical orthodontics.
Adolescence represents an extremely
important time in the dental care of the child
patient. Prevention of dental diseases is
certainly one of the pivotal concerns of the
orthodontist.
Physical Changes
Puberty is the landmark in physical
development when an individual becomes
capable of sexual reproduction. The advent
of genital tissues and secondary sexual
characteristics, such as the development
of hair in the areas of genitals. Increase in
muscle mass, redistribution of body fat and
an increase in the rate of skeletal growth
occurs. The growth spurts are associated with
the adolescence. It is important to realize also
that in females menarche serves as a signal
that growth is ending, but for males there is
no such marker.
In adolescence the nose and the chin
become more prominent, the face increases in
height and convex profile becomes straight. All
permanent teeth have erupted except for the
third molars.
Cognitive Changes
The adolescent continues his cognitive
development and by the middle to late
adolescence is capable of extremely sophisti­
cated intellectual tasks. High ability at
abstract thinking allows the adolescent to
78 Essentials of Orthodontics
deal with comples and difficult vocational
and educational challenges. The thoughts of
adolescents are introspective, analytical and
also egocentric.
Emotional and Social Changes
The very rapid dramatic changes that happen
to adolescents can be paralleled with many
emotional circumstances. Peers are important
social agents in large, adolescents who gets
also well with his peer group seems to relate
successfully with adults. Those who do not get
peer acceptance seem to have more problems
with adults and grow up to have a variety of
social and emotional difficulties.
Three subcategories of adolescents:
Early adolescent: Casting off the childhood role
and emergence into adolescence.
Middle adolescent: Participation in teenage
subculture and peer group identity.
Late adolescence: Emergence of adult behavior.
Role of Orthodontist
The orthodontist should have a knowledge of
the crucial psychosocial tasks to be mastered
that will provide a framework for understanding
the problems facing the young person. The
dentist acts as a parent surrogate and will
take on certain aspects of the parent for the
adolescent, as do the physician, and teacher.
The dentist must perceive his young patient
as a unique individual deserving respect and
capable of independent action. It is important
not to involve the parents unnecessarily in the
adolescents treatment to the point that he is
excluded from all participation.
He should be given as much responsibility
as possible for making his own appointments,
for discussing the nature of his treatment
and for carryingout, on his own, necessary
prophylactic and remedial procedures.
Educating the adolescent regarding the
importance of various procedures and the
necessity of adopting good oral hygiene
practices serve a significant aid in the success
of treatment.
CLINICAL IMPORTANCE OF
GROWTH AND DEVELOPMENT
IN ORTHODONTICS
In orthodontics skeletal growth is emphasized
more than other aspects of craniofacial
development, perhaps because the methods
for study were developed earlier. Knowledge
of skeletal morphology and growth is
routinely applied in craniofacial growth.
Craniofacial skeletal growth is very important
in orthodontics, since the variations in
craniofacial morphology are the source of
most serious malocclusions and clinical
changes of bony growth and morphology are
a fundamental basis of orthodontic treatment.
INFANCY AND EARLY CHILDHOOD
During this period rapid growth of the brain
case occurs which gets completed by the age
of 5 yrs, after which extraoral orthopedic forces
can be used to out advantage. Here the growth
of the face is faster in depth. Rapid growth is
exhibited during this period (4–6years). Growth
modifi­cation using functional appliances for
jaw discre­pancies should be successful at this
stage. Unfor­tunately, relapse occurs because
of continued growth in the original dispro-
portionate pattern due to a phenomenon
known as predominance of morphologic
pattern.
If children are treated very early, they
usually need further treatment during the
mixed dentition and again in the early
permanent dentition to maintain the
correction for this reason, except for the most
severe problems growth modification therapy

for skeletal discrepancies is best not attempted
until the preadolescent years when growth
modification results are more stable.
JUVENILE PERIOD
Studies of Woodside have shown a predom­
inant period of juvenile acceleration that
occurs 1–2 yrs before the adolescent growth
spurt, more particular in girls. Juvenile
acceleration can equal or exceed the jaw
growth that accompanies the secondary sexual
maturation. Careful assessment of physical
growth is clinically important. If the treatment
is delayed too long in girls we may miss this
juvenile spurt.
The preadolescent period is more effective,
for correction of skeletal discrepancies,
because the bones are less mineralized and
therefore more early deformed. Sutures and
ligaments are more cellular resulting in more
rapid biological responses, growing tissues are
generally more responsive to external forces
and best orthopedic results are obtained with
growth is more active. The juvenile period has
greater growth on the average at its beginning.
Substantiated by animal studies using both
functional orthopedics and extraoral forces,
McNamara, Stockl and Droschel showed that
significance craniofacial modification can be
effected in both adult and growing animals.
However, the magnitude and rate at which
these changes were achieved were greater in
younger age group.
In early maturing girls, the adolescent
growth spurt precedes the final transition of
the dentition and hence, if girls are to receive
orthodontic treatment it is best during the
mixed dentition rather that in the permanent
dentition.
In slow maturing boys, a considerable
amount of physical gorwth remains even after
Growth and Development 79
transaction of the dentition it is better to treat
girls earlier than boys.
ADOLESCENT GROWTH
Major events of dentofacial development,
overall facial growth and differential growth of
jaw occur during this period. It is an accepted
fact that all children begin to grow at puberty. It
is only that different children reach puberty at
different times, and as such chronological age
should not be a dictum to diagnose or predict
an individual for growth modification.
In boys, generally puberty begins later and
extends for a longer period which is 5 yrs in
boys as compared to 3½ yrs in girls.
The growth of the jaw correlates with the
general body growth. The cephalocaudal
gradient of growth is a pattern which mediates
that there is an increased growth extending
from the head forwards the feet. A classical
example is the fact that the mandible being
farther away from the brain, grows more and
for a longer time than maxilla. Hence the
convexity of the face reduces the chin becomes
more prominent as a result of differential jaw
growth.
During the adolescent growth spurt,
growth modification and definitive treatment
can be combined and the results are said to be
stable unlike the deciduous dentition period.
CLINICAL IMPLICATIONS OF
REGIONAL DEVELOPMENT
Cranial Vault
The growth of bones of calvaria utilizes future
system and relatively small surface deposits on
both the ectodermal and endodermal layers.
Since brain growth is largely completed in
early childhood, the cranial vault is one of
80 Essentials of Orthodontics
the first regions of the craniofacial skeleton to
achieve full size, by about 6 yrs. The principal
clinical issues are those seen with grossly
abnormal and anomalous growth (cranial
stenosis, hydro-cephaly, etc.). In almost every
serious instance the clinical problem reserves
surgical rather than orthodontic therapy.
Cranial Base
The cranial base not only supports and protects
the brain and spinal cord but also articulates
the skull with the vertebral column, maxilla
and mandible. One of the important functions
is as an adaptive or buffer zone better between
brain and face, whose growth are placed
differently. Growth of the basi cranium is
carried out by a balance among sutural growth,
elongation at synchondrosis and extensive
cortical drift and remodeling.
Growth of the cranial floor has a direct effect
on placement of the midface and mandible. As
the anterior cranial fossa and cranial floor
elongate, the underlying space occupied by the
enlarging nasomaxillary complex, pharynx and
ramus increase correspondingly. The spheno-
occipital complex elongates, displacing the
entire middle face anteriorly, producing an
enlar­gement of the pharyngeal region. Corres-
pondingly ramus enlarges as the mandible is
displaced anteriorly in conjunction with the
forward displacement of the maxilla.
The cranial fossa show reduced growth
with the completion of brain growth the
cranial synostosis are placed differently and
they continue to grow for extended period
of time usually till 25 yrs. The basi cranium
is considered as most stable of all portions
of craniofacial skeleton and least affected by
external influences. Neurocrania sputters
make a significant contribution to mandibular
regions. Treatment consists of alteration in
maxillary and mandi­bular growth of form and
tooth positioning.
Nasomaxillary Complex
Naxomaxillary complex provides important
functions as airway, and attachment of
maxillary dentition. The mechanisms for
growth in the nasomaxillary complex are
sutures, the nasal septum, periosteal and
endosteal surfaces and the alveolar processes.
Maxillary height increases because of sutural
growth towards the frontal and zygomatic
bones and oppositional growth in alveolar
process and maxillary tuberosity.
Maxilla grows in three planes of space of
which Width is completed first, Length (depth)
is completed second and Height is completed
finally.
Growth in width in both jaws completes
if at all, by adolescent growth spurt and is
affected minimally by adolescent growth
changes. Intercanine width does not increase
much after 12 yrs. In maxilla when the length
increases posteriorly the width in second
molar region also increase.
Growth in the length or both jaws continues
through the period of puberty. In girls in length
of jaws ceases 2–3 yrs after first menstruation
(13–15 yrs). In boys, the growth in length does
not decline until 18 yrs (4 years after attainment
of puberty)> Growth in vertical heights of the
jaws and face continues longer in both sexes
than growth in length maxillary growth is
adapted by compensating mechanisms,
when plate is narrow the alveolar process
compensates in both height and width. The
plane of occlusion is coordinated during
growth with the overall morphologic pattern,
alveolar bone deposition and resorption
compensating nicely for palatal displacement.
In skeletal deep bite, where gonial angle is
more nearly orthogonal the occlusal plane
is nearly parallel to the mandibular plane.
On the other hand when anterior face height
is dispro­portionately long, anterior alveolar
growth compensate and occlusal plane in

steep. Orthodontic treatment, irrespective
of the appliance, depends to a great extent
on the adaptive capacity of alveolar process
growth and remodeling when the clinician
can after as maxillary morphology and growth,
the sutural system adapts to posterior forces
(extraoral, cranial, and cervical traction)
anterior traction (face mask) and transverse
forces (lingual arching and RPE) variations in
maxillary growth and morphology may play
important role in some skeletal malocclusions,
e.g. Class II excessive midface growth, Class III
deficient midface growth the region is the site
of most common craniofacial anomaly cleft
lip and palate.
Mandible
Mandible the mobile bone of craniofacial
skeleton is important for mastication,
maintenance of airway, speech and facial
expression. Condylar cartilage is a major
site of growth. The growth movements of the
mandible are complimented by corresponding
changes occurring on maxilla muscle
attachment areas of the ramus plays an
important role in localized remodels and
cortical drift accompanying the downward and
forward mandible displacement. The alveolar
process development is controlled by dental
eruption when corpus growth is essentially
silver, vertical alveolar growth persist as the
occlusal surfaces wear; thus occlusal height
is maintained even in adulthood. Adaptive
remodeling of the process makes orthodontic
tooth movements possible.
Ramus height increase correlates with
length and overall mandibular length. Alveolar
process growth correlates with eruption
pattern of teeth. Bigonal and bicondylar width
increase are a function of growth in overall
mandibular length. It shows small increase
until the end of growth length. The most
important spend in mandibular growth is that
Growth and Development 81
related to puberty. It usually occurs before
peak height velocity almost all first pubertal
spurts occur after under sesamoid ossification
and before menarche.
The areas of muscle attachment and
the alveolar process are the most adaptive,
and hence variable, regions in mandible. In
extremes of facial types these regions shows
great morphologic variance (e.g. Shape of
coronoid the amount and placement of the
alveolar process, and the condylar angle are
greatly different on a skeletal open bite than
skeletal deep bite) maximal differences in
these regions are also seen between Class II
and Class III cases and in skeletal asymmetry.
Orthodontic appliances mostly take advantage
of the adaptive capacity of alveolar process as
it responds to tooth movements. Functional
appliances change the way that muscle
contractions shape the areas of attachment
and guide the eruption of teeth and hence the
shape of the alveolar process, repositioning of
the mandible with a functional appliance may
change the amounts and directions of growth
in the condylar region.
Variation in mandibular morphology and
size contributes more significantly to most
maloc­clusion that does maxillary variability;
mandible is more apt to be fault in both Class
II and Class III malocclusions. The principal
clinical issue in mandibular growth is the extent
to which clinician can alter mandibular morph­
ology. The work of Petrovich, McNamara, and
Carlsson particularly than previ­ously thought
their work provides theoretical framework
for understanding and planning control
of mandibular growth and their animal
experi­ments demonstrate the timing of such
possibilities and the maturational limitations.
Temporomandibular Joint
It is not fully known how temporomandibular
growth and adaptation vary with different
82 Essentials of Orthodontics
craniofacial types. Further there is the question
about the proper position of the condyle within
the fossa and whether or not slight variance in
condylar positioning affects changes in growth
amounts or directions, studies of altered
mandibular function or growing animals
clearly indicates that temporal portion of the
joint is responsive in concert with the condyle
and that maturation plays a similar role in the
duration and extent of the effects of altered
function of the temporomandibular joint.
Facial Growth in Adults
It was generally assumed that growth of
the facial skeleton ceased on late tens or
early twenties. Behrents in early 1980’s
recorded serial cephalograms of more than
100 adults and the results showed facial
growth had continued during adult life. There
was an increase in essentially all of the facial
dimensions but both size and shape of the
craniofacial complex altered with time. Vertical
changes in adult life were more prominent
that anteroposterior changes, whereas width
changes were least evident. Both jaw rotations
and surface changes continued, and shared
net forward rotation slightly decreasing the
mandibular plane angle. Behrents noted that
the pattern of growth associated with the
ori­ginal malocclusion continued to express
itself even in adult life. This finding is consistent
with previous observations of growth in the late
terms it also indicates how gradual worsening
of occlusal relationships could occur in some
patients long after completion of orthodontic
treatment.
Changes in facial soft tissue profile were
greater that changes in facial skeleton,
flattening of lips and augmentation of chin
region were prominent significant sexual
dimorphism exists men are larger at all ages,
they grow more, and their adult growth is
more apt to persist along the same vectors of
adolescent growth. Women shared periods
at increased rates of craniofacial growth,
apparently related to time of pregnan­cies. The
amounts of growth are not sufficient to serve
as a basis for practical adult orthopedist or
functional appliance therapy. The amounts
of growth are sufficient however to came
significant, to adaptations in mandibular
orientation and occlusal relations.
CONCLUSION
Clinical intervention into the growth process
and its control is by either one or two
approaches, both of which analogous to the
intrinsic growth are process itself. The first
approach is by surgical substitutions for the
natural displacement and remodeling process
that were incomplete or detailed. The second
approach is by covering intrinsic control
signals with clinical induced (Orthodontic)
signals that overwhelming the intrinsic
regulation of osteogenic, chondrogenic,
myogenic, neurogenic, and fibrogenic systems.
Then the same actual biologic operations from
these systems proceed, but now under control
revised directions. However in all cases, if
the same conditions that created the original
intrinsic signals still persist after treatment,
then architectonic rebound growth natural
adjusts back to the former balanced pattern.
Inter­estingly, these two forms of clinically inter­
vention are different. Orthodontic intervention
attempts to augment natural compensatory
changes to achieve and improved esthetic and
functional balance among facial components.
 CHAPTER
Occlusion and
3 Malocclusion
OCCLUSION
The study of occlusion is an important aspect
of dentistry. The study and practice of most
branches of dentistry should be based on a
strong foundation of the knowledge of occlusion.
Orthodontics is no exception to this as great
many changes, occur in the occlu­sion during
orthodontic therapy. The orthodontist should
know what constitutes normal occlusion in order
to be able to recognize abnormal condition.
Angle defined occlusion as the normal
relation of the occlusal inclined planes of
the teeth when the jaws are closed. This
definition is an oversimplification of what it
actually constitutes. Occlusion is a complex
phenomenon involving the teeth periodontal
ligament, the jaws, the temporomandibular
joint, muscles and the nervous system.
TERMINOLOGY
Occlusion (Oc-up, clusion-closing): The static
contact of upper and lower teeth.
Articulation: The dynamic movement of lower
jaw with teeth in contact or occlusion in
motion.
Ideal occlusion: It is a preconceived theoretical
concept of occlusal structural and functional
relationships that includes idealized principles
and characteristics.
Physiologic occlusion: This refers to an occlu­
sion that deviates in one or more ways from
ideal yet it is well-adapted to that parti­cular
environment, is esthetic and shows no path­
ologic manifestations or dysfunction.
Balanced occlusion: An occlusion in which,
balanced and equal contacts are maintained
throughout the entire arch during all excursions
of the mandible.
Functional occlusion: It is defined as arrange­
ment of teeth which will provide the highest
efficiency during all the excursive movements
of the mandible which are necessary during
function.
Therapeutic occlusion: Traumatic occlusion
that has been modified by appropriate
therapeutic modalities in order to change a
nonphysiologic occlusion to one that is at least
physiologic physiologic if not ideal.
Traumatic occlusion: Traumatic occlusion is
an abnormal occlusal stress which is capable
of producing or has produces an injury to the
periodontium.
84 Essentials of Orthodontics
Trauma from occlusion: It is defined as perio­
dontal tissue injury caused by occlusal forces
through abnormal occlusal contacts.
TYPES OF CUSPS
The human posterior teeth constitute two types
of cusps. They are the centric holding cusps
and the nonsupporting cusps.
Functional cusps (Centric holding cusps, stamp
cusps): The facial cusps of mandibular and
palatal cusps of maxillary posterior teeth are
called the centric holding cusps. They occlude
into the central fossa and marginal ridges of
opposing teeth.
Nonfunctional cusps (Nonsupporting cusps,
shearing cusps, guiding cusps): The maxillary
buccal and mandibular lingual cusps are called
nonsupporting cusps. They contact and guide
the mandible during lateral excursions and
shear food during mastication.
ARRANGEMENT OF TEETH IN
HUMANS
Human dentition exhibits three types of tooth
arrangement when the upper and lower teeth
occlude with one another. They are cusp-fossa,
cusp-embrasure and cusp-cusp occlusion.
Cusp fossa occlusion: In this type of occlusion,
the functional cusp of one tooth occludes
in a single fossa of a single opponent. The
upper functional cusp fit into all except the
mesial fossa of the lower teeth while the lower
functional cusps fit into all the upper fossa
except the distal ones of bicuspids. This kind
of arrangement where contacts occur between
single opposing teeth is called a cusp-fossa
occlusion or a tooth-to-tooth arrangement.
Cusp embrasure occlusion: Another type of
occlusion between the upper and lower teeth
is called the cusp embrasure or tooth to two
teeth occlusion. In this type of arrangement
each tooth occludes with two opposing teeth.
Cusp-to-cusp occlusion: In this type the upper
buccal cusp occludes with lower buccal cusps
and upper lingual cusp occludes with lower
lingual cusps.
IMAGINARY OCCLUSAL PLANES
AND CURVES
Curve of Spee
It refers to the anteroposterior curvature of the
occlusal surfaces beginning at the tip of the
lower cuspid and following the cusp tips of
the bicuspids and molars continuing as an arc
through the condyle. If the curve is extended,
it would form a circle of about 4 inch diameter.
The curve results from variations in axial
alignment of the lower teeth. The long axis of
each lower tooth is aligned nearly parallel to its
individual arc of closure around the condylar
axis. This requires a gradual progressive
increased mesial tilting of teeth towards molars
which creates the curve of Spee.
Curve of Wilson (Fig. 3.1)
This is a curve that contacts the buccal and
lingual cusp tips of the mandibular buccal
teeth. The curve of Wilson is mediolateral on
each side of the arch. It results from inward
Figure 3.1: Curve of Wilson

inclination of the lower posterior teeth. Curve
of Wilson helps in two ways:
Teeth are aligned parallel to the direction
of medial pterygoid for optimum resistance to
masticatory forces.
Elevated buccal cusps prevent food from
going past the occlusal table.
Curve of Monson (Fig. 3.2)
The curve of Monson is obtained by extending
the curve of Spee and curve of Wilson to all
cusps and incisal edges.
CENTRIC RELATION AND CENTRIC
OCCLUSION
Centric relation is the relation of the mandible
to the maxilla when the mandibular condyles
are in the most superior and retruded position
in their glenoid fossa with the articular disk
properly interposed. Centric relation is also
called ligamentous position or terminal hinge
Figure 3.2: Curve of Monson
Occlusion and Malocclusion 85
position. At centric relation with the condyles
are simultaneously seated most superiorly in
their glenoid fossa. In trying to 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 the
man­di­bular condyle when the teeth are in
maximum intercuspation. Centric occlusion is
also called intercuspal 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
studies have shown that majority of the
population have a maximum intercuspation
1 to 2 mm forward of centric.
Maximum intercuspation can also occur
without the condyles being in centric. This
is called maximum intercuspation, habitual
occlusion, or acquired occlusion.
CENTRIC CONTACTS
They are areas of the teeth that contact the
opposing teeth. Centric contacts have been
classified into posterior centric contacts and
anterior centric contacts.
Posterior Centric Contacts
The posterior centric contact consists of the
facial range of contacts and the lingual range
of contacts. Facial ranges of posterior centric
contacts involve the mandibular facial cusp
tips contacting the central fossa and mesial
marginal ridges of the opposing maxillary
teeth. Lingual range of posterior centric
contats involves the maxillary lingual cusp tips
contacting the central fossa and distal marginal
ridges of the opposing mandi­bular teeth.
86 Essentials of Orthodontics
Anterior Centric Contacts
Anterior teeth have only one range of centric
contacts and are in line with the facial range
of posterior centric contacts.
Posterior centric contacts result in axially
directed forces as convex cusp tip occlude on
an opposing tooth area that 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 an equal contact on
an opposing incline to resolve the forces in an
axial direction. It the contact occurs on two
inclines, the contact is termed bipodal contact.
Contacts that occur on three inclines are called
tripoded contacts. Contacts that occur on four
inclines are called quadrapoded contacts.
ECCENTRIC OCCLUSION
Eccentric occlusion refers to contact of
teeth that occurs during movement of the
mandible. Eccentric occlusion can be of two
types: functional occlusion and nonfunctional
occlusion.
Functional Occlusion (Working Side
Occlusion, Laterocclusion)
Functional occlusion refers to tooth contacts
that occur in the segment of the arch towards
which the mandible moves. It can be of two
types:
Lateral functional occlusion: It includes tooth
contacts that occur on canines and posterior
teeth on the side towards which the mandible
moves. The lateral functional occlusion can
be of two types:
i. Canine guided occlusion: During
lateral mandibular movement, the
opposing upper and lower canines
of the working side contact thereby
causing disocclusion of all posterior
teeth on the working and balancing
sides. Canine guided occlusion is
usually seen in young individuals with
unworn dentition. In a canine guided
occlusion, the mandibular canine cusp
tip tracks from the centric contact point
at the mesial marginal ridge towards the
cusp tip of the maxillary canine.
ii. Grouped lateral occlusion: In addition
to canine guidance, certain other post­
er­ior teeth on the working side also
contact during lateral movement of the
mandible. Such a type of contact during
lateral movement is called grouped
lateral occlusion.
Protrusive functional occlusion: It includes
eccentric contacts that occur when the
mandible moves forward. Ideally the six
mandibular anterior teeth contact along the
lingual inclines of the maxillary anterior teeth
while the posterior disocclude.
Nonfunctional Occlusion
(Mediocclusion)
They are tooth contacts that occur in the
segment away from which the mandible
moves. For example, if the mandible is moved
to the left side, contacts occur on right side of
the arch.
DISCLUSION
The term disclusion is used to describe diso­
cclusion or separation of nonfunctional
posterior teeth during eccentric motions of the
jaw. Disclusion of posterior teeth is brought
about by condylar guidance and incisal
guidance.
Condylar guidance refers to the downward
movement of both the condyles along the
slopes of the articular eminence during

protrusive movements leading to separation
of the posteriors. In case of lateral movements,
the condyle on the nonfunctioning side
translates forward along the eminence while
the condyle on the functioning side pivots in
its fossa leading to disocclusion of posteriors
on the nonfunctional side.
Anterior guidance refers to anterior
tooth functions which separate the posterior
teeth during eccentric motions of the jaw.
During protrusive and lateral movements
of the mandible, the lower anterior teeth
track downwards from their area of centric
contact towards the incisal edges of maxillary
teeth while disoccluding the nonfunctional
posterior teeth.
Condylar guidance has its greatest influence
on discluding the most distal posterior teeth,
while the incisal guidance provides discluding
effect on the more mesial teeth. The condylar
guidance is a fixed anatomic factor that cannot
be controlled by the dentist while the incisal
guidance can be controlled by modifying the
form and arrange­ment of the anterior teeth.
Normal and Ideal Occlusion
Normal occlusion occurs frequently in a
population, whereas ideal occlusion is a rarity.
Normal occlusion includes variations in tooth
positions and relationships that diverge in
minor ways from the ideal.
ANGLE’S CONCEPT OF NORMAL
OCCLUSION (FIG. 3.3)
Angle described normal occlusion as an evenly
placed row of teeth arranged in a graceful curve
with harmony between the upper and lower
arches. According to Angle, the key to normal
occlusion in adults is the anteroposterior
Occlusion and Malocclusion 87
Figure 3.3: Angle’s concept of normal occlusion
relationship between the upper and lower
first molars. Angle’s concept of normal occlu­
sion should include knowledge of the normal
relations of the occlusal surfaces of permanent
and primary teeth, their forms and structures,
and the growth and development of the teeth,
jaws, and muscles. Angle thought that the first
molars and canines were the most reliable
teeth. His description of first molar and
canine relationships in normal occlusion was
and remains a fundamental observation on
which dental and orthodontic diagnoses are
based. Angle stressed the importance of cuspal
interdigitation to the establishment of normal
occlusion during eruption of the teeth and to
the maintenance of good occlusion. Line of
Occlusion is a term used by Angle to describe
a normal arch relationship between the
upper and lower teeth. He stated that normal
occlusion of the teeth is maintained first by the
occlusal inclined planes of the cusps, second
by the support given by the harmony in size
of the upper and lower arches, and third by
the influence of the muscles labially, buccally,
and lingually. He concluded that these same
88 Essentials of Orthodontics
three factors are also powerful in maintaining
a malocclusion.
BEGG’S CONCEPT OF NORMAL
OCCLU­SION (ATTRITIONAL
OCCLUSION)
Begg’s concept of normal occlusion differs
greatly from that of Angle. Begg concluded
that the normal occlusion of tribal people is
the true normal occlusion of humans. The
dentitions of the rural Australian aboriginals
that he studied were characterized by a great
deal of attrition that produced in the majority
of adults an end-to-end incisor relation, mesial
placement of the mandibular arch form, and
occlusal and interproximal wear that reduced
the size of the teeth and reduced the incidence
of crowding. He referred to the relatively
unworn canine teeth of urban Europeans as
abnormal and the root of periodontal, caries,
and occlusal problems so prevalent in these
people. The interproximal tooth wear that
Begg saw in the skeletal remains of Australian
aborigines provided him with a rationale for
the extraction of teeth in urban Europeans who
had malocclusions. Begg’s tendency to extract
permanent teeth in the course of orthodontic
treatment contrasted greatly with Angle’s
determination to avoid the extraction of teeth
during treatment.
ROTH’S CONCEPT OF
FUNCTIONAL OCCLUSION
Ronald Roth discussed the role of functional
occlu­sion to be observed at the end of any
finished ortho­dontic case for good functional
result of occlusion.
The gnathological objectives are aimed
at harmonizing the occlusal morphology or
natural tooth positions with closure of the
mandible in centric relation, and with border
excursions of the mandible.
The first objective of a gnathological
occlusion is to obtain a stable centric relation
of the mandible and have the teeth intercusp
maximally at this mandibular position.
All centric stops should hit equally and
simultaneously and the stress of closure should
be directed, as nearly as possible, down the
long axes of the posterior teeth. There should
be no actual contact of the anterior teeth in
centric closure (.0005” clearance).
The second objective is to have a harmo­
nious glide path of anterior teeth working
against each other to separate or disclude the
posterior teeth immediately, but gently, as soon
as the mandible moves out of centric closure.
The glide path provided by the anterior teeth
must be in harmony with the way in which the
mandible moves through border excursions. If
there is immediate side-shift of the mandible,
there must be a concavity in the lingual surfaces
of the maxillary anterior teeth to accommodate
the side-shift movement, or the anterior teeth
will be stressed. There should be sufficient
overbite and overjet at the maxillary incisor
tips to allow for a gentle glide path.
The cuspids should be the main factor in
gliding inclines on lateral excursion and the
six maxillary anterior teeth should articulate
with the six mandibular anterior teeth and
the mandibular bicuspids (first bicuspid in
nonextraction cases), so that the protrusive
load is spread over 14 teeth.
In this way, a “mutually protective” occlusal
scheme is established, where the anterior teeth
protect the posterior teeth from lateral stress
during movement and the posterior teeth
protect the anterior teeth from lateral stress
during closure into centric relation occlusion.
The anterior teeth are subjected to a minimum
of stress during movements, only if a gentle

glide path is provided that is in harmony with
the manner in which the mandible moves.
Thus, in a mutually protective occlusal
scheme, the mandible can execute its total
range or envelope of motion without inter­
ference from the teeth. In turn, the teeth will
direct and maintain centricity of the condyles
in the fossae in closure. The teeth do not
prevent the mandible from entering or leaving
any possible position that the joints will allow.
Remember, the anterior teeth gently disclude
the posterior teeth. If the anterior teeth act
to “pry” the posterior teeth apart, then the
anterior teeth are in interference. An anterior
interference is just as bad as, if not worse
than, a posterior interference. Therefore, the
posterior occlusion must be organized in
harmony with mandibular movement, so that
very little lift is necessary to keep the posterior
teeth from colliding.
ANDREWS SIX KEYS TO
NORMAL OCCLUSION
Andrews during the 1970’s put forward the six
keys to normal occlusion after studying models
of 120 patients with ideal occlusion. Andrews
considered the presence of these features
essential to achieve an optimal occlusion. The
six keys to normal occlusion are considered
under the following headings:
Molar Interarch Relationship
The mesiobuccal cusp of the upper permanent
first molar should occlude in the mesiobuccal
groove of the lower first permanent molar.
The mesiolingual cusp of the upper first
molar should occlude in the central fossa
of lower first molar. The distobuccal cusp of
the maxillary first molar must occlude with
distobuccal groove of mandibular first molar.
Occlusion and Malocclusion 89
The crown of the upper first molar must be
angulated so that the distal marginal ridge
occludes with the mesial marginal ridge of
lower second molar. Premolars and canines
must occlude cusp to embrasure occlusion on
buccal side and cusp fossa occlusion on lingual
side. Incisors should be in Class I occlusion
and midlines should be coincident.
Mesiodistal Crown Angulations (Tip)
The second key makes use of a line that passes
along 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 part of the long axis of the crown
must be distal to the occlusal part of the
line. Different teeth exhibit different crown
angulations.
Labiolingual Crown Inclinations
(Torque) (Figs 3.4A and B)
The crown inclination is determined from a
mesial or distal view. If the gingival area of
the crown is more lingually placed than the
occlusal area, it is referred to as positive crown
A B
Figures 3.4A and B: Torque
90 Essentials of Orthodontics
inclination. In case the gingival area of the
crown is more labially or bucally placed than
the occlusal area it is referred to as negative
crown inclination.
The maxillary incisors exhibit a positive
crown inclination while the mandibular
incisors show a very mild negative crown
inclination. The maxillary and mandibular
posteriors have a negative crown inclination.
Absence of Rotations
Normal 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 contacts 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.
To these six keys Bennett and McLaughlin
had introduced Seventh key which is normal
tooth size ratio between upper and lower teeth.
CLASSIFICATION OF
MALOCCLUSION
MALOCCLUSION
Any deviation from ideal occlusion is termed
as Malocclusion (Guilford).
Orthodontics has been described as a
Science of infinite variations by Jackson. In
order to acquire a better understanding of
many deviations from normal occlusion it
becomes necessary to group the varieties of
malocclusion into order.
CLASSIFICATION
Classification is grouping of clinical cases
of similar appearance for ease in handling.
It is not a system of diagnosis or method
determining prognosis or a way of defining
treatment.
Occlusion is the end result of the interaction
of three systems namely:
• Dental system
• Skeletal system
• Neuromuscular system:
Any alteration in any one of the above
system can lead on to malocclusion. This
malocclusion can manifest at:
• Primary dentition
• Mixed dentition
• Permanent dentition.
Purpose of Classification
1. To identify the problem.
2. Recalling past difficulties with similar
cases.
3. Alter ourselves to possible strategies
and appliances that may be needed in
treatment.
4. Ease of reference.
5. For purpose of comparison.
6. Self-communication.
7. For better treatment planning.
When to Classify
Study the malocclusion.
Describe it in detail.
Then if possible, classify it.

Strang’s Steps for Proper
Classification
Study the cusp-fossa, ridge-groove relationship
of the teeth (Study models).
Study axial inclination of teeth especially
the canines (Study models).
Study the midline relations (Study models).
Look for any rotated posterior teeth (Study
models).
Examine for prematurely lost teeth,
extracted teeth or congenitally missing teeth
(Intraoral periapicals or orthopantogram).
Study the facial pictures from front and
side, or study the patient from front and side
(Facial photographs).
Interpret tracing from a standard lateral
skull X-rays (Lateral cephalogram).
TYPES OF MALOCCLUSION
Malocclusion can be broadly classified into,
Intraarch malocclusions: Individual teeth mal­
positions.
Interarch malocclusions: Malrelation of dental
arches to one another upon bony bases which
may themselves be normal.
Skeletal malocclusions: Malrelation of bony
bases.
Intra-arch Malocclusions
A tooth can be abnormally related to its
neighboring teeth, such abnormal variations
within an arch (either maxilla or mandible) are
called intraarch malocclusions.
Distal inclination or distal tipping: This refers
to a condition where the crown of the tooth is
tilted or inclined distally.
Mesial inclination or mesial tipping: This is a
condition where the crown of the tooth is tilted
or inclined mesially.
Occlusion and Malocclusion 91
Lingual inclination or lingual tipping: This is an
abnormal lingual or palatal tilting of the tooth.
This condition is also called retroclination.
Buccal inclination or buccal tipping: This refers
to labial or buccal tilting of the tooth. This
condition is also called proclination.
Mesial displacement: This refers to a tooth that
is bodily moved in a mesial direction towards
the midline.
Distal displacement: This refers to a tooth that
is bodily moved in a distal direction away from
the midline.
Lingual displacement: This is a condition
where the entire tooth is displaced in a lingual
direction.
Buccal displacement: This describes a condition
where the tooth is displaced bodily in a labial
or buccal direction.
Infraversion or infraocclusion: They refer to a
tooth that has not erupted enough compared
to the other teeth in the arch.
Supraversion or supraocclusion: This is a tooth
that has over erupted as compared to other
teeth in the arch.
Rotations: This term refers to tooth movements
around its long axis.
Distolingual or mesiobuccal rotation: This
describes a tooth which has moved around
its long axis so that the distal aspect is more
lingually placed.
Mesiolingual or distobuccal rotation: This is a
condition where the tooth has rotated around
its long axis so that the mesial aspect is more
lingually placed.
Transposition: This term describes a condition
where two teeth have exchanged places.
Interarch Malocclusion
These malocclusions are characterized by
abnormal relationship between two teeth
or groups of teeth of one arch to the other
92 Essentials of Orthodontics

arch. Interarch malocclusions occur only on

occlusion of upper and lower teeth, and intra­
arch malocclusions may or may not be present
in these cases. These interarch malocclusions
can occur in the sagittal, vertical, or in
transverse planes.

Sagittal Plane Malocclusions

Malocclusions that occur in anteroposterior
direction are called sagittal malocclusions.
Class II (Postnormal occlusion): This refers to a
condition where the lower arch is more distally
placed than upper arch when the patient bites
in centric occlusion.
Class III (Prenormal occlusion): This term
refers to a condition where lower arch is more
Figure 3.5: Scissors bite
forwardly or mesially placed than the upper
arch.
it can occur in single tooth or in group of teeth,
Vertical Plane Malocclusions and unilateral or bilateral (Fig. 3.5).
Malocclusions that occur in vertical direction Telescoping bite: The term denoting either a
are referred to as vertical malocclusions. complete mandibular lingual or complete
Deep bite or increased overbite: This refers to a maxillary buccal cross bite (Figs 3.6A and B).
condition where there is an excessive vertical The opposite of total mandibular buccal
overlap between the upper and lower anterior and maxillary lingual cross bite is called
teeth. Reverse Telescoping bite.
Open bite: This is a condition where there is no
vertical overlap between the upper and lower Nonocclusion (Figs 3.7A and B)
teeth. Thus a space may exist between the Any situation in which teeth do not have
upper and lower teeth when the patient bites maximal contact with their antagonists in
in centric occlusion. Open bite and occur in habitual occlusion. Nonocclusion may be
anterior or posterior teeth. caused by disturbances in tooth eruption (e.g.
ankylosis) or by factors that inhibit further
Transverse Plane Malocclusions eruption, such as digit-sucking or tongue inter­
The transverse plane interarch malocclusion
includes various types of cross bites and
scissors bites.
Posterior cross bite: Abnormal buccolingual
relation of upper and lower teeth, lower teeth
occludes buccal to upper teeth it may occur in
single tooth or group of teeth.
Scissors bite (X-occlusion): Lower teeth are fully A B
contained within the upper teeth in occlusion, Figures 3.6A and B: Telescoping bite

A B
Figures 3.7A and B: Nonocclusion
position. According to its localization, nono­
cclusion can be classified as anterior, posterior
or total nonocclusion.
Subterms
• Anterior nonocclusion
• Posterior nonocclusion
• Total nonocclusion.
Skeletal Malocclusions (Figs 3.8A to C)
They are malocclusions caused by defects
in maxilla or mandible; they can be due to
abnormalities in size, position or relationship
of jaws.
A B C He used Roman numerals I, II, III to
Figures 3.8A to C: Skeletal malocclusion
Occlusion and Malocclusion 93
Skeletal Class II: Skeletal Class II malocclusions
can occur either due to prognathic maxilla or
retrognathic mandible or combinations, where
lower jaw is placed more distal to upper jaw.
Skeletal Class III: Skeletal Class III malocclusions
can occur either due to retrognathic maxilla or
prognathic mandible or combinations, where
lower jaw is placed more mesial to upper jaw.
SYSTEMS OF CLASSIFICATION
History of Malocclusion
Classifications
Hippocrates included “Crooked teeth” in his 6th
book of epidemics as early as 24 centuries ago.
First person in modern times is Dr EH Angle,
who is considered as Father of Orthodontics
gave us the first classification of malocclusion
which is based on key to occlusion. Later
many classifications have been put forth; but
till today Angle’s classification is being used
widely because of its simplicity. Latest of all the
methods of classification is the Ackermann-
Proffit orthogonal analysis which is based on
Venn diagram (Table 3.1).
Angle’s Classification
Angle in 1898 presented his classification.
Angle’s classification is still in use because of
its simplicity in application.
Basis for Angle’s Classification
It is based on mesiodistal relationship of teeth,
and anterioposterior relationship.
According to Angle the maxillary first
perma­nent molar is the key to occlusion. He
considered these teeth as fixed anatomical
points within the jaws.
designate the three main classes. He employed
Arabic numerals 1, 2 to denote the divisions of
94 Essentials of Orthodontics

Table 3.1: Summary of qualitative methods of recording malocclusion

Angle (1899) Classification of molar relationship devised as a prescription for treatment.

Stallard (1932) The general dental status, including some malocclusion symptoms, was recorded. No definition of
the various symptoms was specified.
McCall (1944) Malocclusion symptoms recorded include: Molar relationship, posterior cross bite, anterior crowding,
rotated incisions, excessive over bite, open bite, labial or lingual version, tooth displacements,
constriction of arches.
No definition of these symptoms was specified.
Symptoms were recorded in an ‘all-or-none’ manner.
Sclare (1945) Specific malocclusion symptoms were recorded, which include Angle’s classification of molar
relationships, arch constriction with incisor crowding, arch constriction without incisor crowding,
superior protrusion with incisor crowding, superior protrusion with incisor crowding, superior
constriction without incisor crowding, labial prominence of canines, lingually placed incisors, rotated
incisors, cross bite, open bite, and close bite.
No definition of these symptoms was specified.
Symptoms were recorded in an ‘all-or-none’ manner.
Fisk (1960) Dental age was used for grouping patients.
Three planes of space were considered:
1. Anteroposterior relationship: Angle’s classification, anterior cross bite, overjet (mm), negative
overjet (mm).
2. Transverse relationship: Posterior cross bite (manually teeth biting buccally or lingually).
3. Vertical relationship: Open bite (mm), overbite (mm).
Additional measurements include labiolingual spread (Draker, 1960), spacing, therapeutic extrac­
tions, postnatal defects, congenital defects, mutilation, congenital absence, supernumerary teeth.
Björk, Krebs Objective registration of malocclusion symptoms based on detailed definitions. Data obtained
and Solow could be analyzed by computers.
(1964) Three parts:
1. Anomalies in the definition: Tooth anomalies, abnormal eruption, malignant of individual teeth.
2. Occlusal anomalies: Deviations in the positional relationship between the upper and lower dental
arches in the sagittal, vertical, and transverse planes.
3. Deviation in space conditions: Spacing or crowding.
Proffit and 5-step procedures of assessing malocclusion (no definite criteria for assessment was given):
Ackerman 1. Alignment: Ideal, crowding spacing multilated.
(1973) 2. Profile: Mandibular prominence, mandibular recession, lip profile relative to nose and chin (convex,
straight, concave).
3. Cross bite: Relationship of the dental arches in the transverse plane, as indicated by buccolingual
relationship of posterior teeth.
4. Angle classification: Relationship of the dental arches in the sagittal plane.
5. Bite depth: Relationship of the dental arches in the vertical plane, as indicated by the presence or absence
of anterior open bite, anterior deep bite, posterior open bite, and posterior collapse bite.
WHO/FDI Five major groups of items were recorded (with well-defined recording criteria):
(1979) 1. Gross anomalies.
2. Dentition: Absent teeth, supernumerary, malformed incisor, ectopic eruption.
3. Space conditions: Diastems, crowding, spacing.
4. Occlusion:
a. Incisal segment: Maxillary overjet, mandibular overjet, cross bite, over bite, open bite, midline
shift.
b. Lateral segment: Anteroposterior relation, open bite, posterior cross bite.
5. Orthodontic treatment need judged subjectively. Not necessary, doubtful necessary urgent.
Kinaan and Five features of occlusion measured:
Bruke (1981) 1. Overjet (mm).
2. Overbite (mm).
3. Posterior cross bite (number of teeth in cross bite, unilateral or bilateral).
4. Buccal segment crowding or spacing (mm).
5. Incisal segment alignment (classified as acceptable, crowded, spaced, displaced or ‘rotated’,
following defined criteria).

the classifications. Unilateral deviations were
termed as subdivisions.
Based on the above mentioned principles,
Angle classified malocclusion into the
following broad categories:
• Class I
• Class II
– Division 1
– Division 2
• Class III.
Class I Malocclusion (Fig. 3.9)
The lower dental arch is in normal relation
to the upper dental arch as evidenced by the
occlusion of the mesiobuccal cusp of upper
first permanent molar lies in the mesiobuccal
grooves of the lower first permanent molars.
This class includes cases of irregularity of
individual teeth such as crowding, spac­ing
rotations missing tooth, etc.Another maloc­
clusion common with Class I maloc­clusion
is bimaxillary proclination where dentition of
both upper and lower arch is forwardly placed
in relation to facial profile. Approximately 60 to
70 percent of cases fall into this class.
Class II Malocclusion
In Angle’s Class II malocclusion the distobuccal
cusps of upper first permanent molars
occluding in the mesiobuccal grooves of the
lower first permanent molar.
Figure 3.9: Class I malocclusion
Occlusion and Malocclusion 95
Figure 3.10: Class II division 1 malocclusion
There are two divisions of Class II mal­­-
o­cclusion:
Class II division 1: The Class II division 1
malocclusion is characterized by Class II molar
relation and proclined upper incisors with a
resultant increased overjet (Fig. 3.10).
Class II division 2: The Class II division 2
malocclusion is characterized by Class II molar
relation and retroclined upper central incisors
and the lateral incisors overlap the central
incisors (Fig. 3.11).
Class II Subdivisions
When a Class II molar relation exist on one side
and a Class I relation on the other, it is referred
to as Class II subdivision. Based on whether
it is a division 1 or division 2, it can be called
as Class II division 1 subdivision, or Class II
division 2 subdivision.
Figure 3.11: Class II division 2 malocclusion
96 Essentials of Orthodontics
Figure 3.12: Class III malocclusion
Class III Malocclusion (Fig. 3.12)
The Class III molar relation is characterized
by mesio-buccal cusp of the maxillary first
permanent molar occluding in the interdental
space between the mandibular first and
second molars, the lower first permanent
molar lies mesial to upper first permanent
molar by a premolar width or cuspal width.
Class III Subdivision
This is a condition characterized by a Class III
molar relation on one side and a Class I relation
on the other side.
Class IV
This condition is characterized by Class II
molar relation on one side and Class III molar
relation on the other side (Not commonly
used).
Drawbacks of Angle’s Classification
Although Angle’s classification has been used
for almost a hundred years it still has a number
of drawbacks that include:
1. The first permanent molars are not fixed
points in the skull anatomy.
2. Does not differentiate between skeletal
and dental malocclusions.
3. It does not consider the skeletal bases.
4. Considers malocclusion only in antero­
posterior plane.
5. Vertical and transverse plane malposi­
tions are not considered.
6. Does not consider individual tooth
malpositions.
7. When first permanent molars are
extracted this classification cannot be
applied.
8. Cannot be applied to deciduous denti­
tion.
9. Severity of malocclusion is not known.
10. Does not differentiate between true and
pseudo Class III malocclusion.
11. Does not consider the etiology of malo­
cclusion.
In spite of all the above mentioned draw­
backs Angle’s classification is still widely used
because of its simplicity, easy to use, and easy
to communicate.
Lischer’s Classification
Lischer modified Angle’s classification and
introduced the following terms which are
widely used to describe the varieties of
malocclusion.
Neutro-occlusion: Normal relation of dental
arc­h es. Synonymous with Angle’s Class I
malocclusion.
Disto-occlusion: Distal relation of mandible
with maxilla. Synonymous with Angle’s Class
II malocclusion.
Mesio-occlusion: Mesial relation of mandible
with maxilla. Synonymous with Angle’s Class
III malocclusion.
In addition to above classification he used
cer­tain terms for individual tooth malposi­tions:
Bucco-occlusion: Buccal placement of a tooth
or a group of teeth.
Linguo-occlusion: Lingual placement of a tooth
or a group of teeth.
Supraocclusion: When a tooth or group of teeth
have erupted beyond normal level.

Infraocclusion: When a tooth or group of teeth
have not erupted to normal level.
Lischer gives the suffix ‘version’ to describe
the wrong position of individual teeth as
follows:
Mesioversion: Mesial to normal position.
Distoversion: Distal to normal position.
Transiversion: Transposition of two teeth.
Axiversion: Abnormal axial inclination of a
tooth.
Torsiversion: Rotation of a tooth around its
long axis.
Perversion: Impacted tooth.
Dewey’s Classification
(Dewey-Anderson’s Modification)
Dewey proposed a modification of the Angle’s
classification of malocclusion. He divided
Angle’s Class I into five types and Angle’s Class
III into three types.
Class I Modifications of Dewey
Type 1: Crowded or bunched incisors.
Type 2: Proclined maxillary incisors.
Type 3: Anterior cross bite.
Type 4: Posterior cross bite.
Type 5: Permanent molars have drifted
mesi­ally due to early loss of tooth anterior
to first molars; all other teeth are in normal
relationship.
No modifications for Angle’s Class II malo­
cclusion.
Class III Modifications of Dewey
Type 1: Normal incisal overlapping present.
Type 2: Edge-to-edge incisor relationship.
Type 3: Incisors are in cross bite.
Simon’s Classification
Simon had put forward a craniometric classifi­
cation of malocclusion that related the den­
tal arches in all the three planes. Simon’s
Occlusion and Malocclusion 97
system of classification made use of three
anthropometric planes namely, Frankfort
hori­zontal plane (FHP), median sagittal plane,
and orbital plane, these three planes are
perpendicular to each other. The classifications
of malocclusion were based on abnormal
deviations of the dental arches from their
normal position in relation to these three
planes.
Frankfort Horizontal Plane
This is a plane that connects the upper
margin of the external auditory meatus to
the infraorbital margin. This plane is used
to classify malocclusion in a vertical plane.
According to this plane.
Attraction = Teeth are placed close to this
plane.
Abstraction = Teeth are placed away from
this plane.
Median Sagittal Plane
This is perpendicular to Frankfort horizontal
plane. Two points on median palatine raphae
is placed to derive at this midsagittal plane.
This will explain the transverse anomalies.
Accor­dingly,
Contraction = Teeth are placed closer to
this plane.
Distraction = Teeth are placed away from
this plane.
Orbital Plane
A perpendicular plane dropped at right
angles to the Frankfort horizontal plane from
the lowermost border of the bony orbit is
the orbital plane. This plane will explain the
anteroposterior relation­ship. Accordingly,
Protraction = Teeth are placed forward to
this plane.
Retraction = Teeth are placed backward to
this plane.
98 Essentials of Orthodontics
Simon placed emphasis on the fact that the
orbital plane passes through maxillary cuspid
region in high percentage of cases in normal
occlusion. This finding was termed as Simon’s
Law of Cuspid.
Drawbacks of Simon’s Classification
• Maxillary cuspid does not coincide with
orbital plane.
• Confusing.
Bennett’s Classification
Norman Bennett classified 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
defects of bone.
Class III: Abnormal relationship between
upper and lower arches, and between both arch
and facial contour and correlated abnormal
formation of either arch.
Ballard’s Classification
It is a classification used to know the various
skeletal relationships. It is used more accurately
at the chairside. According to this the different
skeletal classes are:
Skeletal Class I: The inclination of the teeth is
normal and the dental base relationship is also
normal. The upward projections of the axis
of the lower incisors would pass through the
crowns of the upper incisors.
Skeletal Class II: The lower apical base is
relatively too far back. The lower incisor axis
would pass palatally to the upper incisor
crowns.
Skeletal Class III: The lower apical base
is placed relatively too far forward, the
projections of the lower incisor axis would pass
labially to upper incisor crowns.
Assumptions made in this classification:
Inclinations of the incisor teeth within each
arch are normal.
If this is not so, then dental correction of
the incisor inclinations are made such that the
lower central will make an angle of about 90o
with the mandibular plane and upper centrals
an angle of 110o to the Frankfort plane.
Incisor Classification: British
Standard Classification of Incisor
Relationship
(Fig. 3.13)
Incisor classification is based on the
relationship of upper and lower incisors and
they can be used when the permanent first
molars are missing.
Class I: The lower incisor edges occlude with
or lie immediately below the lingual plateau of
the upper central incisors.
Class II: The lower incisor edges lie posterior
to the cingulum plateau of the upper incisors.
Division 1: The upper central incisors are
proclined or of average inclination and there
is increase in overjet.
Division 2: The upper central incisors are
retroclined and there is increased overbite.
Figure 3.13: Incisor classification

Class III: The lower incisor edges lie anterior
to the cingulum plateau of the upper incisors.
The overjet is reduced and there may be
anterior cross bite.
Canine Classification
Canine classification is based on the relation­
ship of upper and lower permanent canines,
and they can be used when the permanent first
molars are missing.
Class I: The mesial slope of the upper perm­
anent canines overlaps the distal slope of the
lower permanent canines.
Class II: The distal slope of the upper perma­
nent canines overlaps the mesial slope of the
lower permanent canines.
Class III: The lower permanent canines are
ahead of the upper permanent canines.
Ackerman-proffit Classification
Ackerman and Proffit in 1960 proposed a
diagrammatic classification of malocclusion
to overcome the limitations of the Angle’s
classification. It is based on venn diagrams.
Salient features of this classification include:
Anteroposterior, vertical and transverse
malocclusions can be classified.
Crowding and arch symmetry can be evalu­
ated.
Incisor Protrusion is taken into Account
This classification has 9 groups as shown, since
the degree of alignment and symmetry are
common to all dentitions this is represented
as the outer envelope or universe (Group 1).
The profile is affected by many malocclusions,
so it becomes a major set within the universe
(Group 2). Deviations in three planes are
represented by groups 3 to 9 which include the
overlapping or interlocking sub-sets, all within
profile or Group 2 set.
Occlusion and Malocclusion 99
Nine Categories of the Ackerman and
Proffit Diagram
1. Alignment: (Crowding, spacing)
2. Profile: (Convex, straight, concave)
3. Transverse deviation: (Cross bites)
4. Sagittal deviation: (Angle’s class)
5. Vertical deviation: (Deep bite, open bite)
6. Transsagittal deviation: (Combination of
cross bite and angle class)
7. Sagittovertical deviation: (Combination of
angle class and deep bite or open bite)
8. Verticotransverse deviation: (Combination
of deep bite or open bite with cross bite)
9. Transsagittovertical deviation: (Combin­
ation of problems in three planes of space
(Fig. 3.14).
Method of Classification
Step 1 (Alignment): The first step involves
assessment of the alignment and symmetry
of the dental arch. It is classified as ideal/
crowded/spaced.
Step 2 (Profile): It involves the consideration of
the profile. The profile is described as convex/
straight/concave. The facial divergence is also
considered, anterior/posterior divergence.
Step 3 (Type): The transverse skeletal and
dental relationship is evaluated. Buccal and
palatal cross bites if any are noted. The cross
bite is further sub- divided as unilateral or
bilateral. In addition, differentiation is made
between skeletal and dental cross bite.
Step 4 (Class): This involves the assessment
of the sagittal relationship. It is classified as
Angle’s Class I/Class II/Class III malocclusion.
Differentiation is made between skeletal and
dental malocclusions.
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
100 Essentials of Orthodontics
Figure 3.14: Ackerman-Proffit classification
made whether the malocclusion is skeletal or
dental.
Katz Classification
According to Katz (1992)
Class I: An exact fit between the mid-cusp of
the most anterior upper premolar and the
embrasure created by the distal contact of
the most anterior lower premolar. This ideal
relationship has been designated by Katz as ‘0’,
while a (+) sign indicates a Class II tendency
and (–) sign denotes Class III tendency.
The same rules are applicable to the first
deciduous molar in deciduous dentition
or mixed dentition. Each side is evaluated
separately.
McCallins Classification of Class III
Group I: Cases with retruded maxilla, progn­
athic mandible with high FMA, excessive lower
anterior facial height and open bite.
Group II: Both maxilla and mandible are
protrusive with true mandibular prognathism
and average FMA.

Group III: Pseudo class III malocclusion on a
mild skeletal class III pattern.
EPIDEMIOLOGY OF
MALOCCLUSION
Epidemiology is the study of the distribution
(pattern) and determinants (factors) of health-
related states or events in a specified human
population and the application of study
findings to control health problems. Disease
does not occur at random in the population,
but rather subgroups differ in the frequency
of disease. Traditionally, epidemiology was a
science that dealt with the study of infectious
diseases, but now it is applicable to the study
of chronic diseases as well. The principles of
epidemiology are applicable to both medicine
and dentistry. In medicine and certain dental
diseases, such as periodontitis and dental
caries, one can distinguish individuals as
having or not having the disease. However,
malocclusion is not considered to be a disease
and is difficult to define. Recently developed
occlusal indices (Peer Assessment Rating,
Index of Treatment Need) may be used to
estimate some aspects of malocclusion that
are based on occlusal characteristics.
However, the subjective nature of facial
esthetics poses a unique challenge in
orthodontic research. To the extent that
orthodontic outcomes can be measured, the
principles of epidemiology can be applied to
the conduct of valid and reliable research.
Many organized population surveys have
been carried out in different parts of the world
with the objective of estimating prevalence
of malocclusion and orthodontic treatment
needs. Prevalence of malocclusion is estimated
to be higher in developed countries as
compared to developing and under developed
countries.
Occlusion and Malocclusion 101
Indians exhibit a low incidence of variation
in molar relation both in the mesial and
distal direction. Distoocclusion in India is
very low in contrast to USA (34% in Whites
and 15% in Blacks) and Europe 29 percent.
However, Indians have more tendencies for
Class II malocclusion than Africans (4.26% in
Nigeria). Class III malocclusion is also much
less prevalent in India compared to USA,
Netherlands, and Kenya.
A number of studies have been conducted
to determine the prevalence of malocclusion
among Indian children. The prevalence of
malocclusion among Indian children has been
reported to be as low as 19.6 percent in Madras
by Miglani DC et al in 1965 and as high as 90
percent in Delhi by Sidhu SS in 1968.
APPLICATIONS OF
EPIDE­MIO­LOGICAL-PRINCIPLES
1. To describe normal biological processes:
Usually, data collected for these purposes
use a population of healthy individuals to
establish a standard for normal biological
processes.
Orthodontic examples include the longi­
tud­inal craniofacial growth studies, such
as the Bolton Collection, the Michigan
high school study, and the Burlington
Collection.
2. To understand the natural history of disease:
Data on populations of diseased individuals
provide clues for distinguishing diseases
that are potentially fatal from disabling
ones that will resolve satisfactorily.
3. To measure the distribution of diseases in
populations: Surveys are usually conducted
to measure disease prevalence.
4. To identify the cause or the determinants of
disease: There are specific study designs that
102 Essentials of Orthodontics
can be used to determine the risk factors
associated with a disease. Identification of
such causal or noncausal relationships can
lead to intervention strategies that prevent
or control the disease.
5. To plan and evaluate health care services:
Data collected for these purposes are used
to describe and evaluate the population’s
utilization of health care services and assist
in planning for services and personnel.
STUDY DESIGNS
Epidemiological studies often begin with
descriptive data and then proceed to analytic
studies (observational and experimental).
Descriptive studies are useful for describing the
characteristics of an outcome and generating
a hypothesis for future analytic studies.
However, this type of study is not useful to
establish associations or causal inferences
regarding an exposure (usually a risk factor or
any other factor responsible for the outcome)
and outcome (usually disease or death,
prevention of disease, treatment of disease,
change in quality of life). Conversely, analytic
studies are useful for drawing inferences
about an exposure-outcome association.
Analytic studies are helpful for studying
cause, treatment, prognosis, prevention, and
health services evaluation. An important
distinction between the two types of study is
that for descriptive studies, an appropriate
comparison or control group is not necessary
for description, whereas for analytic studies,
an appropriate comparison or control group is
absolutely essential for testing the hypothesis.
Descriptive Studies
The three types of descriptive studies are as
follows:
1. Correlational studies use population-based
data to compare disease frequencies.
2. Case reports and case series are useful
for describing unusual occurrences in
individuals or groups of individuals. For
example, several orthognathic surgery
cases with severe condylar resorption
leading to posttreatment open bite might
alert the clinician to investigate the reason
for this occurrence.
3. Cross-sectional surveys are useful for
assessing exposure and outcome at a
single point in time. Such surveys require
selecting a representative sample of
individuals from a population.
Analytic Studies
Analytic studies can be further divided into
observational and interventional (experi­
mental).
Observational studies are those in which
individuals are observed as far as exposure
is concerned, and the investigator has no
control over the assignment of exposure. In
orthodontic studies, treatment strategy (e.g.
extraction— nonextraction or single-phase—
two-phase) or methods (e.g. Begg–Tweed)
are usually the exposures of interest that are
investigated. Interventional or experimental
studies are those in which exposure is assigned
by the investigator, and individuals are
followed up longitudinally.
Analytic observational studies: These can be
further subdivided based on the manner in
which subjects are recruited.
1. Cross-sectional studies under the analytic
design require a comparison or control
group in which exposure and outcome
are assessed at a single point in time. For
example, determining the root resorption
rate (outcome) at a given point in time in
a sample of subjects who either did or did

not wear high-pull headgear (exposure) to
the upper incisors.
2. Case-control studies are retrospective
studies in which the history of past and
current exposure factors is evaluated in
individuals with and without outcome.
An example would be a sample of subjects
recruited based on having or not having
root resorption, and then an inquiry made
regarding the type and duration of their
orthodontic treatment.
3. Traditional epidemiological cohort
studies are prospective (longitudinal)
investigations in which subjects are
recruited based on the presence or absence
of exposure and then followed-up overtime
to evaluate the development of outcome.
At the start of the study, the subjects
should be free of the outcome; thus,
only new occurrences of the outcome
during the follow-up period are counted.
In orthodontic research, retrospective
cohort studies are often conducted. These
use existing treatment records but apply
the principles of cohort design. Because
of the extended time associated with
orthodontic treatment, retrospective study
designs often provide more timely data
that can be used to aid clinicians in the
decision-making process. The orthodontic
literature contains excellent examples of
well-designed retrospective cohort studies
of Class II treatment alternatives.
Analytic interventional studies. Interventional
or experimental (clinical trials) studies are
a form of longitudinal investigation, in
that the investigator has control over the
assignment of exposure and then follows-up
the individuals overtime for the development
of outcome. Randomization (the random
assignment of exposure) is often used to
ensure that every subject has the same
Occlusion and Malocclusion 103
probability of receiving exposure. For example,
to examine the effectiveness of early treatment
for Class II mandibular retrognathia, the
investigator randomly assigns patients to
competing therapies. Some are assigned to
early orthopedic treatment with a bionator,
followed by a second phase of fixed appliance
treatment, and a second group is treated in one
phase with fixed appliances in the permanent
dentition. The groups are then followed-up
overtime to evaluate their response to the
treatment. Inherent in this design is the
potential for all subjects to have the same
probability of receiving either treatment.
Investigations that use animal models
usually use the experimental design. The
hierarchy of epidemiological investigations
starts with descriptive studies, proceeds
to observational analytic studies, and
concludes with experimental analytic studies.
Each research level offers advantages and
disadvantages in time, effort, and the ability
to prove a causal relationship. Using this
utilitarian approach minimizes research time
and maximizes the probability of obtaining
clinically meaningful results.
Sampling
To investigate an exposure-outcome
association, a study design appropriate to the
testing of the hypothesis must be chosen. Next,
a sample or population must be selected to
study the problem under question. There is a
distinction between a sample and a population.
The study sample is usually a collection of
individuals who have been selected from
a target population of interest. The target
population is the collection of individuals of
restricted interest from which one has sampled
and about which one wishes to make statistical
inferences with regard to the study objective.
There is also another kind of population to
104 Essentials of Orthodontics
consider, the external population. The external
population is the collection of all individuals to
whom the study results could be applied. If an
investigator wishes to conduct a case-control
study of the association between treatment
duration and root resorption, the selection of
subjects is based on the presence or absence
of root resorption. Investigator usually selects
a representative sample from the target
population of interest and hopes that the study
results will be applicable to at least the target
population. A representative sample can be
selected using a random sampling process.
There are different methods for selecting
random samples. The most commonly used
methods are simple random sampling and
stratified random sampling. Simple random
sampling uses a table of random numbers
to select a sample. If there is concern that a
certain segment of the population might be
under-represented or over-represented, then
stratified random sampling is sometimes
used. Stratification is a simple process in
which the population is divided into groups
or strata. Other methods of choosing a
representative sample include systematic and
cluster sampling. Systematic sampling is based
on selecting every rth (r determined by a ratio)
individual from a list or file after choosing a
random number from one to r as a starting
point. Cluster sampling is often performed in
population-based studies in which clusters
(e.g. families, schools, hospitals) are chosen,
and random sampling within clusters is
performed to ensure representativeness.
The four sampling methods (simple random
sampling, stratified random sampling,
systematic sampling and cluster sampling)
are called probability sampling because
every member in the population has an equal
chance of being included in the sample. For
other researchers to replicate the sample, the
method of random sample selection must be
clearly documented. Here lies the problem
of choosing a nonprobability sample or a
convenient sample using methods such as coin
flips, volunteers, patients who have already
been treated, and so on. These methods result
in a biased sample. This bias can sometimes
limit the inferences that can be made regarding
the population. Selection bias occurs in
orthodontic studies when investigators use
success of treatment as an inclusion criterion.
BIAS IN RESEARCH
Validity and reliability are two terms that
epidemiologists often use in research.
Validity refers to the accuracy, with which
a measurement is representative of the
true value, i.e. does the value accurately
reflect what it is supposed to bemeasuring.
Reliability refers to the precision with which
a measurement is reproducible within the
same observer or between different observers,
i.e. can one get the same value two times
when measured twice. Systematic error and
random error affect validity and reliability,
respectively. Systematic error (bias) can be
decreased or eliminated by following sound
research principles (calibration and blinding
of observers, standardization of procedures,
selecting a large and representative sample,
and so on). Validity is affected by systematic
error. In contrast, random error usually arises
because of chance and has an influence
on reliability. Of the two errors, systematic
error is more harmful than random error.
However, random error can be a problem when
studying associations between an exposure
and outcome. The extent of the association is
usually underestimated because of random
error. Although random error can be reduced

by increasing sample size, systematic error
can only be decreased by careful designing of
methods and procedures.
In orthodontics, cephalometric studies
provide examples of random and systematic
error. When an investigator accurately locates
the landmark nasion, there is good validity.
When an investigator is consistent in the
identification of the landmark nasion, i.e.
repeats the process and pinpoints the same
spot each time, there is good reliability.
Validity is affected by systematic error. For
example, when the investigator is not properly
trained or calibrated in the identification of
cephalometric landmarks and mistakenly
identifies the frontal sinus as nasion, this
results in a systematic error. In contrast,
random error influences reliability. Poor
lighting or background noise can cause an
investigator to be imprecise. Chance factors
(random errors) should be estimated for all
studies by repeating the process for at least 10
percent of the subjects.
Systematic error can seriously jeopardize
the validity of research findings, i.e. one may
find a positive association when none exists or
a negative association when one really exists.
In this context, systematic error is sometimes
referred to as analytic bias and can be divided
into four types.
First, sample distortion bias, such as non­
representativeness of the sample, inappro­
priate selection procedures, or dropouts
in the case of longitudinal studies, can
affect the validity of the association. These
errors can be minimized by selecting a
representative random sample, applying
stringent selection criteria and maximizing
participation (monetary or clinical benefits).
Second, measurement bias, such as
errors in the measurement of exposure and
Occlusion and Malocclusion 105
outcome, can lead to spurious conclusions.
It is essential to minimize these errors by
calibrating observers with standardized or
pretested protocols, and, if possible, blinding
the observers to the status of the subject.
Third, confounding bias is present when the
estimated association between exposure and
outcome is distorted by one or more extraneous
variables. These extraneous variables have the
potential for altering study results if they are
not considered. A form of confounding bias
is susceptibility bias. Orthodontic studies of
extraction versus nonextraction treatment
often show susceptibility bias because patients
with crowded teeth are more susceptible to
extraction treatment.
A statistical technique that eliminates
susceptibility bias in retrospective cohort
studies has been developed. In the design of
research, randomization, stringent selection
criteria, matching (a process by which an
experimental subject is matched on a one-to-
one basis with a control subject based on the
confounding factor), and blinding of observers
can be used to reduce bias.
Fourth, reverse causality bias can affect
validity when one is not sure of the sequence
of causation, i.e. whether exposure preceded
outcome or outcome preceded exposure. An
investigator can be confident of an association
only if exposure precedes outcome. This bias is
a problem with cross-sectional studies because
exposure and outcome are determined at a
single point in time. In studying craniofacial risk-
factors for obstructive sleep apnea syndrome,
a lowered hyoid bone position has been a
significant factor in cross-sectional studies.
It is not clear at the present time whether the
lowered hyoid bone position is a response to a
compromised airway or if it is a predisposing risk
factor for apnea manifested from childhood.
106 Essentials of Orthodontics
In summary, validity can be achieved by
decreasing systematic bias, and reliability can
be improved by increasing the sample size.
Internal and External Validity
These terms apply to the validity of the
inference as it applies to the population from
which the sample is derived. A study has
good internal validity if the sample results
can be applied to the target population of
interest. A study has good external validity if
the sample results can also be applicable to
the external population of interest. External
validity is dependent on internal validity, but
can be difficult to evaluate. Most research
studies would aim for good internal validity
by minimizing the extent of systematic bias.
One also has to remember that it is difficult to
eliminate all forms of bias because the study
of humans is complicated and subject to great
variation. An appropriate study design, proper
sampling technique, and minimization of bias
will lend itself to collecting good quality data.
Once data are collected, appropriate statistical
analyses must be performed to reach the
correct conclusions regarding the association
between exposure and outcome.
STATISTICS MEASUREMENT
OF DATA
Data collected for research are usually meas­
ured as either continuous or categorical.
Continuous data are quantitative data mea­
sured on a mathematical scale. Examples
include age, height, weight, cephalometric
variables, and so on. Categorical data are
qualitative data placed in categories and
assigned numerical values. Examples include
dichotomous variables such as men/women,
yes/no answers, and so on; nominal (having no
ordered relationship to each other) variables,
such as ethnicity, hair color, and so on; and
ordinal (having an ordered relationship to
each other) variables, such as scales of pain,
stress, esthetic appearance, are measured
on an ordinal-type scale. There are powerful
statistical tests to analyze continuous data,
but less so for categorical data. It is essential to
know the measurement scale because different
statistical tests are used for continuous and
for categorical data. With continuous data,
it is possible to calculate mean, median and
standard deviation. With categorical data, it is
possible to calculate frequency or proportion.
In descriptive studies, data are usually
described using means, standard deviations,
and frequencies. Table 3.2 shows the common
statistical tests that can be applied depending
on the type of exposure and outcome measures
used.
HYPOTHESIS TESTING
Analytic studies require the testing of a
hypothesis to make the correct inference.
There are four stages in the execution of an
analytic study.
The first is the statement of null and
alternate (research) hypotheses. The null
Table 3.2: Commonly used statistical tests according
to the measure of exposure and outcome
Exposure Outcome Statistical test
Categorical Continuous Test, ANOVA
Categorical Categorical Chi-square
Continuous Continuous Correlation,
linear
regression
Continuous Categorical Logistic
regression
Abbreviations: ANOVA—Analysis of variance

hypothesis is usually stated as “exposure is not
associated with outcome”, and the alternate
hypothesis, which is the research question
of interest, is stated as either “exposure is
associated with outcome” or “exposure
increases or decreases the risk of outcome”.
The second stage is to select an appropriate
study design to test the research hypothesis.
The third stage is the implementation of
the study and collection of data. This stage
requires the measurement of data using an
appropriate scale. The fourth and final stage is
the statistical analysis of the data that includes
both descriptive statistics and statistical
inference.
The purpose of hypothesis testing is to aid
the investigator in reaching the correct decision
concerning a population by examining a
sample from that population. The process of
hypothesis testing begins with the assumption
that the null hypothesis is true in the target
population. Under this assumption, we then
calculate the probability of obtaining by
chance alone a degree of association between
exposure and outcome at least as strong as that
observed in the sample.
What is the chance of finding a difference
between two groups when in fact there is no
real difference? This probability value is called
the P value. For clinical research to be useful
for decision making, the P value should be 05
or less. Even at this level, 5 percent of the time,
the difference found between two groups will
be a chance occurrence.
Type I Error (a)
Type I error (a) is the probability of rejecting a
true null hypothesis. With respect to hypothesis
testing, there are some rules that should be
followed. The P value threshold for rejection
of the null hypothesis should be established
before the experiment is started. This threshold
Occlusion and Malocclusion 107
is called the type I error (a) that the investigator
is willing to commit. The value for this error is
usually set at 05. When the calculated P value
from the sample is less than the a value, then
the investigator rejects the null hypothesis
and says there is a significant association
between exposure and outcome or a significant
difference between groups (usually between
experimental and control groups). Therefore,
when an investigator rejects a null hypothesis
at P < 0.05, there is less than a 5 percent chance
of a mistake, i.e. a true null hypothesis was
rejected.
Type II Error (p)
Type II (ft) errors occur when the study does
not find a difference between groups when in
fact there is a true difference. This different
type of error can occur when the investigator
fails to reject the null hypothesis, i.e. finding
no difference between the groups. In these
instances, there is the danger of committing
a type II (p) error. For example, the studies on
open bite correction presented later in this
issue failed to show a significant change in
mandibular growth with the Active Vertical
Corrector appliance. In that study, a type II
error may have occurred. It is important to
remember that type I and II errors are mutually
exclusive; therefore, we are never at risk for
committing both errors for a given inference.
However, a given study that has more than one
hypothesis can be at risk for committing type
I errors for the significant findings and type II
errors for findings that do not reach statistical
significance.
Power
Power is calculated as l to 3 and is the probability
of rejecting the null hypothesis when indeed
it is false. P error can be set a priori and is
usually set at 0.20 or 0.10. To set B error a priori,
108 Essentials of Orthodontics
an investigator has to decide the magnitude
of difference (effect size) he/she wants to
detect between two groups. For example, if
an investigator wants to detect a 20 percent
difference in mandible size between patients
treated with bionators or headgears, then the
effect size he/she wants to detect between
the two groups is 0.20.3 errors can also be
calculated a posteriori (after data collection)
and is usually performed to determine the
power of the study. If the value of the power is
close to 100 percent, then p error is negligible
and the investigator can be confident of the
results. To use studies for clinical decision
making, the power of the study should be at
least 80 percent.
Sample Size
Sample size has a major role in reducing both
type I and type II errors. The most frequent
question asked by clinicians is the sample
size required to test the research hypothesis.
The answer to this question depends on three
factors:
1. The level of a and p error the investigator is
willing to risk (usually set at 0.05 and 0.20,
respectively).
2. The magnitude of difference (effect size)
to be detected. This can be in the form of
frequencies for categorical data or means
for continuous data. The effect size can be
estimated from previous studies or from
pilot work performed by the investigator.
3. The underlying variance of the target
population. The variance is again estimated
from previous studies. This is a major
concern in orthodontic studies because of
the wide variation in facial appearance.
Central Limit Theorem
Because of large variance in the target
population for cephalometric measures, it may
not be feasible to recruit the required number
of subjects estimated from a sample size
calculation. In such instances, the properties
of the central limit theorem can be useful
to answer the dilemma of an appropriate
sample size. Before discussing the central
limit theorem, an explanation of the sampling
theory on which the theorem is based is
provided. Suppose an investigator wanted
to estimate the oral hygiene status of the
population of the United States. It would be
impractical to study the entire population and
calculate the oral hygiene index. Therefore,
an investigator will select a sample from
this population and calculate the mean oral
hygiene index (measured on a continuous
scale) and make inferences regarding the
population. If there are several investigators
studying the same problem, each one will take
a sample from the population and calculate
the mean oral hygiene index. The means and
standard deviations calculated from each of
the samples will be a little different because of
the vagaries of sampling. If the sample means
were plotted, the distribution would resemble
a normal distribution (bell-shaped curve).
Therefore, the mean of the sample means
would approximate the population mean,
and the standard deviation of the sample
means would be equivalent to the standard
error of the mean (standard deviation of the
sample/square root of the sample size). This
mathematical property is called the central
limit theorem and will apply to sample sizes
of 30 or greater. In general, the approximation
to normality of the sampling distribution
becomes better as the sample size increases.
Therefore, as long as our sample sizes are at
least 30, we can still make inferences about
the target population from a sample because
of the central limit theorem. However, this
does not ensure the investigator that there

would be sufficient power to detect an effect
size of a certain magnitude. Therefore, it is
always better to calculate the sample size
before the start of the study and then recruit
subjects accordingly to ensure sufficient power
to detect associations or differences between
groups.
Statistical versus Clinical
Significance
For situations in which the magnitude of
difference between two groups, for example,
treated versus nontreated subjects, is large, then
a small sample size would be sufficient to detect
a statistically significant difference between the
groups. In instances in which the magnitude
of difference is small, then a large sample size
would be necessary to detect a statistically
significant difference between the groups. It
is, however, important for the investigator to
evaluate statistical significance versus clinical
significance. Statistical significance in the
absence of clinical significance is of limited
value to clinicians. For example, if bionators
were effective in providing a statistically
significant 0.01 mm of additional mandibular
length, this finding would be clinically trivial.
Therefore, clinicians conducting research or
reading/evaluating journal articles should
be cautious in the interpretation of the
P value with reference to clinical significance.
The P value should be carefully evaluated
because data derived from a poorly designed
study could provide meaningless information
that is inappropriate for clinical decision
making.
INDICES OF MALOCCLUSION
Malocclusion and dentofacial deformity are
conditions that constitute a hazard to the
maintenance of oral health and interfere with
the well-being of the person by adversely
Occlusion and Malocclusion 109
affecting dentofacial esthetics, mandibular
function or speech.
The measurement of malocclusion as a
public health problem is extremely difficult
since most orthodontic treatment is undertaken
for esthetic reasons and it is very difficult
to estimate the extent to which malposed
teeth or dentofacial anomalies constitute
a psychological hazard. Malocclusion has
proved to be a difficult entity to define because
individual perceptions of what constitutes
a malocclusion problem differ widely. As a
result, no generally accepted epidemiological
index of malocclusion has yet been devised.
INDEX
Russell defined Index as, “A numerical value
describing the relative status of a population
on a graduated scale with definite upper and
lower limits which is designed to permit and
facilitate comparison with other populations
classified by the same criteria and methods”.
Jamison HD and McMillan RS have
proposed a list of requirements for an
ideal orthodontic index that can be used in
the epidemiologic studies of orthodontic
problems, as follows:
The index should be simple, accurate,
reliable and reproducible.
The index should be objective in nature and
yield quantitative data which may be analyzed
by current statistical methods.
The index must be so designed as to
differentiate between handicapping and non-
handicapping malocclusion.
The examination required must be one that
can be performed quickly by examiners even
without special instructions in orthodontic
diagnosis.
The index should lend itself to modification
for the collection of epidemiological data,
110 Essentials of Orthodontics
regarding malocclusion other than prevalence,
incidence, severity, e.g. frequency of malpo-
sitioning of individual teeth.
The index should be usable either on
patients or on study models.
The index should measure the degree
of handicap, if any and avoid classifying
‘malocclusion’ (Tables 3.3 and 3.4).
Orthodontic Indices
Occlusal Index
Occlusal index was developed by Master and
Frankel in 1951. In this index count of the
number of teeth displaced or rotated is seen.
Assessment of tooth displacement and rotations
in this index is qualitative (all or none).
Malalignment Index
Malalignment index was devised by Vankirk
and Pennel in 1959. In this index tooth
Table 3.3: The requirement for an index of occlusion
1. Status of the group is expressed by a single number
which corresponds to a relative position on a finite
seals with definite upper and lower limits; running
by progressive gradation from zero, i.e. absence
of disease, to the ultimate point, i.e. disease in its
terminal stage.
2. The index should be equally sensitive throughout
the scale.
3. Index value should correspond closely with the
clinically importance of the disease stage it represents.
4. Index value should be amendable to statistical
analysis.
5. Reproductive.
6. Requisite equipment and instruments should be
practicable in actual field situation.
7. Examination procedure should require a minimum
of judgment.
8. The index should be facile enough to permit the
study of a large population without undue cost in
time or energy.
9. The index would permit the prompt detection of a
shift in group condition, for better or for worst.
10. The index should be valid during time.
displacement and rotation were measured.
Tooth displacement defined quantitatively:
<1.5 mm or >1.5 mm. Tooth rotation defined
quantitatively: <45° or >45°.
Handicapping Labiolingual Deviation
Index
The handicapping labiolingual deviation index
(HLD index) was developed by Harry L Draker
in 1960. The HLD index was proposed to select
subjects with severe or handicapping malo­
cclusion and dentofacial anomalies. The index
is applicable only to the permanent dentition.
HLD index was the first orthodontic index
designed to meet the administrative needs of
program planners.
Method: The three planes commonly used
for orthodontic orientation, i.e. the sagittal
plane, the Frankfort horizontal plane, and the
orbital plane are the basis for the HLD index
measurements. The main intention of the HLD
index is to measure the presence or absence
and the degree of the handicap caused by the
components of the index. The HLD index is
based on seven components. All measure­
ments are made with a Boley gauge scaled in
millimeters. The seven component conditions
of the HLD index are as follows:
Condition # 1 Cleft palate: This condition is
described as malocclusion resulting from
serious structural deformities involving growth
and development of the mandible and maxilla.
The presence of cleft palate is indicated by an
‘X’ in the recording chart.
Condition # 2 Traumatic deviations: The
tra­u ­m atic deviations referred to are, e.g.
loss of a premaxilla segment by burns or by
accident, the results of osteomyelitis, or other
gross pathology. The presence of a traumatic
deviation is also indicated by an ‘X’ in the
recording sheet.
Condition # 3 Overjet: This condition is mea­
sured with the patient in centric relationship.

Table 3.4: Summary of various indices of occlusion
Massler and Frankel (1951)
Malalignment index by Vankirk
and Penneli (1959)
Handicapping labiolingual deviation
index by
Draker (1960)
Occlusal features index by
Poulton and Aaronson (1961)
Malocclusion severity estimate
by Grainger (1960-61)
Occlusal index by Summers (1966)
Treatment priority index by
Grainger (1967)
Occlusion and Malocclusion 111
Count the number of teeth displaced or rotated.
Assessment of tooth displacement and rotation is qualitative—all or none.
Tooth displacement and rotation were measured.
Tooth displacement defined quantitatively : <1.5 mm or >1.5 mm.
Tooth rotation defined quantitatively: <45° or >45°.
Measurements include cleft palate (all or none), traumatic deviations (all or
none), overjet (mm), overbite (mm), mandibular protrusion (mm), anterior
open bite (mm), and labiolingual spread (a measurement of tooth displacement
in mm).
Measurements include lower anterior crowding cuspal interdigitation, vertical
overbite, and horizontal overjet.
Occlusion features measured and scored according to defined criteria.
Seven weighted and defined measurements: (1) overjet, (2) overbite, (3) anter­
ior open bite, (4) congenitally missing maxillary incisors, (5) first permanent
molar relationship, (6) posterior cross bite, (7) tooth displacement (actual
and potential).
Six malocclusion syndromes were defined:
1. Positive overjet and anterior open bite.
2. Positive overjet, positive over bite, distal molar relationship and posterior
cross bite with maxillary teeth buccal to mandibular teeth.
3. Negative overjet, mesial molar relationship, and posterior cross bite with
maxillary teeth lingual to mandibular teeth.
4. Congenitally missing maxillary incisor.
5. Tooth displacement.
6. Potential tooth displacement.
Nine weighted and defined measurements: (1) molar relationship, (2) overbite,
(3) overjet, (4) posterior cross bite, (5) posterior open bite, (6) tooth displacement,
(7) midline relation, (8) maxillary median diastema, (9) congenitally missing
maxillary incisors.
Seven malocclusion syndromes defined:
1. Overjet and open bite.
2. Distal molar relation, overjet, over bite, posterior cross bite, midline
diastema and midline deviation.
3. Congenitally missing maxillary incisors.
4. Tooth displacement (actual and potential).
5. Posterior open bite.
6. Mesial molar relation, overjet, over bite, posterior cross bite, midline
diastema and midline deviation.
7. Mesial molar relation, mixed dentition analysis (potential tooth
displacement) and tooth displacement.
Different scoring schemes and forms for different stages of dental development:
deciduous dentition, mixed dentition and permanent dentition.
Eleven weighted and defined measurements: (1) upper anterior segment
overjet, (2) lower anterior segment overjet, (3) overbite of upper anterior over
lower anterior, (4) anterior open bite, (5) congenitally absence of incisors,
(6) distal molar relation, (7) mesial molar relation, (8) posterior cross bite
(maxillary teeth buccal to normal), (9) posterior cross bite (maxillary teeth
lingual to normal), (10) tooth displacement, (11) gross anomalies.
Contd...
112 Essentials of Orthodontics

Contd...

Seven malocclusion syndromes were defined:

Handicapping malocclusion assess­
ment record by Salzmann (1968)
1. Maxillary expansion syndromes
2. Overbite
3. Retrognathism,
4. Open bite,
5. Prognathism,
6. Maxillary collapse syndromes,
7. Congenitally missing incisors.
Weighted measurements consist of three parts:
1. Intra-arch deviation—missing teeth, crowding, rotation, spacing.
2. Interarch deviation—overjet, overbite, cross bite, open bite, mesiodistal
deviation.
3. Six handicapping dentofacial deformities: (1) facial and oral clefts, (2) lower
lip palatal to maxillary incisors, (3) occlusal interference, (4) functional jaw
limitation, (5) facial asymmetry (6) speech impairment.
This part can only be assessed on life patients.

The measurement can be applied to a protru­
ding single tooth as well as to the whole arch.
The measurements of read and rounded off to
the nearest millimeter and recorded.
Condition # 4 Overbite: This measurement
is also rounded off to the nearest millimeter
and recorded. Reverse overbite may exist in
some conditions and should be measured
and recorded.
Condition # 5 Mandibular protrusion: This
is measured from the labial of the lower
incisor to the labial of the upper incisor. The
measurement in millimeters is recorded.
Condition # 6 Openbite: The condition is
defined as the absence of occlusal contact in
the anterior region. It is measured from edge-
to-edge in millimeters and recorded.
Condition # 7 Labiolingual spread: To measure
labio-lingual spread, the Boley gauge is used
to determine the extent of deviation from a
normal arch. The total distance between the
most protruded and the lingually displaced
anterior is measured.
In the event of multiple anterior teeth
crowding, all deviations from the normal
arch should be measured for labiolingual
spread, but only the most severe individual
measurement should be entered on the index.
This is done to give the patient the benefit of
the greatest deviation.
The above explained HLD index system
is a modification of an earlier used HLD
index. The HLD index used prior to 1960’s
made use of weighing factors developed by
trial and error. This index system had nine
components conditions measured. The
conditions measured. The conditions observed
are cleft palate, severe traumatic deviations,
overjet, overbite, mandibular protrusion, open
bite, ectopic eruption in anteriors, and anterior
crowding in maxilla and mandible.
The score of 13 and over constitutes
‘physical handicap’.
The following codes are used in this index:
O = Condition absent
X = Condition present
M = Mixed dentition
A = Clinical approval
D = Clinical disapproval.
Occlusal Feature index
Occlusal feature index was developed by
Poulton and Aaronson in 1961. Measurements
include lower anterior crowding, cuspal
 Occlusion and Malocclusion 113

interdigitation, vertical overbite, and horizontal 3. Overbite

overjet. 4. Open bite
5. Tooth displacement
Malocclusion Severity Estimate 6. Congenitally missing teeth
Malocclusion severity estimate was developed 7. Unerupted central incisors
by Grainger in 1961. He later modified it into 8. Mandibular prognathism
Orthodontic treatment priority index (TPI). 9. Mandibular retrognathism
Occlusal features measured and scored 10. Posterior cross bite.
according to defined criteria. Seven weighted Seven malocclusion syndromes have been
and defined measurements are: defined in TPI:
1. Overjet Maxillary expansion syndrome
2. Overbite Overbite
3. Anterior open bite Retrognathism
4. Congenitally missing maxillary incisors Open bite
5. First permanent molar relationship Prognathism
6. Posterior cross bite Maxillary collapse syndrome
7. Tooth displacements. Congenitally missing incisors.
Six malocclusion syndromes were defined: TPI is based on a scale of ‘0’ to ‘3’, ‘4’ to
1. Positive overjet and anterior open bite. ‘6’ and over ‘6’. The TPI tends to give more
2. Positive overjet, positive over bite, distal consistent percentage of prevalence, relative
molar relationship and posterior cross bite to age.
with maxillary teeth buccal to mandibular TPI scores can be expressed in the ranges
teeth. of:
3. Negative overjet, mesial molar relationship 0 to 2.5 = Low
and posterior cross bite with maxillary 2.5 to 4.5 = Middle
teeth lingual to mandibular teeth. Above 4.5 = High
4. Congenitally missing maxillary incisors. TPI serves as a guide for epidemiologic
5. Tooth displacements. surveys of populations as well as an instrument
6. Potential tooth displacement. for screening. TPI has been used in national
studies of orthodontic needs of children.
Orthodontic Treatment Priority Index
The Orthodontic Treatment Priority Index (TPI) Occlusal Index
was developed by Grainger RM in 1967. The TPI Occlusal index was devised by Summers in 1966.
was revision or modification made by Grainger Nine weighted and defined measurements are:
over the earlier developed ‘Malocclusion 1. Molar relationship
severity estimate’. TPI is based on the study 2. Overbite
of inter-relationships of ten manifestations of 3. Overjet
malo­cclusion. TPI includes seven syndromes 4. Posterior cross bite
and quantifies oral interrelationships in terms 5. Posterior open bite
of the seven syndromes. The ten manifestations 6. Tooth displacement
of malocclusion measured in TPI are: 7. Midline relation
1. Bimolar relationship 8. Maxillary median diastema
2. Overjet 9. Congenitally missing maxillary incisors.
114 Essentials of Orthodontics
Seven malocclusion syndromes were defined:
1. Overjet and open bite
2. Distal molar relation, overjet, overbite,
posterior cross bite, midline diastema, and
midline deviation
3. Congenitally missing maxillary incisors
4. Tooth displacements
5. Posterior open bite
6. Mesial molar relation, overjet, overbite,
posterior cross bite, midline diastema and
midline deviation
7. Mesial molar relation, mixed dentition
analysis (potential tooth displacement)
and tooth displacement.
There are different scoring schemes and
forms for different stages of dental deve­
lop­m ent, like deciduous dentition, mixed
dentition, and permanent dentition.
Handicapping Malocclusion Assessment
Handicapping malocclusion assessment was
given by Salzmann in 1968. The weighted
measurements consist of three parts:
Intra-arch deviation—missing teeth,
crowding, rotation, spacing.
Interarch deviation—overjet, overbite,
cross bite, open bite, mesiodistal deviation.
Functional deviations—functional shifts,
speech disorders.
Six handicapping dentofacial deformities
including:
1. Facial and oral clefts
2. Lower lip palatal to maxillary incisors
3. Occlusal interference
4. Functional jaw limitation
5. Facial asymmetry
6. Speech impairment.
Irregularity index (Little’s index)
An index introduced by RM Little, in 1975
for standardized assessment of mandibular
anterior crowding. It involves measuring the
linear displacement of the anatomic contact
points (as distinguished from the clinical
contact points) of each mandibular incisor
from the respective points of the adjacent teeth.
The sum of these five displacements represents
the relative degree of anterior irregularity.
Perfect alignment from the mesial aspect of
the left to the right canine would yield a score
of 0, with increased crowding represented by
greater displacement, and thus a higher index
score. The measurements are performed with a
caliper, parallel to the occlusal plane. Vertical
discrepancies between adjacent contact points
are not taken into account, as it is assumed
that correction of such discrepancies would
not appreciably affect anterior arch length.
Mesiodistal interdental spacing also is dis­
regarded provided the teeth in question are in
proper arch form. If spacing as well as rotations
are present, only the labiolingual displacement
from the proper arch form is recorded.
Peer Assessment rating index
The peer assessment rating (PAR) index is
an occlusal index designed and validated
as an instrument to measure how much a
patient deviates from normal alignment
and occlusion. The PAR index was designed
to measure the success or the outcome
of treatment by comparing the severity of
the initial malocclusion with the result on
pretreatment and posttreatment casts. The
index measures maxillary and mandibular
anterior alignment (crowding and spacing),
buccal segment occlusion (anteroposterior,
transverse, and vertical), overjet (including
anterior cross bite), over-bite and midline
discrepancies. The index has been validated
in the United Kingdom (UK PAR) and, with
different weightings and eliminating the
mandibular anterior alignment component,
in the United States (US PAR). The PAR index

has been used widely for evaluating the effects
of treatment in a variety of circumstances.
However, there is disagreement about using
the PAR index in determining treatment
need. One group of investigators concluded
that it is unsuitable as an index of treatment
need. Another group developed a model for
the PAR index that was highly correlated with
orthodontists’ subjective opinions of treatment
need. There have been no reports of a large
panel of orthodontic experts used as a gold or
truth standard against which to compare the
PAR index as an index of treatment need.
PAR index is an index for recording the
severity of a malocclusion in the mixed and
permanent dentition, developed in 1987 by a
group of 10 orthodontists in Great Britain (Bri­
tish Orthodontic Standards Working Party).
The index consists of a scoring system of study
casts, facilitated by a ruler. Individual scores for
the components of alignment and occlusion
finally are summed to calculate an overall
score. Thus, a score of zero would indicate
perfect alignment and occlusion, with scores
above zero (but rarely beyond 50) indicating
increasing levels of irregularity. The index is
applied to both the start and end of treatment
study casts, and the change in the total score
reflects the success of treatment with regard to
the alignment and occlusion.
Index for orthodontic treatment needs
Index of Orthodontic Treatment Needs was
developed by Brook and Shaw in 1989.
The dental health component (DHC) of index
for orthodontic treatment need (IOTN) specifi­-
­c ally addresses the deficiencies noted in
this academic outcomes study. The DHC of
IOTN is a distillation of the factors currently
believed to be related to the deleterious
health effects of malocclusion. The five traits
assessed by the DHC are missing teeth, overjet,
Occlusion and Malocclusion 115
cross bites, displacement of contact points
(crowding), and over bite. The AC of the IOTN
consists of a 10-point scale, illustrated by a
series of numbered photographs. Brook and
Shaw originally developed the IOTN as a
second-generation occlusal index with two
components to provide a balanced approach
to allocating need.
Dental Health Component of Index for
Orthodontic Treatment Need
Grade 5 (Need Treatment): Impeded eruption of
teeth (except for third molars) due to crowding
displacement, presence of supernumerary
teeth, retained deciduous teeth, and any
pathological cause.
Extensive hypodontia with restorative
impli­c ations (more than 1 tooth missing
in any quadrant) requiring prerestorative
orthodontics. Increased overjet 9 mm. Reverse
overjet 3.5 mm with reported masticatory
and speech difficulties. Defects of cleft lip
and palate and other craniofacial anomalies.
Submerged deciduous teeth.
Grade 4 (Need Treatment): Less extensive hypo­
d­ontia requiring pre-restorative orthodontics
or orthodontic space closure to obviate the
need for prosthesis. Increased overjet 6 mm,
9 mm.
Reverse overjet 3.5 mm with no masticatory
or speech difficulties.
Anterior or posterior cross bites with 2
mm discrepancy between retruded contact
position and intercuspal position.
Posterior lingual cross bite with no fun­
ctional occlusal contact in 1 or both buccal
segments.
Severe contact point displacements _4 mm.
Extreme lateral or anterior open bites _4
mm.
Increased and complete overbite with
gingival or palatal trauma.
116 Essentials of Orthodontics
Partially erupted teeth, tipped and impac­
ted against adjacent teeth.
Presence of supernumerary teeth.
Grade 3 (Borderline Need): Increased overjet
3.5 mm, 6 mm with incompetent lips.
Reverse overjet 1 mm, 3.5 mm.
Anterior or posterior cross bites with 1 mm,
2 mm discrepancy between retruded contact
position and intercuspal position.
Contact point displacements 2 mm, 4 mm.
Lateral or anterior open bite 2 mm, 4 mm.
Deep overbite complete on gingival or
palatal tissues but no trauma.
Grade 2 (Little Need): Increased overjet 3.5 mm,
6 mm with competent lips.
Reverse overjet 0 mm, 1 mm.
Anterior or posterior cross bite with 1
mm discrepancy between retruded contact
position and intercuspal position.
Contact point displacements 1 mm, 2 mm.
Anterior or posterior open bite 1 mm, 2
mm.
Increased over bite 3.5 mm without gingival
contact.
Prenormal or postnormal occlusions with
no other anomalies (Included up to half a unit
discrepancy).
Grade 1 (No Need): Extremely minor maloc­
clusions including contact point displacements
1 mm.
Index of Complexity, Outcome and Need
Index of Complexity, Outcome and Need
(ICON) was developed by Richmond and
Daniels in 2000, to find the difficulties in
treatment, outcome of the orthodontic
treatment and the need to treat the existing
malocclusion. This is the only index developed
to assess the need, outcome and complexity
of the orthodontic treatment. The dental casts
were examined by occlusal traits in the sample
were comprehensively scored according to an
objective scoring protocol. The occlusal traits
scored included:
1. Upper and lower labial segment alignment.
2. Anterior vertical relationship, centerline,
impacted teeth, upper and lower buccal
segment alignment (left and right added
together), buccal segment anteroposterior
relationship (left and right added together),
buccal segment vertical relationship (left
and right added together), cross bite,
missing teeth for any reason (excluding
third molars).
3. Aesthetic assessment based on IOTN aes­
thetic component, overjet in mm (centered
at 3 mm), reverse overjet in mm, upper
and lower incisor inclination relative to
the occlusal plane, overall upper arch
crowding and spacing, overall lower arch
crowding and spacing, lip competency.
The practitioners’ subjective judgements of
the casts were then related to the occlusal trait
scores for each case using regression analysis.
Ideal Tooth Relationship Index
Ideal Tooth Relationship Index (ITRI) was
developed in 1992 by Robert S Haeger, Bernard
J Schneider, and Ellen A BeGole.
The use of an ideal tooth relationship
index (ITRI) has many applications, such
as evaluating the results of orthodontic
treatment, post-treatment stability, settling,
relapse and different orthodontic treatment
modalities.
Relationships Used in the Index
(Table 3.5)
Study models in centric occlusion were
examined visually to determine tooth
relationships. Assuming that all teeth are
present, there are 62 potential ideal tooth
relationships that make up ITRI.

Table 3.5: Tooth relationships used in ITRI
Description Number
Mesial and distal inclined planes of the 14
maxi­llary buccal cusps of first molars and
premolars occluding with the buccal
cusps of their mandibular antagonists
Mesial and distal inclined planes of the 14
mandi­bular first molar lingual cusps and
marginal ridge contact on the distal of the
mandibular first and premolars and mesial
and distal of the second premolars and the
lingual cusp of their maxillary antagonist
Anterior interarch contacts between the 12
lingual surface of the maxillary incisors
and canines and the labial surface of their
mandibular antagonists
Intra-arch (interproximal) contacts on the 22
maxillary and mandibular arches from first
molar to first molar
Total 62
The index was based on the percentage of
actual to potential ideal relationships present on
the dental casts and was calculated as the sum
of maxillary buccal cusps, mandibular lingual
relationships, and anterior and inter­pro­ximal
contacts divided by the number of potential
relationships. The ITRI scores were computed
for the following: total index score for the entire
dentition; anterior segment score, which is the
summation of intraarch and interarch scores;
and posterior segment score, which is the
summation of intraarch and interarch scores,
including buccal and lingual scores.
The number of potential ideal relationships
varied depending on the number of teeth
included, i.e. extraction cases and inclusion
of second molars. The relationships were
scored only when they were correct and
no range of “normal” was incorporated.
However, if a buccal segment interdigitated
mesially or distally to the Class I position,
contacts were still counted as being present
since functional inclined plane relation­ships
were of primary interest. All evaluations were
Occlusion and Malocclusion 117
performed by visual examination; no leaf
gauges, linear measurements, or wax bites
were employed. Models with congenitally
miss­­ing teeth, questionable articulation,
mal­for­med teeth, or broken or chipped teeth
were not included in this study. Third molars
were not included because of variability
in form and occurrence. Second molars
were included initially but subsequently
elimi­nated on the basis of a pilot study that
revealed no difference in scores if only first
molars were included. Deciduous teeth were
excluded. In some cases, band spaces were
present resulting in a lack of interproximal
contact; these were not recorded as correct.
How­e ver, in cases when posttreatment
records were taken after a lower banded
retai­ner had been cemented, the intraarch
contact on either side of the banded tooth
was scored when correctly related to the
banded tooth.
ANTHROPOLOGY
Anthropology is the science of man as a whole.
It encloses different aspects of the lift of man
from the date of his origin up to the present
day. It includes study of man from every aspect
of life, e.g. physical feature differences, cultural
variations, social political, religious and all
other affairs.
Customarily anthropology is divided into
two branches: (i) Physical and (ii) Cultural.
Physical anthropology deals with the physical
aspects of man, his evolution, structural
variations, racial compositions, etc. Cultural
anthropology on the other hand deals with life
activates of man, his behavior, social patterns,
etc.
Man is the product of a long experiment
by nature. Knowledge of basic facts of this
experiment are not only fascinating but are
immediate practical use to dental profession.
118 Essentials of Orthodontics
The exact place of human origin is a matter
of controversy. South Central Asia is widely
accepted as the birth place of man. Recently
however, Doctor and Mrs Leakey with their
discoveries in Africa claimed that our early
progenitors lived in the African continent than
elsewhere.
All the living varieties of modern man bel­
ong to the species, Homo sapiens, Man today,
though differ in certain cases outwardly are
similar to one another in basic characteristics.
But men of prehistoric beds differ widely from
modern man. It is seen that one group of people
exhibits certain common hereditary features
which differ in various ways from the other
groups. The men of the world can be divided
into several such groups known as the race.
Physical anthropology is the study of man
not as is done in anatomy and physiology. It
tries to find out the differences on the basis
of physical traits. With the help of these traits
individuals are distinguished within the species.
The methodology in phy­sical anthropology has
changed from a purely mechanical technique
to an analytical interpretive form. Nose for
example, which was regarded as an independent
entity is now considered as an integral part of
the face. The facial region is greatly influenced
by the stresses of mastication. The force of
developing teeth increases the size of the bone
of the neighboring region. The classical physical
anthropology did not stress these interrelating
factors. There is at present a stress on genetic
composition of a population and mechanism
of heredity.
Dental anthropology is a part of physical
anthropology. It deals with the shape, size and
variation of teeth, jaw and occlusion. Human
teeth and jaw bones are hard and long-lasting
and have contributed greatly to anthropology.
Dental anthropologists have been called upon
to identify individuals on the basis of tooth
and haw form. Identification of remains of
victims of airplane crashes and victims of
criminal assaults are frequently done by dental
anthropologists. Dental anthropologists study
teeth, both fossiled and modern, for the study
of evolution of man. One of the major tasks of
the dental anthropology is to learn how teeth
evolved to their present form.
The teeth and related bony parts of
face of primates and mammals reveal the
differences among those animals. Zygoma is
an important bone for the anthropologists.
The higher the primate, the less prominent is
the zygomatic arch. The probable evolution of
man is revealed from fossiled teeth and jaws.
The shape and size of teeth have undergone a
great change due to change of diet. In man the
canines have decreased in size, all other teeth
have become smaller and are closely set and
the dental arch has become parabolic.
Anthropometry is a systematized technique
for measuring and observing different parts
of human body, living or dead. It helps to
express the form of the body quantitatively.
It consists of Somatometry (measurement
of living body or cadaver), Cephalometry
(measurement of the head and face only),
Osteometry (measurement of the skeletal
parts) and Craniometry (measurements of
bone restricted to the skull).
Some of the indices that are used in dental
anthropology are as follows:
1. Cephalic index:
Maximum head breadth
× 100
Maximum head length
Result:
Dolicocephalic = <75.9
Mesocephalic = 76 – 80.9
Brachycephalic = >81
2. Facial index:
Morphological facial height
(n-gn)
× 100
Bizygomatic width (zy-zy)

Result:
Euryoprosopic = <83.9
Mesoprosopic = 84-87.9
Leptoprosopic = >88
3. Jugomandibular index:
Bigonial breadth (go-go)
× 100
Bizygomatic width (zy-zy)
Result:
Narrow = <74.9
Medium = 75-79.9
Broad = >80
4. Lip index:
Height of integumental lip
× 100
Lip length
5. Nasal index:
Nasal breadth × 100
Nasal length
Result:
Leptorhine = <69.9
Mesorhine = 70-84.9
Chamaerhine = >85
6. Maxilloalveolar index:
Maxilloalveolar breadth
× 100
Maxilloalveolar length
Result:
Dolichuranic = <109
Mesoranic = 110-114.9
Brachyuranic = >115
7. Palatal index:
Maximum palatal breadth
× 100
Maximum palatal length
Result:
Leptostaphyline = < 79.9
Mesostaphyline = 80 – 84.9
Brachystaphyline = > 85
8. Tooth crown index:
Buccolingual diameter
× 100
Mesiodistal diameter
Occlusion and Malocclusion 119
9. Step index:
First molar is least variable. Other mol­
ars are compared with first molar, e.g.
Third molar mesiodistal
diameter
× 100
First molar mesiodistal
diameeter
10. Arch index:
Width between canines × 100
Distance between central
incisors and second premolars
or third predecessors
11. Tooth width index:
Mesiodistal width × 100
Height
Some of the dental peculiarities that are
of interest to the dental anthropologists are as
follows:
1. Shovel-shaped incisors: It is seen in the
maxillary incisors. In modern population
marked shovel morphology suggests
mongoloid affinities. The mesial and distal
ridges are prominent and the lingual fossa
is deep. The depth is measured at a point
midway between incisal and gingival
margins and midway from mesial and
distal margins. The nomenclature and
scores are as follows.
Depth in mm Nomenclature Score
0 mm No shovel 0
Less than 1 mm Trace shovel 1
1 mm Semi-shovel 2
Over 1 mm Shovel 3
2. Barrel-shaped lateral incisors: The cingulum
is so deep that the lateral incisor looks like
a premolar.
3. Carabelli’s trait: It has been concerned
with the racial difference, genetic and
120 Essentials of Orthodontics
evolutionary studies. Depending on its
prominence or presence of pit or groove,
it is classified into seven subgroups:
Position of the trait Score
Smooth surface
A shallow groove on mesial side of lingual
surface
A shallow groove or depression without any
change in curvature of lingual surface
Depression or pit deeper than number 2, but
no bulge is seen on lingual surface
Same as number 3 but there is slight eminence
on lingual surface or mesiolingual cusp
(protocone)
Lingual eminence is stronger, but the cusp
extends smoothly to the rest of the lingual
surface without interruption
The cusp is completely encircled by a groove
so that it seems to form a fifth cusp
Strongly developed cusp which may be longer
than distolingual cusp (hypocone)
The shape of tooth is variable. It is regulated
by various factors including genetic control.
Much reliance is placed on occlusal fissure
pattern. ‘Y’ type fissure is diagnostic of hominid
forms. Number of cusps is independent of
the type of fissure. The fissural pattern is
polygenic, that is its expression is determined
by combination of alleles at two or more loci.
The Carabelli trait is the expression of alleles at
a single locus. The determinants of Carabelli’s
expression act early in tooth embryology
as compared with those for the fissural
pattern. Carabelli’s cusp and Carabelli’s pit are
expressions of the same genotype. Carabelli’s
cusp is the maximum expressions of the same
genotype. Carabelli’s cusp is the maximum
expression of the lingual cingulum in man
and pit or groove occurs when the cingulum
is absent. On no other site of a tooth a tubercle
or cusp alternate with a pit or groove.
Anthropologic nomenclatures of cusps of
molar teeth are as follows:
Cusp Upper molar Lower molar
Mesiobuccal Paracone Protoconoid
Mesiolingual Protocone Metaconoid
0 Distolingual Hypocone Entoconid
1 Distobuccal Metacone Hypoconid
Carabelli’s cusp – –
2
Distal – Hypoconulid
3 Extracusp on mesio­ – Protostylid
buccal
4
ANTHROPOLOGY AND
5 ORTHODONTICS
6 Orthodontists are functioning anthropologists.
We measure the bones of the face, skull and
7 teeth, and study the relationships of these
structures. We should also be interested, then
in learning as much as possible about the
origins of human beings and the evolutionary
development of our anatomy.
Study of the other primates contributes to
this field of knowledge. Primates are defined
as mammals with thumbs and large toes that
oppose the other digits. The ends of the digits
are flattened and have nails rather than claws.
As we shall see, however, there are interesting
exceptions.
Fossil evidence has uncovered a very old,
very small, warm-blooded creature called
mega-zostrodon. It had a sharp snout and
pointed ears, nursed its young, and is the oldest
known mammal. Geological dating places
it on earth some 200 million years ago. The
brain of this mouse-sized creature was large
in proportion to its weight and compared with
the brains of other creatures then existing. It
survived the Jurassic Age of the now-extinct
terrestrial dinosaurs. It lived by its wits.

Charles Darwin was a close observer of
nature. His theory of evolution grew from
watch­­ing an undisturbed patch in his garden.
He plotted the 2-by-3-foot area and carefully
recorded every wild sprout of grass and
weed. He followed the fate of each individual
organism and continued his study for years.
He concluded it with three basic assum­ptions:
1. Each individual of a species is different
from every other.
2. Each individual can reproduce in geometric
proportion.
3. Because of a resulting overpopulation, only
the most fit will survive.
EARLY PRIMATES
Tree shrews, the most primitive of primates, are
an arboreal variation of the megazostrodon.
When terrestrial living became too crowded
or too hazardous, some individuals took to
the trees. From them, tree shrews developed
50 to 60 million years ago, following the mass
extinction of the dinosaurs.
The earliest extent remains of a hominid,
the family of Homo sapiens (modern humans),
are about 4 million years old. That ancient
being had ancestors whose remains have yet
to be discovered. These early hominids stood
upright and although their cranial capacity was
limited, it was relatively large for the overall size
of this hominid. The orbits were surrounded by
heavy bone, especially the glabella. The teeth
were about the size of modern man’s, but this
creature stood only three or four feet tall.
Homo sapiens, maturing more slowly
than other primates, retained many primitive
features, which may be why the genus has
been successful. Hands and teeth, for example,
are quite primitive. Genera that become
specialized tend to become extinct when their
Occlusion and Malocclusion 121
environment changes. Special adaptations
are beneficial only so long as the conditions
to which the adaptations were made remain
static. Climatic and geologic changes through
millions of year’s reshaped environments and
organisms that failed to adapt became extinct.
During the evolution of man millions
of years since the tiny tree shrew became
arboreal, and to describe how present day man
may be resisting some of these changes.
From Shrews to Humans
The tree shrew developed a shortened snout
and an increased cranial capacity. Being
nocturnal, its orbits are large and there is
no bony separation from the muscles of
mastication. It does not have stereoscopic
vision. The shrew climbs vertically and
scampers along the tops of branches. The large
toe is flattened and has a nail, but the other
digits have claws, which make the shrew’s
arboreal existence more secure. The basic
mammalian (Eutherian) dental formula of
44 teeth includes: 3 incisors (I), 1 canine (C),
4 premolars (P), and 3 molars (M), right and
left, in both the upper and lower arches. The
tree shrew fromulae are: upper I-2, C-1, P-3,
M-3; and lower I-3, C-1, P-3, M-3. The teeth
are generally more cone-shaped than those
of other primates. The basic building blocks
for teeth are the cones, from which all teeth
have evolved.
The next step up the primate ladder, lemur,
includes numerous genera and subfamilies
that vary in size from the attractive furry little
mouse lemur to the cat-sized, ring-tailed
lemur. Lemurs are good climbers, using their
tails for balance. Their hind legs are well-
developed, allowing the lemur to leap along
or between branches. Like the tree shrew,
the lemur is almost entirely arboreal. Their
digits have flattened ends on both hands and
122 Essentials of Orthodontics
feet with nails instead of claws, except for the
second toe, which is elongated and has a claw
with which to scratch and groom (called the
“toilet digit”).
Lemur brains are more developed in vision,
but less well-developed in smell. The animal
is nocturnal and has large orbits. As in the tree
shrew, there is no bony separation between
the orbit and the muscles of mastication. The
snout of the lemur is less pointed than that of
the shrew, and it projects beyond the lower
jaw. The upper lip has a median cleft and is
bound to the gums on either side. Its ears are
large and mobile.
The dental formula for lemur, both upper
and lower, is: I-2, C-1, P-3, M-3. The two central
incisors are separated by a wide diastema, and
like the laterals, are small and cone-shaped. In
some lemurs, the upper anteriors are entirely
missing. The lower centrals and laterals form
a specialized comb. They are elongated and
procumbent, and are joined by the adjacent
similarly formed canines. The lower first
premolar has developed a canine form. The
anterior comb is used for grooming, but has
also been observed being used to scoop fresh
gum and juice from trees.
A strange lemur genus is the aye-aye. It lives
in cane brakes and bamboo forests where it
bores into stalks for juices and grubs. Digits of
the aye-aye have sharp curved claws on all but
the great toe, which is flattened and has a broad
nail. Its long specialized second toe is used for
extracting grubs as well as for grooming.
The dentition of this creature is of special
interest. The dental formula is: upper I-0, C-1,
P-1, M-3; and lower I-0, C-1, P-0, M-3. The
upper and lower canines are inclined labially
and are in contact right with left. The teeth
erupt throughout the lifetime of the individual,
which maintains their length. Breaking into
cane and bamboo, they perform much as the
beak of a woodpecker. Upper canines of the
aye-aye form in the maxilla rather than in the
premaxilla, where the continuously erupting
anteriors form in rodents.
The next species in primate evolution is the
tarsier, which has a combination of primitive
and advanced features. In past geologic times
various genera of tarsiers were present in
most parts of the world, and they became
considerably diverse anatomically. There
are some who believe that from these many
genera evolved the branch leading to modern
great apes and to man. Today only one genus
remains: a small animal about the size of a
two-week old kitten. Its habitat is confined to
three islands in the Asian Pacific. This tarsier is
arboreal and insectivorous. It is nocturnal with
enormous eyes encased in bony sockets. The
brain resembles that of a monkey, especially the
part dealing with vision. The snout is shortened
and the ears are large and mobile. The tarsier’s
hind legs are specialized for jumping, and the
elongated tarsal bone accounts for the animal’s
name. The digits end with rounded pads that
have nails.
Tarsier has the following dental formula:
upper I-2, C-1, P-3, M-3; and lower I-1, C-1,
P-3, M-3. All of the incisors and canines are
coniform in shape as are the lower premolars
and one of the uppers.
Next among these primates are the
monkeys, with noticeable differences
between old and new world monkeys. Most
old world monkeys are no longer completely
arboreal, instead combining arboreal life
with excursions on the ground. Some, like the
mandrill and baboon have become terrestrial.
Monkeys have a quadrupedal gait, using all
four extremities in locomotion. In the trees,
they run and leap along the tops of branches.
When hanging from limbs they have hands
and/or feet on opposite sides of the limb. The

monkey clavicle has become vestigial. Without
it, the monkey cannot brachiate or hang with
both hands on the same side of the limb and
elbows extended laterally.
Monkey brains are more developed for
vision and less for smell than the above-
mentioned primates. They are diurnal and
have stereoscopic vision, with their eyes on
the front of the head rather than on the sides.
Most monkeys have snouts that are quite blunt,
with the exception of mandrills and baboons.
The ears are rather small and close to the head.
The dental formula for old world monkeys is:
upper and lower, I-2, C-1, P-2, M-3. This is the
same as that for great apes and hominids.
New world monkeys are almost completely
arboreal, and much of their forest habitat
covers swamps. Unlike any of the old world
monkeys, most of the new world species have
prehensile tails that have a bald sensitive area
near the tip. The tail is used in locomotion,
swinging, and even feeding. All of these
monkeys use their tails for balance while
ambulating or while sitting on all four limbs
high in the trees.
The smallest of living monkeys is the
marmoset. This new world creature has two
rather than three molars in each quadrant. It
also has curved claws on all digits except for
the large toes, similar to the tree shrew and the
aye-aye.
The dental formula for new world monkeys
is: upper and lower I-2, C-1, P-3, M-3. Canines
in both old world and new world monkeys are
generally long and pointed and are used for
fighting or are displayed as a threat.
There are four living types of anthropoid
apes : gorilla, gibbon, orangutan, and
chimpanzee. Fossil remains indicate many
more existed at one time. These great apes have
greater cranial capacity proportionate to body
mass compared with the primates mentioned
Occlusion and Malocclusion 123
above. Being sexually dimorphic, males are
larger than the females.
The gorilla is the largest of the four great
apes. It is vegetarian except for occasional
grubs, and this is reflected in its large grinding
molars, especially the lowers. Gorillas have
strong incisors with chisel-like edges. The
central is larger than the lateral, which slopes
gingivally on the distal; both have concave
labial surfaces. There is a diastema between
the laterals and canines in both arches. The
maxillary premolars have definite buccal and
lingual cusps while the mandibulars display
a more subdued lingual cusp. As mentioned
above, the dental formula is the same as in
hominids, the other great apes, and old world
monkeys.
Sexual dimorphism in the canines is well-
defined. Females have strong curved maxillary
canines that extend well-beyond the occlusal
plane, while the mandibulars are conical in
shape and extend only slightly above the plane.
In males, the canines are like fangs; both upper
and lower are robust, long, curved, sharp and
are well-adapted for defense and aggression.
The gorilla is diurnal with stereoscopic vision.
It has heavy bony ridges above the orbits.
The ears are small and sit close to the head.
Gorillas have become largely terrestrial,
ambulating on all four limbs and using the
backs of the knuckles and the soles of the feet.
Like other great apes and hominids, gorillas
have clavicles, which play an important role
in brachiation. Gorillas brachiate, using the
fingers as hooks over branches. The thumb
has become small and rudimentary. Great
apes and hominids have lost their tails, while
tree shrews, lemurs, tarsiers, and monkeys all
use theirs for balance in their arboreal running
and leaping. Lacking clavicles, they do not
brachiate. The toes of the gorilla are prehensile
and all digits have flattened nails.
124 Essentials of Orthodontics
The gibbon is a world-class athlete. Its
habitat is confined to Southeast Asia and
some offshore islands. It is almost completely
arboreal. When descending to the ground,
primarily for water, it ambulates in bipedal
fashion, extending its arms high overhead for
balance. It swings from branch-to-branch,
using its long slender arms and sure grip. A
web unites the index and middle fingers as far
as the terminal joint. The gibbon doesn’t need
a balancing tail. Its locomotion is primarily
brachiation and is not confined to walking and
leaping; it’s a real swinger. The lower limbs are
diminished. Its habitat is now confined to the
forests of Southeast Asia. About 80 percent of
its diet is fruit, augmented by leaves, flowers
and buds, insects, birds’ eggs, and nestlings.
Compared with other anthropoids, the
gibbon’s upper central incisors are broad and
the laterals more pointed. Both are labially
convex and lingually concave mesiodistally.
The lower incisors are equal in size and
shape and have sharp chisel edges. The upper
canines are saber-like, being long and curved.
The lower canines are large and conical, with
the tips standing well above the occlusal plane.
In occlusion, this tooth occupies a definite
diastema between the upper lateral incisor and
canine. The premolars are definitely bicuspid,
with the lingual cusp smaller than the buccal.
The lower first premolar is narrow mesially
and widens to a definite buccal cusp distally,
which slopes down to the curved cervical ridge
that supports a small lingual cingulum. The
second lower premolar is bicuspid, but the
cusps are mesial and distal rather than buccal
and lingual. In both upper and lower arches,
the second molar is larger than the first and
third.
The orangutan is arboreal and, like the
gibbon, its locomotion is based primarily on
brachiation. Its legs are shortened and its arms
lengthened. The skull and face are elongated
and surrounded by a heavy fringe of fur. The
dentition is similar to that of gorillas except that
the jaws are narrower. The canines are sexually
dimorphic, again as with the gorilla. Where
the gorilla’s second molar tends to be larger
than the first, the orangutan’s are of equal size.
Its habitat is now limited to a small region of
marsh forests in Borneo and Sumatra. At one
time it inhabited much of Asia, including
China. The orangutan is selective and few are
left, having been hunted by natives for food
and by animal trappers for zoos.
Chimpanzees are both arboreal and
terrestrial, spending about one-third of their
time on the ground. Although primarily
vegetarian, they eat a variety of termites, grubs,
and occasionally small animals that they kill.
They select and modify twigs, which they use
to extract termites from their mounds. The
termites attach to the intrusive twigs and the
chimpanzees lick them off. Besides these
modified termite twigs, chimpanzees also
throw stones and use stripped branches as
striking weapons. Hominids are not the only
toolmakers.
The chimpanzee’s legs are not as pro­
portionately diminished as those of the gibbon
or orangutan, but their arms are long and
strong. They can ambulate on their feet, but
the anatomy of the femur and pelvis creates a
swaggering gait. The backs of the knuckles and
the soles of the feet are used. The chimpanzee
is a good climber and brachiates. As with
other great apes, the chimpanzee exhibits
sexual dimorphism. The canines of males are
heavier, longer, and more curved. Chimpanzee
dentition is much the same as the orangutans
except that the dental arch is a little wider.
Comparing chromosomes of the great apes
with those of Homo sapiens, the chimpanzee
is the closest match.

The change from arboreal to terrestrial
life in Homo sapiens could not have occurred
without changes in anatomy. The most
reasonable explanation for these adaptations
is changes in climate. Tropical forests gave way
to forested areas interspersed with brush and
grass. Savanna lands eventually predominated
where forests had prevailed. Some forest areas
became isolated and gradually diminished
to the point of extinction. Arboreal primates
became terrestrial or they perished.
Being grounded, the ability to rise up
and see surrounding vegetation became an
advantage. As Charles Darwin observed, no
individuals are the same. Those best able to
stand tall could see danger and food first.
Upright locomotion freed the hands for
balancing and carrying weapons, food, and
offspring. Those individuals with legs closer
together could walk or run with the feet closer
to a straight line, eliminating the inefficient
swagger of the great apes. New foods were
required, as leaves, nuts, and fruits were no
longer available. The hominid became an
omnivore.
As structural changes occurred in the
skeleton, the skull also adapted. The forward
stance of an arboreal existence required strong
muscles on the back of the neck and shoulders,
which attached to three nuchal ridges on the
top and back of the skull. With the weight of
the head now resting on the spinal column,
the foramen magnum has shifted from the
posterior to the inferior of the skull. The strong
nuchal muscles reduced and their articulating
surfaces, the nuchal ridges, migrated down the
back of the head.
The coarse diet of roots, leaves, seeds, and
fruits required heavy muscles of mastication.
Fossil remains show that early predecessors of
Homo sapiens, or an extinct offshoot relative,
had a crest of bone along the top of the skull
Occlusion and Malocclusion 125
to which these strong muscles were attached.
Early hominids had robust zygomatic arches
and glabellum.
Hominid fossil remains indicate upright
posture existed before cranial capacity
increased. The strong nuchal and masticating
muscles formed a restraining muscular cap.
Their retreat from the top and sides of the skull
made expansion possible, allowing increased
cranial capacity and development of the
forebrain.
Homo sapiens are diurnal, have stereo­
scopic vision, and have greater cranial capacity
than other primates and most other mammals.
They are omnivorous and sexually dimorphic.
They can brachiate and, having upright
posture, can walk, run, and jump.
Upright posture exposed the jugular notch,
that vulnerable spot above the sternum and
between the clavicles. The forward stance of
the other primates hid this vital weak spot,
and when necessary, both males and females
used ferocious upper canines to defend it.
Losing those advantages, hominids developed
a chinbutton, pogonion, which nicely defends
the jugular notch when the head is ducked.
Male Homo sapiens have larger chinbuttons
than females. Males are the hunters and
protectors and a larger chinbutton provides
greater skin area on which a beard can grow,
adding protection for the jugular notch.
Man and elephant are the only mammals
with chinbuttons. The elephant has a very long
and mobile lower lip, which aids in guiding
the enormous amount of coarse food ingested
daily. The chinbutton provides necessary
muscle attachment for the lip.
The hominid chinbutton provides lower
muscle attachment to orbicularis oris, the
ring of musculature that restrains protrusion.
Study of those selected for having untreated
excellent occlusions finds that for each
126 Essentials of Orthodontics
millimeter of chinbutton, there is a 4 mm
reduction of the distance from the labial of the
maxillary incisor to the facial plane. Those who
perform cosmetic chinbutton implants should
keep in mind the disruption of this muscular
resistance to anterior dental protrusion.
The lower extremities and pelvis of homi­
nids adapted to upright posture, yet this was
accomplished without a balancing tail: arms
and hands suffice. Arboreal living occupied the
hands, clinging to branches. The feet adapted
to bipedal walking and running, but in doing
so, lost much of their former prehensile ability.
Some of us, however, carry with us Morton’s
toes, a second toe that is as long as the great toe.
CONCLUSION
The canine, C-1, is the one constant number in
all the dental formulae of the various primates.
Even in the strange aye-aye, canines replaced
the incisors.
The left and right posterior teeth of old
world monkeys and anthropoid apes are
parallel, but hominid arches diverge distally
and the canines do not protrude beyond the
occlusal plane. This combination allows for
greater lateral excursion and more efficient
mastication. The posterior widening of the
mandible occurred as the temporal bones
widened with increasing cranial capacity.
The maintenance of efficient occlusion and
mastication would promote a corresponding
change in the maxillary arch. In some of us,
however the upper arch presents parallel rows
of posterior teeth. We call it bilateral cross bite.
Diastemas occur in the very space two
incisors occupy in the basic mammalian
dental formula, I-3. This is also a site where
supernumerary teeth, often coniform, are
located. Supernumeraries are also often
located in the premolar sites where tree
shrew, lemur, tarsier and new world monkey
have three premolars. Premolars are two
fused cones modified and molars present
clusters. The man in the ice, discovered in
Italy’s Southern Tyrolean Alps, was from the
late Neolithic age, 5200 years ago. He had a
wide diastema between his maxillary central
incisors and missing third molars.
Charles Darwin’s acute observation about
individual variation evidences itself when
considering all the above common anomalies.
These variations are the experimental labor­
atory of evolution. Those mentioned above
seem regressions, but perhaps they are
progressions. They pertain to only a small
portion of the interweaving systems of which
we are composed. Not only anatomic, but
physiologic, biochemical and psychological
differences probably carry within them a share
of inherent and regressive aberrations. They
are our connection not only to other primates
and mammals, past, present, and future, but
to all living things.
 CHAPTER

4 Etiology

ETIOLOGY OF MALOCCLUSION c. Teeth

Etiology is the science that deals with deter­­ d. Soft tissue
mination of the cause. Etiology in ortho­ 2. Developmental defects of unknown origin
dontics is the study of the actual causes of 3. Trauma
malocclusion. a. Prenatal trauma and birth injuries
Comprehensive orthodontic manage­ment b. Postnatal trauma
involves identification of the possible etiologic 4. Physical agents
factors and an attempt to eliminate the same. a. Premature removal of primary tooth
Although it may not be possible to eliminate b. Nature of food.
the cause in most cases of malo­c­clusion, it 5. Habits
nevertheless is of value in pre­ventive and a. Thumb sucking and finger sucking
inter­­ceptive orthodontic procedures where a b. Tongue thrusting
possible malocclusion is prevented or inter­ c. Lip sucking
cepted by timely removal of the cause. d. Posture
e. Nail biting
f. Other habits
CLASSIFICATION OF ETIOLOGIC 6. Diseases
FACTORS IN MALOCCLUSION a. Systemic diseases
b. Endocrine disorders
A number of classifications of etiologic factors c. Local diseases
of malocclusion have been put forward: i. Nasopharyngeal diseases and distur­
bed respiratory function
Moyer’s Classification ii. Gingival and periodontal diseases
1. Heredity iii. Tumors
a. Neuromuscular system iv. Caries
b. Bone 7. Malnutrition.
128 Essentials of Orthodontics
Salzmann’s Classification
Salzmann gives a diagrammatic representation
of the etiologic factors in malocclusion which
includes prenatal and postnatal factors as
follows.
Genetic Environmental
Developmental
Congenital Functional
White and Gardiner’s Classification
A. Dental base abnormalities
1. Anteroposterior malrelationship
2. Vertical malrelationship
3. Lateral malrelationship
4. Disproportion of size between teeth and
basal bone
5. Congenital abnormalities.
B. Preeruption abnormalities
1. Abnormalities in position of developing
tooth germ
2. Missing teeth
3. Supernumerary teeth and teeth in
abnormal form
4. Prolonged retention of deciduous tooth
5. Large labial frenum
6. Traumatic injury
C. Posteruption abnormalities
1. Muscular
a. Active muscle force—swallowing
b. Rest position of musculature
c. Sucking habits
d. Abnormalities in path of closure
2. Premature loss of deciduous teeth
3. Extraction of permanent teeth.
Graber’s Classification
Graber classifies causes of malocclusion as
general and local factors.
General Factors
1. Hereditary
2. Congenital
3. Environmental
a. Prenatal (Trauma, maternal diet, Ger­
man measles, maternal metabolism,
etc.)
b. Postnatal (Birth injury, cerebral palsy,
TMJ injury, etc.)
4. Predisposing metabolic climate and
disease.
a. Endocrine imbalance
b. Metabolic disturbances
c. Infectious diseases.
5. Dietary problems (Nutritional deficiency)
6. Abnormal pressure habits and functional
aberrations
a. Abnormal suckling
b. Thumb and finger sucking
c. Tongue thrust and tongue sucking
d. Lip and nail biting
e. Speech defects
f. Abnormal swallowing habits
g. Respiratory abnormalities
h. Tonsils and adenoids
i. Psychogenic tics and bruxism
7. Posture
8. Trauma and accidents.
Local Factors
1. Anomalies of number
a. Supernumerary teeth
b. Missing teeth
2. Anomalies of tooth size
3. Anomalies of tooth shape
4. Abnormal labial frenum; mucosal
barriers
5. Premature loss
6. Prolonged retention
7. Delayed eruption of permanent teeth
8. Abnormal eruptive path
9. Ankylosis
10. Dental caries
11. Improper dental restorations.

General Factors
Heredity
Heredity or Genetic factors have long been
indicated as a chief cause of malocclusion,
although the genetic aberrations may make
their appearance prenatally or they may not
be seen until many years after birth. This
heredity factor is modified by the environment,
physical entities, by pressures, abnormal ha­
bits, nutritional disturbance and idiopathic
phenomenon. A child may have facial features
that markedly resemble of the parents or a
combination of both the parents.
Dental characters like facial features also
show a racial influence. In a homogenous
racial grouping the incidence of malocclusion
seems relatively low. But where there has been
a mixture of racial strains the incidence of jaw
size discrepancies and occlusal disharmonies is
significantly greater. But the racial influence in
the production of malocclusion is contro­versial.
Heredity plays a significant role in deter­
mining the following characteristics namely:
• Tooth size
• Width and length of the arch (Arch size)
• Height of the palate
• Crowding and spacing of teeth.
• Position and formation of perioral mus­
culature to tongue size and shape.
• Soft tissue peculiarities (Character and
texture of mucosa, frenum size, shape and
position, etc.)
Thus, heredity plays a part in the following
conditions namely:
• Congenital deformities, e.g. cleft lip and
palate
• Facial asymmetries
• Macrognathia and micrognathia
• Macrodontia and microdontia
• Oligodontia and anodontia.
• Tooth shape variations, e.g. Peg laterals,
Carabelli’s cusp, mamelleons.
Etiology 129
• Cleft palate and harelip
• Frenum, diastema
• Deep overbite
• Crowding and rotations of teeth
• Mandibular retrusion
• Mandibular prognathism
Congenital
Congenital or developmental defects are
malformations seen at the time of birth, are
usually assumed to have a strong genetic
relationship. They may be caused by various
factors such as genetic, radiological, chemical,
endocrine, infections and mechanical.
Congenital abnormalities that cause malo­
cclusion can be classified as general and local
congenital abnormalities.
General congenital factors: They include
abnormal state of mother during pregnancy,
malnutrition, endocrinopathies, infectious
diseases, metabolic disturbances, accidental
during pregnancy and child birth, intrauterine
pressure and accidental traumatization of the
fetus by external pressure.
Local congenital factors: Local congenital
factors include abnormalities of jaw develop­
ment due to intrauterine position, clefts of
the face and palate, macro, microglossia and
cleidocranial dysplasia.
Following are some of the congenital
conditions with associated dental maloc­
clusion:
• Cleft lip and palate
• Cerebral palsy
• Torticollis
• Cleidocranial dysostosis
• Congenital syphilis
• Maternal rubella.
Environment
There are a number of prenatal and postnatal
environmental factors that can cause malo­
cclusion.
130 Essentials of Orthodontics
a. Prenatal factors: The role of prenatal
influ­ences on malocclusion is probably
very small. Uterine posture, fibroids of
the mother, amniotic lesions, etc. have
been blamed for malocclusion. Other
possible causes are maternal diet and
metabolism, drug induced deformities as
with thalidomide, possible injury or trauma
and German measles. German measles
and medications taken during pregnancy
usually causes gross congenital deformities
including malocclusions.
b. Postnatal factors: The plasticity of the
cranial bones are such that any injury would
be temporary except in rare instances,
while it is possible to injure the infant at
birth with a high forceps delivery. Birth
injuries can lead on the a hypoplasia of
mandible, Vogel-Geischt (This is inhibited
growth of mandible due to ankylosis of TMJ
which may be due to developmental defect
or due to trauma at birth.
Cerebral palsy is a condition characterized
by muscle in coordination. This may occur due
to birth injuries.
Accidents and traumatic injuries that cause
condylar fracture can cause growth retardation
resulting in marked facial asymmetry.
Presence of extensive scar tissue after burns
or as a result of cleft lip surgery may produce
malocclusion due to their restrictive influence
on growth.
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.
Predisposing Metabolic, Climate and
Disease
a. Endocrine imbalance: Of all the endo-
crinopathies thyroid problems are of impor­
tance to an orthodontist. Hypo-thyroidism
is related to abnormal resorption pattern,
delayed eruption pattern and gingival
disturbances in addition there are retained
deciduous teeth and individually malposed
teeth. Irregular tooth arrangement and
crowding can occur.
Hyperthyroidism is characterized by
incre­­a­sed rate of maturation and an increase
in metabolic rate. The patient exhibits
premature eruption of deciduous teeth,
disturbed root resorption of deciduous
tooth and early eruption of permanent
teeth. The patient may have osteoporosis
which contraindicates orthodontic
treatment.
Hypoparathyroidism is associated with
changes in calcium metabolism. It can
cause delay in tooth eruption, altered tooth
morphology delayed eruption of deciduous
and permanent teeth and hyperplastic
teeth.
Hyperparathyroidism is associated with
demineralization of bone and disruption
of trabecular pattern. In growing children
interruption of tooth development occurs,
the teeth may become mobile due to loss
of cortical bone and resorption of alveolar
process.
Hyperpituitarism in adult is associated
with prognathic mandible and Class III
malocclusion known as Acromegaly.
b. Metabolic disturbances: The exact eff­
ects of acute febrile conditions on the
development of occlusion is not known;
there is some recent evidence that acute
febrile dentition may temporarily slow-
down the pace of growth and development.
It can affect the complex timetable of
eruption, resorption and tooth loss, etc.
c. Infectious diseases: Diseases with a paralytic
effect such as poliomyelitis are capable of
producing bizarre malocclusions. Diseases

with muscle malfunction such as muscular
dystrophy and cerebral palsy also have
characteristic deforming effects on the
dental arch.
Dietary Problems (Nutritional Deficiency)
Malocclusion developing due to dietary
problems is quite rare. But this is an interrelated
problem, if a patient suffers an acute febrile
condition during active growth period can lead
on to temporary slowing down of the pace of
growth and development, which will upset the
dental development timetable leading on to
malocclusion.
Nutrition related disturbances such as
rickets, scurvy, and beriberi, can produce
severe malocclusion and may upset the dental
develop­ment.
Abnormal Pressure Habits and
Functional Aberrations
The role of abnormal pressure habits in the
causation of malocclusion will be dealt in
detail in later chapter, here the trident of factors
are important they are Frequency, Intensity
and Duration.
Posture
Poor postural habits are said to be a cause for
malocclusion. Although not substantiated,
they may be associated with abnormal
pressure and muscle imbalance thereby
increasing the risk of malocclusion.
Children who support their head by resting
the chin on their hand and those who hang their
head so that the chin rests against the chest
are observed to have mandibular deficiency.
Poor posture as a cause of malocclusion
although not proved may nevertheless be an
accentuating factor for other malocclusions.
Etiology 131
Accidents and Trauma
Children’s are highly prone to injuries of the
dentofacial region during the early years of life
when they learn to crawl, walk or during play.
Most of these injuries go unnoticed and may
be responsible for nonvital teeth that do not
resorb and deflection of erupting permanent
teeth into abnormal positions.
Local Factors
Anomalies in number of Tooth
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.
a. Supernumerary teeth: Teeth that are extra to
the normal complement are termed super-
numerary teeth. These teeth may have
abnormal morphology and do not resemble
normal teeth. Extra teeth that resemble
normal teeth are called supplemental teeth.
Several theories have been put forth to
explain about the occurrence of supernum­
erary teeth. Frequently seen supernumerary
teeth is the mesiodens which occurs in the
maxillary midline. They can occur singly or
as a pair and are usually conical in shape.
Unerupted mesiodens is one of the causes
of midline spacing. Supernumerary teeth
can also occur in the premolar or third molar
regions. Supple­mental teeth are most often
seen in the premolar and lateral incisor
region. It is not uncommon to find an
extra lower incisor. The supernumerary
and supplemental teeth can deflect the
erupting adjacent teeth into abnormal
locations. Unerupted supernumerary teeth
pose a risk of cystic transformation.
b. Missing teeth: Congenitally missing teeth are
by far more common than supernumerary
132 Essentials of Orthodontics
teeth and can occur in either of the jaws.
The following are some of the commonly
missing teeth in decreasing order of
frequency, third molars, maxillary lateral
incisors, mandibular second premolars,
mandibular incisors, maxillary second
premolars. Absence of teeth can be
unilateral or sometimes bilateral. They
may occur along with other anomalies
such as presence of extra teeth. Absence of
one or more teeth predispose to spacing in
the dental arch. The adjacent teeth migrate
and therefore cause abnormal location
and axial inclination of teeth. Absence of a
permanent tooth quite often results in over
retained deciduous teeth.
Anomalies of Tooth Size
Tooth size is largely determined by heredity.
There is no correlation between tooth size and
arch size. Most commonly we come across
disproportion between tooth size and arch
size leading on to crowding or spacing of teeth.
Commonly seen anomaly is the presence of
smaller sized maxillary lateral incisors, and
mandibular premolars. Occasionally localized
developmental aberrations like supernumerary
tooth fused with adjacent tooth giving rise to a
large tooth, which leads on to crowding of teeth.
Anomalies of Tooth Shape
Anomalies of tooth size and shape are very
often interrelated. Abnormally shaped teeth
predispose to malocclusion. The following are
some of the examples of frequently seen tooth
shape anomalies, presence of peg-shaped
lateral incisor, presence of additional cusp in
mandibular second premolar, mulberry molars
and peg-shaped incisors in congenital syphilis,
anomalies like amelogenesis imperfecta,
hypoplasia of teeth, fusion gemination and
dilacerations.
Abnormal labial Frenum
Abnormalities of the maxillary labial frenum
are quite often associated with maxillary
midline spacing. Prior to the eruption of
teeth, the maxillary labial frenum is attached
to the alveolar ridge with some fibers crossing
over lingually to the region of the incisive
papilla. As the teeth start erupting, alveolar
bone is deposited and the frenal attachment
migrates into a more apical position. Rarely, a
heavy fibrous frenum is found attached to the
interdental papilla region. This type of frenal
attachment can prevent the two maxillary
central incisors from approximating each other.
This condition is diagnosed by a positive
blanch test. When the upper lip is stretched
for a period of time, a noticeable blanching
occurs over the interdental papilla. A middling
intraoral periapical radiograph usually exhibits
notching of the interdental alveolar crest.
Midline diastema may also occur due to
a number of causes including presence of
unerupted mesiodens, anomalies of tooth size
and numbers.
Premature loss of Deciduous Tooth
This refers to loss of a tooth before its perma­
nent successor is sufficiently advanced in
development and eruption to occupy its
place. Early loss of deciduous teeth can cause
migration of adjacent teeth into the space
and can therefore prevent the eruption of the
permanent successor.
Loss of second deciduous second molar can
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 and abnormal position.
Prolonged Retention of Deciduous Teeth
There is no rigid timetable for dental deve­
lopment. Before making a diagnosis of prolon­

ged retention, consideration must be given
to the age of the patient, degree of resorption
of roots of deciduous tooth and the state of
calcification of the permanent teeth. Prolon­
ged retention of decid­uous tooth leads to
altered path of eruption of permanent tooth,
for example, upper permanent central incisor
erupts lingually if the deciduous central incisor
is retained.
Prolonged retention could be due to failure
of resorption of roots of deciduous tooth,
ankylosis, nonvital tooth that do not resorb
and hyper­thyroidism.
Delayed Eruption of Permanent Teeth
There are a number of reasons that can delay
the eruption of permanent teeth, they are,
congenital absence of permanent tooth,
presence of supernumerary tooth, presence
of heavy mucosal barrier, premature loss of
deciduous tooth, endocrinal disorders like
hypothyroidism, and presence of deciduous
root fragments that block the erupting
permanent tooth.
Abnormal Eruptive Path
One of the causes of malocclusion is an
abnormal path of eruption which could be due
to trauma, arch length deficiency, presence of
supernumerary teeth, retained root fragments,
or formation of a bony barrier or idiopathic
in origin. Tooth in abnor­mal eruptive path is
referred to as ectopic eruption.
The maxillary canines develop almost near
the floor of the orbit and travel down to their
final position in the oral cavity. Thus they are
most often found erupting in an abnormal
position.
Ankylosis
Ankylosis is a condition where a part or whole
of the root surface is directly fused to the bone
with the absence of the intervening periodontal
Etiology 133
membrane. This most often occurs as a result
of trauma to the tooth which perforates the
period­ontal membrane. Ankylosis can also be
associated with certain infections, endocrinal
disorders and congenital disorders such as
cleidocranial dysos­t osis. Clinically, these
teeth fail to erupt to the normal level and are
therefore called submerged teeth. At times
these teeth are totally submerged within the
jaw and therefore cause migration of adjacent
teeth into the space.
Dental Caries
Caries can lead to premature loss of deciduous
or permanent teeth thereby causing migration
of contiguous tooth, abnormal axial inclination
and supraeruption of opposing teeth. Proximal
caries that cause migration of the adjacent
teeth into the space leading to a reduction in
arch length. A substantial reduction in arch
length can be expected if several adjacent teeth
involved by proximal caries are left unrestored.
Improper Dental Restorations
Improper dental restorations may predispose
to malocclusion. Over contoured occlusal
restor­a tions cause premature contacts
leading to fun­ctional shift of the mandible
during jaw closure. Under contoured occlusal
restorations can permit the opposing dentition
to supraerupt. Proximal restorations that are
under contoured invariably result in loss of
arch length due to drifting of adjacent teeth
to occupy the space. Poor proximal contact
also causes food lodgments and period­ontal
weakening of the teeth.
ETIOLOGY FOR SPECIFIC TYPES
OF MALOCCLUSION
Causes of crowding: Crowding is commonly
caused by disproportion between arch size and
134 Essentials of Orthodontics
tooth size or arch length discrepancy or relative
macrodontia or micrognathia. Other causes
include prolonged retention of deciduous tooth,
altered path of eruption, premature loss of
deciduous tooth, delayed eruption of permanent
tooth, presence of supernumerary tooth,
trauma, localized abnormal size and shape of
teeth, late horizontal growth of mandible, and
mesial migration of buccal segments.
Causes of generalized spacing: Common
causes of generalized spacing include relative
microdontia and macrognathia, oligodontia,
large tongue, and sucking habits.
Causes of localized spacing: Causes of
local­i­z ed spacing include missing teeth,
undue retention of primary teeth, sucking
habits, premature loss of permanent teeth and
localized soft tissue abnormalities.
Causes of midline diastema: Midline diastema
commonly occurs in maxilla and common
reasons are macrognathia, microdontia,
here­­ditary, Negroid, mild spacing of teeth,
developmental ugly duckling stage, missing
teeth, peg laterals, presence of supernumerary
teeth, extracted teeth, ectopic teeth, midline
cystic lesions, increased overjet and overbite,
thumb sucking, tongue thrusting, frenum
sucking, abnormal labial frenum, retained
deciduous teeth, crowding of teeth, palatally
erupted lateral incisors, and during rapid
palatal expansion (Fig. 4.1).
Causes of anterior cross bite: Causes for ant­er­­ior
cross bites include retained deciduous tooth,
trauma, arch length discrepancy, failure of
resorption of roots of deciduous upper anterior
leads of lingual eruption of permanent teeth,
occlusal prematurities leads to forward path
of closure, loss of upper deciduous molars
leading to collapse of maxillary anterior
segment, asymmetric growth of maxilla and
mandible and class III malocclusion.
Causes of posterior cross bite: Causes of
posterior cross bites are space deficiency,
Figure 4.1: Midline diastema
retained deciduous tooth, sucking habits, nasal
obstruction, narrow maxilla, mouth breathing
and cleft lip and palate.
Causes of anterior open bite: Anterior openbite
occurs during normal course of eruption.
Open bite occurs commonly due to distur­
bances in eruption of teeth and alveolar process,
mechanical interference with eruption and
alveolar growth, gross osseous dysplasias like
micrognathia and mandibular hypertrophy,
soft tissue factors like tongue thrusting, dental
factors like localized alveolar development, and
skeletal factors such as increased lower face
height, increased ramal height, and increased
maxillo mandibular plane angle.
Causes of posterior open bite: Posterior open
bites also occurs during normal course of
eruption,
Posterior open bites can also be due to
lateral tongue thrusting, ankylosed primary
teeth, faulty orthodontic treatment, primary
failure of eruption, chronic cheek biting, and
unilateral chewing habit.
Causes of deep bite: Deep bite commonly
occurs due to combination of skeletal, dental
and neuromuscular factors, common skeletal
factors include decreased lower facial height,

decreased ramus height and low mandibular
plane angle. Dental factors include interincisal
angle, supraeruption of anterior teeth,
undereruption of posteriors, and soft tissue
factors include tongue and high lip line.
Causes for Class II division 1 malocclusion:
Class II division 1 malocclusion commonly
occurs due to Heredity, other causes include
habits and unknown factors.
Causes for Class II division 2 malocclusion:
Class II division 2 malocclusion occurs due to
low tongue posture, and high lip line.
Causes for Class III malocclusion: True Class
III malocclusion is commonly hereditary,
and pseudo Class III occurs due to occlusal
prematurities and early loss of upper deciduous
molars.
HABITS
Oral habits in children have a definite bearing
on the development of occlusion. Frequently,
children acquire certain habits that may either
temporarily or permanently be harmful to
dental structures.
DEFINITION
Habits are learned patterns of muscle contr­
action of a very complex nature.
Habits can also be defined as the tendency
towards an act that has become a repeated
performance, relatively fixed, consistent and
easy to perform by an individual.
Habits are thus acquired as a result of
repetition. In the initial stages there is a
conscious effort to perform the act. Later the
act becomes less conscious and if repeated
often enough may enter the realms of
unconsciousness.
Etiology 135
Johnson (1938) a habit is an inclination or
aptitude for some action acquired by frequent
repetition and showing itself in increased
facility to performance and reduced power of
resistance.
Dorland (1957) defined habit as a fixed
or constant practice established by frequent
repetition.
Stedman: Habit is an act, behavioral res­
ponse, practice or custom established in one’s
repertoire by frequent repetitions of the same act.
Buttersworth (1961) defined a habit as
a frequent or constant practice or acquired
tendency, which has been fixed by frequent
repetition.
Mathewson (1982) defined habit as learned
patterns of muscular contraction.
William James: A new pathway of discharge
formed in the brain by which certain incoming
currents lead to escape.
Maslow (1949): A habit is a formed reaction
that is resistant to change, whether useful or
harmful depending on the degree to which it
interferes with the child’s physical, emotional
and social functions.
CLASSIFICATION OF HABITS
Habits can be generally classified as:
• Useful habits or harmful habits
• Empty habits or meaningful habits
• Pressure habits or nonpressure habits or
biting habits
• Compulsive habits or noncompulsive
habits.
• Primary habits or secondary habits.
William James Classification (1923)
1. Useful habits
2. Harmful habits.
136 Essentials of Orthodontics
Kingsley Classification (1956)
1. Functional oral habit (mouth-breathing)
2. Muscular habits (tongue thrusting)
3. Combined muscular habits (thumb and
finger sucking)
4. Postural habits (abnormal pillowing).
Ernest Klien (1971)
1. Intentional or meaningful habits
2. Unintentional or empty habits.
Graber
Graber classified habits as extrinsic causes of
malocclusion:
1. Thumb or digit sucking
2. Tongue thrusting
3. Lip or nail biting, bobby pin opening
4. Mouth-breathing
5. Abnormal swallow
6. Speech defects
7. Postural defects
8. Psychogenic habits—bruxism
9. Defective occlusal habits.
Finn and Sim (1975)
1. Compulsive oral habits
2. Noncompulsive habits.
Eric Johnson and Brent Larson
Classification of Non-nutritive Sucking
Level 1: Habit that occurs during sleep.
Level 2: Under age of 8 years and occurs at one
sitting during waking hours.
Level 3: Under age of 8 years and occurs
multiple sittings during waking hours.
Level 4: Age over 8 years and occurs one sitting
during waking hours.
Level 5: Age over 8 years and occurs multiple
sittings during waking hours.
Level 6: Girls over 8 years with habits during
waking hours.
According to etiology they are classified as:
1. Physiologic habit (nasal breathing)
2. Pathologic (mouth-breathing).
Useful Habits
These include habits that are considered
essential for normal function such as proper
positioning of the tongue, respiration and
normal deglutition.
Harmful Habits
These include habits that have a deleterious
effect on the teeth and their supporting
structures such as thumb sucking, tongue
thrusting, etc.
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
Pressure habits: These include sucking habits
such as thumb sucking, lip sucking, finger
sucking and also tongue thrusting.
Nonpressure habit: Habit which do not apply
a direct force on the teeth or its supporting
structures are termed nonpressure habit, e.g.
mouth breathing.
Biting habits: These include habits such as nail
biting, pencil biting, lip biting and bruxism.
Compulsive habits: These are deep rooted
habits that have acquired a fixation in the child
to the extent that the child retreats to the habit
whenever his security is threatened by events
which occur around him. The child tends to
suffer increased anxiety when attempts are
made to correct the habit.
Noncompulsive habits: They are habits that are
easily learned and dropped as the child matures.
Primary and secondary habits: Primary habit
is the basic habit along with it may be one

other habit occurring simultaneously called as
secondary habit such as nose probing during
thumb sucking.
THUMB SUCKING AND FINGER
SUCKING
Thumb sucking or finger 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. Recent
studies have shown that thumb sucking may
be practiced even during intrauterine life. In
a newborn infant sucking is well developed
and is the means of his most important single
exchange with the outside world. It not only
receives nutrient from it but also feeling of
euphoria or wellbeing that is so essential
in early life. A sense of security a feeling of
warmth of association and of being wanted
all these universally needed requirements are
satisfied by the infant largely through sucking.
The lips of the infant are sensory organ and
the pathway to brain is well-developed. Later
on as other synapses are developed and
other pathways made available, the child
need not rely so strongly on this venue of
communication. The presence of this habit is
considered quite normal till the age of 3½ to 4
years. Persistence of the habit beyond this age
can lead to various malocclusions.
Sucking Reflex
Sucking reflex is one of the first reflexes present
early in life. The sucking reflex occurs in the oral
stage of development and disappears at abour
3-4 years. Two types of sucking reflexes are
present:
Etiology 137
Nutritive Sucking
Sucking which provides essential nutrients are
known as nutrient sucking.
Breastfeeding: Rapid mandibular protrusion
movements and buccinator mechanism
alternately contracts and relaxes during breast-
feeding. The pressure is exerted so as to suck in
the milk towards esophagus. Gum pads are apart;
tongue and lower lip are in constant contact.
Bottle feeding: Bottle feeding is not normally
advocated till 1 year. Two types of nipples are
available:
Nonphysiological (Conventional nipple): Milk
is directly releases into the digestive tract
reducing the period of predigestion. Flow of
the milk is too rapid. Mouth held wide open.
Greater demand on buccinator mechanism
and suckling is converted to sucking.
Physiological nipple: Forward movement of
tongue under the flat surface of nipple. Nipple
is drawn upward and backward towards the
palate. Child has to work and exercise the
lower jaw. Posterior part of tongue awaits milk
and pushes it into esophageal area. Milk flows
down by the peristaltic action of the tongue
and cheeks. Flat shape of the nipple improves
lip seal, e.g. functionally designed latex nuk
sauger nipple.
Non-nutritive Sucking
Larsson described non-nutritive sucking to be
the earliest sucking habit adopted by infants in
response to frustration and to satisfy their urge
and need for contact. Children who neither
receive unrestricted breastfeeding nor have
access to a pacifier may satisfy their need
with habits like thumb sucking which ensures
a feeling of warmth and sense of security
but may be detrimental to their dentofacial
development.
138 Essentials of Orthodontics
Etiology
A number of theories have been put forth
to explain the causes for thumb and finger
sucking. The following are some of the more
accepted theories:
Non-nutritive digital sucking: Non-nutritive
digit sucking as a means of satisfying hunger.
Classic Freudian theory (1919): This theory was
proposed by Sigmond Freud, he suggested that
a child passes through various distinct phases
of psychological development of which the oral
and the anal phases are seen in the first three
years of life. In the oral phase, the mouth is
believed to be an oroerotic zone. The child has
the tendency to place his fingers or any other
object into the oral cavity. Prevention of such an
act is believed to result in emotional insecurity
and poses the risk of the child diversifying into
other habits. Orality in the infant is related to
pregenital organization and the sexual activity
is not yet separated from taking of nourishment.
Thus the object of one acti­vity thumb sucking
also is that of another, nursing.
Oral drive theory of Sears and Wise (1950):
Their work suggests that strength of oral drive is
in part a function of how long a child continues
to feed by sucking. Thus it is not frustration of
weaning that produces thumb sucking. But,
rather oral drive which, has been strengthened
by the prolongation of nursing.
Benjamin’s theory: This theory holds that
thumb sucking is an expression of or need to
suck arises because of association of sucking
with the primary reinforcing aspects of feeding.
Thumb sucking arises from rooting or placing
reflex seen in all mammalian infants. Rooting
reflex is the movement of the infants head and
tongue towards an object touching his cheek.
The object is usually the mother’s breast but
may also be a finger or a pacifier. This rooting
reflex disappears in normal infants around 7-8
months of age.
Psychological aspects: Children deprived of
parental love; care and affection are believed to
resort to this habit due to a feeling of insecurity.
The mouth an early and perdurable zone of
pleasure is a natural resource for the child
and the adult seeking relief from anxiety. Its
stimulation with a finger, thumb, tongue,
finger­nail, blanket, or pacifier is a universal
tran­quillizer.
Haryettatal’s theory (1957): Haryettatal stro­
n­g ly support that digital sucking habit in
humans are a simple learned response.
Learned patterns: According to Davidson
(1967), thumb sucking is merely a learned
pattern with no underlying cause or psycholo­
gical bearing.
Johnson and Larson (1993): They believed
that it is a combination of psychoanalytic
and learning theories which explains that all
children possess an inherent biologic drive
for sucking. The rooting and placing reflexes
are merely a means of expression of this drive.
Environmental factors also may contribute to
this sucking drive to nonnutritive sources such
as thumb or fingers.
Process of Sucking
The process of sucking is a reflex occurring
in the oral stage of development and is seen
even at 29 weeks IU and may disappear during
normal growth between the ages of 1 and
3½ years. It is the first coordinated muscular
activity of the infant. It is important for meeting
both psychological and nutritive needs during
feeding and apart from seeking nutritional
satisfaction they also experience pleasurable
stimuli from lips, tongue and oral mucosa
and learns to associate these with enjoyable
sensations such as fondling, closeness of a
parent. Babies who are restricted from sucking
due to a disease or other factors become
restless and irritable.

Time of appearance of thumb sucking and
significance:
Those that appear during first weeks of life
are typically related to feeding problems.
Some children do not begin to suck the
thumb or finger until it is used as a teething
device during the difficult eruption of a
primary molar.
Still later some children use it for the
release of mental tension.
Some child’s suck their thumb to attract the
attention of parent.
For the clinical orthodontist most impor­
tant question is simply does the digital sucking
cause malocclusion or not.
Thumb sucking can be allowed till 3 years
of life. It has been shown that damage to
occlusion is confined to anterior segment.
This damage usually is temporary provided
the child starts with normal occlusion.
Thumb sucking after the age of 4 years.
There is likelihood of the permanence of the
deformation of the occlusion. It is not entirely
due to the thumb sucking habit but to an
important assist from perioral musculature.
Type of malocclusion that may develop
depends upon number of variables, like
position of digit, associated orofacial muscle
contractions, the position of mandible during
sucking, the facial skeletal pattern, and force
applied to teeth and alveolar process and
frequency and duration of sucking.
Phases of Development of
Thumb Sucking
Phase I (Normal or subclinically significant):
The first phase is seen during the first three
years of life. The presence of thumb sucking
during this phase is considered quite normal
and usually terminates at the end of phase one.
Phase II (Clinically significant): The second
Etiology 139
phase extends between 3-6½ years of age. The
presence of sucking during this period is an
indication that the child is under great anxiety.
Treatment to solve the dental problem should
be initiated during this phase.
Phase III (Intractable sucking): Any thumb
sucking persisting beyond 5-6 years should
alert the dentist to the underlying psychological
aspect of the habit. A psychologist might have
to be consulted during this phase.
Subteleny Graded Thumb Sucking
into Four Types (1973)
Type A: This type is seen in almost 50% of
the children; where in whole digit is placed
inside the mouth with the pad of the thumb
pressing over the palate, while at the same time
maxillary and mandibular anteriors contact
is present.
Type B: This type is seen in almost 13-24% of
the children wherein the thumb is placed into
the oral cavity without touching the vault of the
palate, while at the same time maxillary and
mandibular anteriors contact is maintained.
Type C: This type is seen in almost 18% of the
children where in the thumb is placed into the
mouth just beyond the first joint and contacts
the hard palate and only the maxillary incisors,
but there is no contact with the mandibular
incisors.
Type D: This type is seen in almost 6% of the
children wherein very little portion of the
thumb is placed into the mouth.
Cook (1953) described three patterns of
thumb sucking based on buccal contractions:
1. Alpha Group: Pushed palate in a vertical
direction and displayed only little buccal
wall contractions.
2. Beta Group: Registered strong buccal wall
contractions and a negative pressure in the
oral cavity show posterior cross bite.
140 Essentials of Orthodontics
3. Gamma group: Alternate positive and
negative pressure; least effect on anterior
occlusion.
Clinical Features
Effects and sequel of thumb sucking:
Thumb and digit sucking are believed to
cause a 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:
Intensity: The vigor with which the habit is
performed.
Duration: The amount of time spent indulging
in the habit.
Frequency: The number of times the habit is
activated in a day.
The following are some of the commonly
seen clinical features of thumb and digit
sucking.
Proclination of maxillary anterior teeth if
thumb is held upwards against the palate.
Increased overjet due to proclination
of upper incisors, some children rest their
hand on the mandibular anteriors during the
sucking act, in such children lingual tipping of
the mandibular incisor can be expected.
Anterior open bite can occur as a result
of restriction of incisor eruption and supra­
eruption of posterior teeth.
The cheek muscles contract during thumb
sucking resulting in a narrow maxillary arch
which predisposes to posterior cross bites.
The child may develop compensatory
tongue thrust habit as a result of anterior open
bite.
The upper lip is generally hypotonic while
the lower part of the face exhibits hyperactive
mentalis activity.
With upset in the force system in and
around the maxillary complex it is often
impossible for the nasal floor to drop vertically
to its expected position during growth,
therefore thumb suckers have a narrow nasal
floor and high palatal vault.
Compensatory tongue thrust, retained
infantile swallow pattern and abnormal
perioral muscle function are strong assists
for thumb sucking in producing the above
mentioned malocclusion.
Diagnosis
The parents should be questioned on the
frequency and duration of the habit. The child’s
emotional status should be assessed enquiring
into such things as feeding habits, parental care
of the child, whether parents are working. An
intraoral clinical examination should record
all the features seen such as proclination,
increased overjet, anterior open bite, etc. The
child’s fingers should be examined. Presence
of clean nails that are chapped with short
fingernails and fibrous roughened callus on
the fingers is commonly associated with thumb
sucking.
Management of Thumb Sucking
Management of thumb sucking involves
preventive measures, psychological methods,
orthodontic appliances and chemical appro­
ach.
Preventive Methods
Prevention of thumb sucking is carried out
by proper nursing of the child. Proper choice
of psychologically designed nursing nipple
is given. Pacifier is given to enhance normal
function and deglutition pattern. Proper kine­
sthetic, neuro­muscular, gratification activity at
this time may well prevent abnormal finger, lip
and tongue deforming action later.
Psychological Methods
Psychological methods involved in correction
of thumb sucking aim at the psychological
cause of the habit.

Basic considerations: The problem is of con­
tro­lling a physiologic process. Therefore,
rationale of therapy must be physiological and
not mech­anical. The attempt always should
be to alter the afferent arm of the reflex, and
this alteration should be thought in terms of
muscle relearning. The rationale of therapy is
that of conditioning responses, not mechanics.
It must be determined whether maloc­
clusion is of primary or secondary concern.
Habit should be treated with the help of a
psychologist, pediatrician, and physicist.
It is usually said that children lacking
parental care, love and affection resort to this
habit. Thus, the parents should be counseled
to provide the child with adequate love and
affection. The parents should also be advised
to divert the child’s attention to other things
such as play and toys.
The success of any habit interception
procedure largely depends upon 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
the child.
Five questions to be asked before habit
retraining (Finn):
• Child’s understanding
• Parent’s cooperation
• Friendly rapport
• Goal orientation
• Maturity.
Role of parents: Parents’ role is that of an
umpire, the arbitrator who calls the fouls and
decides, when the child is safe or not. The
referee has an essential function otherwise
chaos would ensure without him. Child should
be explained with the help of audiovisual aids,
that he will develop crooked teeth if the habit
is continued.
Etiology 141
Dunlap’s Beta Hypothesis
This theory states that the best way to break a
habit is by its conscious, purposeful repetition.
Dunlap suggests that the child should be asked
to sit in front of a large mirror and asked to suck
his thumb observing himself as he indulges in
the habit. This procedure is very effective if the
child is asked to do the same at a time when
he is involved in an enjoyable activity. This
theory holds that by practicing a bad habit with
the intent to stop it one learns not to perform
the undesirable act. The method can only be
practices successfully in older children whose
cooperation can be obtained.
Precautions/Care to be Taken
Child must know that the intention in having
him practice the habit is to break the habit.
Child is not to be allowed to fall into day
dreaming or derive satisfaction from the
repetition of the habit, but will experience
painful reaction in its performance and will
gradually abandon the habit.
Chemical Methods
Use of bitter tasting or foul smelling preparation
that is nonpalatable is placed on the thumb
that is sucked can make the habit distasteful.
The medicaments that may be used are Pepper
dissolved in a volatile medium, Quinine,
Asafetida, Neem oil.
Mechanical Methods
Mechanical aids that can be used to control the
thumb sucking include, bandaging the thumb,
applying socks or gloves to fingers, tying fingers
with tongue spatula, arms can be tied to the
bed, and bandaging with elbow.
Do it yourself kit as advocated by Whitman:
Reminder lotion is applied on the thumb a
142 Essentials of Orthodontics
magic pill (placebo) to be taken at bed time.
The child is told the pill goes into the stomach
up into your shoulder, down the arm into your
arms into your thumb, and then automatically
pops out of your mouth.
Three alarm system: It is effective in more
mature children in age group of 8 years and
above. During the time when the child engages
in sucking habit ask him to tie an adhesive
tape. When he feels the tape in the mouth it
acts as first alarm and reminds him to stop.
At the same time, elbow of the arm with the
offending thumb is firmly but not tightly
wrapped in a two inch elastic bandage. Safety
pins are placed in proximal and distal ends of
the bandage. One pin is placed lengthwise in
the medial bend of the elbow. When he sucks,
pin mildly jabbing indicates second alarm. If
the child continues, elastic bandage will be
tightened and his hand falls asleep as a third
and final alarm.
Thermoplastic Thumb Posts
Allen in 1991 devised a thermoplastic thumb
post which was placed on the offending digit. A
total of 6 weeks of treatment time was required
for elimination of habit.
Orthodontic Treatment
Orthodontic appliances for correcting thumb
sucking habit acts as a mechanical barriers
and prevent thumb sucking. They are basically
reminding appliances that assist the child who
is willing to quit the habit but is not able to do
so as the habit has entered a subconscious
level. These appliances usually consist of a
crib placed palatal to the maxillary incisors.
They can be:
a. Removable appliances: They are a passive
removable habit breaking appliances that
consist of a crib and is usually anchored to
the oral cavity by means of clasps on the
posterior teeth. For example,
i. Reminder appliance—simple acrylic
plate
ii. Appliance with tongue spikes
iii. Appliance with tongue guard
iv. Oral screen.
b. Fixed appliances: These habit breakers are
fixed to the teeth. Heavy gauge stainless
steel wire can be designed to form a frame
that is soldered to bands on the molars.
They are commonly used in uncooperative
patients. For example:
i. Fixed rakes
ii. Sharpened fork
iii. Soldered grate appliance
iv. Upper lingual arch
v. Quadhelix appliance.
Blue Grass Appliance
Haskell (1991) introduced this appliance, for
children with a continued thumb sucking
habit, which is affecting the mixed or
permanent dentition. It consists of a modified
six sided roller machined from Teflon to permit
purchase of the tongue. This is slipped over a
0.045 stainless steel wire soldered to molar
orthodontic bands. This appliance is placed for
3-6 months. Instructions are given to turn the
roller instead of sucking the digit. Digit sucking
is often seen to stop easily.
Once the thumb sucking habit is corrected
the associated features of the habit such as
increased overjet, deep bite, etc. are corrected
with removable appliances or fixed appliances.
TONGUE THRUSTING HABIT
Tongue thrusting is defined as a condition in
which the tongue makes contact with any teeth
anterior to the molars during swallowing.
Proffit defined tongue thrust as placement
of the tongue tip forward between incisors
during swallowing.

Brauer (1965) defined tongue thrusting as
when tongue was observed thrusting between
and the teeth that did not close in centric
occlusion during deglutition.
Tulley (1969) states tongue thrust as a
forward movement of the tongue tip between
the teeth to meet the lower lip during deglu­
tition and in sounds of speech, so that the
tongue becomes interdental.
Barber (1975) tongue thrust is an oral
habit pattern related to the persistence of an
infantile swallow pattern during childhood and
adolescence and thereby produces an open bite
and protrusion of the anterior tooth segments.
Norton (1978) explained it as condition in
which the tongue protrudes between anterior
and posterior teeth during swallowing with or
without affecting tooth position.
Schneider (1982) tongue thrust is a forward
placement of the tongue between the anterior
teeth against the lower lip during swallowing.
Etiology
Fletcher has developed the following factors
as etiologic factors in tongue thrust syndrome:
Genetic Factors
Genetic factors are most common cause
for tongue thrusting, inherited variation
on orofacial form that precipitate a tongue
thrust patterns. Inherited orbicularis oris
hypertony resulting from specific anatomical
consideration and neuromuscular interplay
gener­ating a tongue thrust pattern of swallow­
ing. Genetically predetermined patterns of
mouth behaviors are also one of main causes
of tongue thrusting.
Learned Patterns
Learned patterns include, improper bottle
feeding, which results in abnormal functional
patterns of lingual movements in the form of
Etiology 143
tongue thrust. Protracted period of tenderness
of soreness of gum tissue and teeth, keeping
the teeth apart during swallowing and thereby
changing swallowing pattern causing tongue
thrusting.
Prolonged thumb sucking with the habitual
movements generalized to tongue activity.
Tongue held in open spaces during mixed
dentition.
Prolonged tonsillar and upper respiratory
tract infections may lead to forward placement
of tongue.
Maturation: Maturation factors include:
Tongue thrust as a part of normal childhood
oral behavioral pattern that is gradually
modified as the lingual space and suspensory
system change.
Tongue thrust as an evidence of late matu­
ration from infantile suckle swallow.
Late maturation or retention of immature
patterns of general oral behavior, of which
tongue thrust, is a symptom.
Mechanical restriction: Macroglossia which
limits space in the oral cavity and forces as
forward thrust to manipulate the bolus.
Constricted dental arches, which causes
the tongue to function in a lower than usual
position.
Enlargement of tonsils and adenoids,
which reduces the space available for lingual
movements.
Neurological disturbances: Hyposensitive
palate which precipitate crude patterns of food
manipulation and swallowing.
Disruption in tactile sensory control
and coordination of swallowing because of
inadequate underlying skeletodental configur­
ation.
Psychogenic Factors
Substitution of tongue thrust for forcibly
discontinued finger sucking.
144 Essentials of Orthodontics
Exaggerated motor image of tongue.
Craniofacial growth and maturation:
At birth size of tongue is half of the adult
size; hence it is usually protruded between
gum pads. By adulthood, the skeletal jaws will
usually grow sufficiently to compare favorably
in size with the muscular tongue and thereby
permit the tongue to rest and function more
within the confines of the oral cavity. This
could explain the degree of reduction of tongue
thrusting with advanced age.
Open Spaces during Mixed Dentition
Rogers proposed that diastema caused by loss
of primary teeth would entertain the tongue to
interpose in their open spaces. Such gap filling
excursion of the tongue may be an adaptive
tongue thrusting tendency.
Other Factors
Other factors which may cause tongue
thrusting include anesthetic throat, brain
injury, faulty orthodontic treatment, sleeping
habits, sleeping towards one side, oral sensory
deficiency, etc.
Classification of Tongue Thrust
Moyer’s classified tongue thrusting as:
• Normal infantile swallow
• Normal mature swallow
• Simple tongue thrust swallow
• Complex tongue thrust swallow
• Retained infantile swallow
• Backlund (1963) classified tongue thrust
as:
Anterior tongue thrust: Tongue thrusting
in anterior direction.
Posterior tongue thrust: Tongue thrusting
in lateral directions causing posterior open
bite.
Pickett (1966) classified tongue thrust as:
Adaptive: Tongue adapts to the open bite
caused by missing teeth or thumb sucking
habit.
Transitory: Tongue is put forward only for a
short period.
Habitual: Tongue is placed habitually due to
postural problems or open bite.
James S Braner and Holt classified tongue
thrust as:
Type I: Nondeformity tongue thrust
Type II: Deformity anterior tongue thrust
Subgroup 1: Anterior open bite
Subgroup 2: Anterior proclined
Subgroup 3: Posterior cross bite
Type III: Deformity lateral tongue thrust
Subgroup 1: Posterior open bite
Subgroup 2: Posterior cross bite
Subgroup 3: Deep over bite
Type IV: Deformity anterior and lateral tongue
thrust
Subgroup 1: Anterior and posterior open
bite
Subgroup 2: Anterior proclined
Subgroup3: Posterior cross bite
Clinical Features
Tongue thrusting habit can be deforming
or nondeforming, the term nondeforming
indicates that the interdigitation of teeth and
the profile are acceptable and within normal
range. Deforming tongue thrust is associated
with some dentoal­veolar defects.
Tongue thrusting habit can be associated
with the following features, proclined upper
anterior teeth, anterior open bite, bimaxillary
protrusion, posterior open bite in case of
lateral tongue thrust, posterior crossbite.
Simple Tongue Thrust
It is defined as tongue thrust with a teeth toge­
ther swallow. Malocclusion which is associated
with it is usually a well-circumscribed type of
open bite in the anterior region. No cuspal

interference, there is perfect fir of posterior
teeth in occlusion. Intercuspation is firm
but the anteroposterior relationship is not
necessarily correct (may be Class II or Class
III). It is associated with abnormal functioning
of the lips, mentalis and other circum- oral
muscles. As the patient swallows anterior lip
seal is made partly with the teeth and partly
with the lips. The inferior orbicularis cannot
elevate itself; it must be elevated with help of
mentalis. Teeth are held together prior to and
throughout swallowing (reverse swallowing).
Open bite observed has a definite beginning
and ending. Prognosis is excellent.
Complex Tongue Thrust
This is defined as tongue thrust with teeth apart
swallow. The malocclusion associated with it
has two distinct characters, poor occlusal fit
prompting a sliding into occlusion. There is
generalized anterior open bite. Absence of
temporal contraction during swallowing is
common in complex tongue thrust. There is
dropping of mandible and strong contraction of
circum oral muscles. Prognosis for correction
of a complex tongue thrust is fair at best as
there are two neuromuscular problems that
of abnormal occlusal reflex and abnormal
swallow reflex.
Retained Infantile Swallow (Figs 4.2A and B)
This is persistence of the infantile swallowing
reflex after the arrival of the permanent teeth.
Very few people have this problem. Teeth
occlude only on one molar in each quadrant.
They demonstrate violent contractions of
seventh cranial nerve musculature during
swallowing and tongue is markedly protruded
between all the teeth during initial stages
of swallow. Expressionless face since facial
muscles is used for stabilizing mandible.
Following teeth loss, satisfactory denture
Etiology 145
A
B
Figures 4.2A and B: Infantile swallow
prosthesis is almost impossible. Prognosis for
correction is poor.
Diagnosis
Careful diagnosis of tongue thrust is made
and it must be differentiated between simple
tongue thrust, complex tongue thrust, and
retention of an infantile swallowing pattern or
just faulty tongue posture.
Tests for diagnosis: When the jaw drops and
ment­alis muscle contracts strongly there is
probably a tongue thrust.
Part the lips to watch tongue thrust and in
doing so we can feel the strong muscle con­
tractions.
Cinefluorography study: When the patient
was told to swallow the camera is started,
a cine­fluorographic film was made of the
movements of the tongue from the beginning
of the swallowing pattern regarding backward
and downward movements of the tip of tongue
until the tongue moved back to its original
position at the end of swallowing which was a
matter of seconds. After the cinefluorographic
film had been developed the tracing technique
consisted of drawing a straight line from labial
of the upper central incisor downwards until
it extended past the lower incisor. Then a
measurement was made of how far the tongue
146 Essentials of Orthodontics
extended past this line or of how much tongue
failed to meet this line.
Payne technique: Orabase with 1% sodium
fluorescein solution in a water-soluble base
is used to identify the movements of tongue.
Management of Tongue Thrust
Management of tongue thrust involves inter­
ception of the habit followed by treatment to
correct the malocclusion.
Factors to be considered: Factors that are
to be considered before correcting tongue
thrust includes, identification of type of
malocclusion (Class I, II, III) degree of maloc­
clusion, scope of problem, maturity of child,
attitude and degree of cooperativeness of
the parents, speech defects, other associated
habits, progressive malocclusion should
be considered for immediate treatment,
structural considerations such as nasal block,
narrow palate, macroglossia or ankyloglossia.
Psychological methods: Learning of a new
reflex at the conscious level, teach the exact
position of tongue by pointing with patients
own index finger; ask the patient to swallow
by holding the tongue in that position. The
child is taught the correct swallowing method.
Transferal to the subconscious level: By
this position it is to reinforce the reflex at
subconscious level done by placing flat
sugarless fruit drops at the position occupied
by tip of tongue. Tongue thrusting often self
corrects by 8-9 years when the permanent
anteriors completely erupt and the improved
muscular balance during swallowing.
Orthodontic Treatment
The tongue thrust can be intercepted by use of
habit breakers as described for thumb sucking.
Both fixed and removable cribs and rakes are
valuable aids in breaking the habit (Fig. 4.3).
Oral screens can be used. Nance palatal
button can be used to guide the tongue.
Figure 4.3: Fixed tongue guard
Bead appliance or lingual pearl: They are small
bead like rollers placed in the rugal areas;
patient is asked to place the tip of tongue over
the beads and asked to swallow.
Once the habit is corrected the associated
features such as anterior open bite, posterior
cross bite, etc. are corrected with either
removable or fixed orthodontic appliances.
Preorthodontic trainer: This appliance aids in
the correct positioning of the tongue with the
help of tongue tags. The tongue guards prevent
tongue thrusting when in place.
Myotherapeutic exercises: Various muscle
exercises of tongue can help in training it to
adapt to the new swallowing pattern.
Initial exercises: Assure molar occlusion,
position the tip of the tongue and sucking.
Total exercise: With elastic on tip of the tongue,
lift the elastic into position on the rugal edge,
check mentally see that elastic is not slipped,
keeping lips apart slurp and swallow, close
teeth in molar occlusion.
Exercises for anterior position of tongue: Tongue
lifting exercises—tongue hold pull exercise—
similar to total exercise but mandible is lowe­
red resulting in stretching of lingual frenum.
Positioning the blade of the tongue—molar
occlusion: Locate masseter muscle, bite with
sufficient force, ‘T’ sound is made, relax and

repeat, this exercise is similar to masseter
count to 10 exercise.
Exercise for Middle 1/3rd and
Posterior Tongue
Two elastic swallow—put one elastic on tip of
tongue, another on middle 1/3rd of tongue,
raise it against the palate and swallow.
Three elastic swallow—in addition to the above
one elastic is placed on posterior part of tongue
and exercises are repeated.
‘K’ swallow—put three fingers between teeth,
make ‘k’ sound, freeze in that position and
swallow as quickly as possible.
4S exercises: This includes identifying the spot,
salivating, squeezing the spot and swallowing.
Use the pressure point on the papilla to
show where the spot is. This tip is against this
spot at rest position. The child then learns the
2S exercise. Spot and squeeze. Spot should
be the rest position for the tip of the tongue.
Squeeze is done by squeezing the tongue
vigorously against the spot with the teeth
closed, followed by relaxing. When the child
has done the 2S exercise have him do the 4S
exercise. Place the tongue on the spot, salivate,
squeeze against the spot and swallow.
Speech Therapy
The first step towards speech therapy should
be to train in the correct positioning of the
tongue. This tongue posture is more conductive
to the articulation of speech and to the normal
alignment of the teeth. However, such therapy is
not indicated before the age of 8 years. The child
is asked to repeat simple multiplication table of
sized and to pronounce words beginning with
‘s’ sound.
Surgical Treatment
The treatment of retained infantile swallow
behavior is difficult and often consists of
orthognathic surgical procedures to correct
Etiology 147
the skeletal malformation as well as myofun­
ctional therapy. The prognosis is guarded and
the relapse may occur if the tongue does not
adapt to the new skeletal environment.
In cases involving excessive increase in
lymphoid tissue with resulting abnormality of
tongue position, reduction of that lymph­oid
tissue is followed by a spontaneous impro­
vement in tongue position.
MOUTH-BREATHING
There are two conditions of upper respiratory
tract which complicate the breathing process
at birth.
Complete or partial atresia (of posterior
nares).
Congenital Micrognathia
As the child grows older laryngeal skeleton
descends in the neck and air can be taken
through the mouth, but this is normally
prevented by three sphincter mechanism
(Whillis) namely anterior sphincter formed
by lips, intermediate sphincter by tongue and
hard palate and posterior sphincter formed
between soft palate and dorsum of the tongue.
Mouth-breathing can only occur with
the failure of any of these barriers. When
it does occur it is mostly intermittent and
more common at night. Very rarely there is
complete nasal obstruction (e.g. complete
congenital atresia). Therefore, strictly speaking
mouth-breathing should be termed oronasal
breathing.
Mouth-breathing has been attributed as
a possible etiologic factor for malocclusion.
The mode of respiration influences the
posture of the jaws, the tongue and to a lesser
extent the head. Thus it seems quite logical
that mouth-breathing can result in altered
jaw and tongue posture which could alter
148 Essentials of Orthodontics
the orofacial equilibrium thereby leading to
malocclusion. Most normal people indulge
in mouth-breathing when they are under
physical exertion such as during strenuous
exercise or sports activity.
Sassouni (1971): Defined mouth-breathing
as habitual respiration through the mouth
instead of the nose.
Merle (1980): Suggested the term oronasal
breathing instead of mouth-breathing.
Chacker (1961): Defined mouth-breathing as a
prolonged or continued exposure of the tissues
of anterior areas of mouth to the drying effects
of inspired air.
Etiology
Physiologic
Mouth breathing occurs where there is air
hunger, e.g. in normal children with heart
disease, as a normal behavior during exercise,
e.g. running.
Obstructive
Complete or partial obstruction of the nasal
passage can result in mouth-breathing. The
following are some of the obstructive causes
of mouth-breathing, Deviated nasal septum,
narrow nasal passage associated with narrow
maxilla, inflammatory reaction of nasal
mucosa with edema, allergic reaction of
nasal mucosa, nasal polyps, localized benign
tumors, congenital enlargement of nasal
turbinates and obstructive adenoids.
Habitual
A habitual mouth breather is one who
continues to breathe through his mouth even
though the nasal obstruction is removed. Thus,
mouth-breathing becomes a deep rooted habit
that is performed unconsciously.
Anatomic
An anatomic mouth-breather is one whose
lip morphology does not permit complete
closure of the mouth, such as a patient having
short upper lip. In rare cases mandible is not
supported in normal position at rest. For
no apparent reason, there is an increased
freeway space or interocclusal clearance.
The tongue falls away from palate. The lip
therefore do not effect in anterior seal through
competent to do so. This type can be found in
the complete absence of any upper respiratory
tract obstruction and is seen in children who
are intelligent and are not mentally alert.
Classification
Sim and Finn classified mouth-breathing as:
1. Obstructive
2. Habitual
3. Anatomical.
Pathophysiology
During oral respiration, the following three
changes in the posture occur, lowering of
mandible, positioning the tongue downwards
and forwards and tipping back of the head.
Lowering of the tongue and mandible
upsets the orofacial equilibrium. There is an
unrestricted buccinator activity that influences
the position of the teeth and also the growth of
the jaws.
Clinical Features
The type of malocclusion most often associated
with mouth-breathing is called “long face
syndrome” or the classic “adenoid facies”.
These patients have a combination of clinical
signs as follows:
• Long and narrow face
• Narrow nose and nasal passage

• Short and flaccid upper lip
• Contracted upper arch with possibility of
posterior cross bite.
• Receeded lower jaw
• An expressionless or blank face
• Increased overjet as a result of flaring of the
incisors.
Anterior marginal gingivitis can occur
due to drying of the gingiva and increase in
gingival inflammation and the prevalence of
supragingival and subgingival calculus, but
not associated with plaque accumulation.
Lips are apart in posture many of these
patients have incompetent lips with gummy
smile, hypotonic upper lip and hypertonic and
curled lower lip.
Dryness of mouth which predisposes to
dental caries.
Anterior open bite may occur, along with
speech defects.
Disuse atrophy of external nares is seen in
chronic mouth breathing.
Associated habits like thumb sucking and
tongue thrusting.
Chronic mouth-breathing may lead to otitis
media. There is also dull sense of smell and loss
of taste.
Diagnosis
History: Good clinical history should be
recorded from the patient as well as parents.
History of frequent nasal blocks or allergy will
suggest mouth-breathing.
Clinical examination: Look for the classical
clinical features, simple tests such as mirror
test; water test, etc. can be done to diagnose
the mouth-breathing habit.
Clinical signs such as dry gingival, frequent
dryness of mouth, hoarseness of voice,
presence of typical malocclusion of mouth-
breathing and association of other habits may
suggest mouth-breathing.
Etiology 149
Dr Bushey has given a six point clinical
routine examination designed to alert the
orthodontist to a significant morphologic
and functional characteristics of a mouth-
breathing patient.
Step 1: Look for mouth gaping or lip incom­
petancy when the patient is in a relaxed
posture. A short, flaccid and atrophic upper
lip is typical of adenoid faces.
Step 2: Evaluation of nares and nasofacial
angle. The nares are narrow and pinched-
together the entire base of the nose is often
tipped up.
Step 3: Evaluation of the mode of respiration.
Simple techniques can be used such as,
first asking the patient to seal the lips for
1-2 minutes and assessing the ease of nasal
breathing. Then ask the patient to seal the
lips and alternately collapse each nostril to
evaluate nasal and/or pharyngeal obstruction.
The potential obstruction is amplified by
having the patient to hum through one nostril
while other is closed. A cold mirror test can
also be used or a cotton tuft can be held at the
nostrils to check for nasal breathing.
Also ask history of upper respiratory
infections, tonsillitis, respiratory allergies,
middle ear infections, etc.
Step 4: Determination of whether there is a
teeth-together or a tooth-apart swallow. The
presence of a simple or a complex tongue
thrust can alert the clinician to the potential
complications caused by an adaptive or active
tongue habit.
Step 5: Clinical assessment of frontal facial
morphology. The long, dolichofacial form is
more often associated with mouth-breathing.
Step 6: Assessment of the most significant
clinical characteristics which are found within
the oral cavity.
Cephalometrics: Cephalometric evaluation
helps in establishing the amount of nasoph­
150 Essentials of Orthodontics
aryngeal space, size of adenoids and also helps
in diagnosing the long face associated with
mouth-breathing.
Rhinomanometry: It is the study of nasal
airflow characteristics using devices consisting
of flow- meters and pressure gauges. These
devices help in estimation of airflow through
the nasal passage and nasal resistance.
Management
Elimination of Etiology
Elimination of the causative factors such as
removal of nasal or pharyngeal obstruction
should be removed by referring the patient to
the ENT surgeon.
Symptomatic Treatment
The gingival of the mouth breathers should
be restored to normal health by coating the
gingival with petrolatum jelly, by applying
preventive dentistry methods and by clinically
correcting the periodontal defects that have
occurred due to the habit.
Interception of Habit
Exercises: If there is no physiologic cause the
patient should be instructed I breathing and lip
exercises. Deep breathing exercises are done
with deep inhalation through the nose with
arms raised sideways. After a short period,
the arms are dropped to the sides and the air
is exhaled through the mouth.
Lip exercises: Hypotonicity and flaccidity of the
upper lip are the most obvious characteristics.
The child is instructed to extend the upper lip
as far as possible to covering the vermilion
border under and behind the maxillary
incisors. The exercise should be done 15-30
minutes a day for a period of 4-5 months when
the child has a short upper lip. If the maxillary
incisors are protruded, the lower lip can be
used to augment the upper lip exercise. The
upper lip is first extended into the previously
described position. The vermilion border of
the lower lip is then placed against the outside
of the extended upper lip and pressed as hard
as possible against the upper lip. This type of
exercise exerts a strong retraction influence
on the maxillary incisors, which increases the
tonicity of both the upper and lower lips.
Mouth-breathing can be intercepted by use
of an oral or vestibular screen. Alternatively
adhesive tapes can be used to establish lip seal.
Ehrlich states that mouth breather present a
special problem at night times parent should
check the sleeping child and close the lips.
Patients with narrow, constricted maxillary
arches benefit from rapid maxillary expansion
procedures aimed at widening the arch.
Rapid maxillary expansion has been found to
increase the nasal airflow and decrease the
nasal air resistance.
Maxillothorax myotherapy: This was advo­cated
by Macaray in 1960. These expanding exercises
are used in conjunction with the Macaray
activator. Macaray constructed an activator
out of aluminium with which development of
the dental arches and dental base relationship
could be corrected at the same time as
enco­uraging mouth breathing. This stable
aluminium activator is incorporated at the
angle of the mouth, with horizontal hooks to
which expanding rubber bands are attached.
The mouth breather holds the activator in the
mouth and at the same time with the left and
right arms alternately carries out 10 exercises
3 times a day.
He stands with his back against the wall,
rises and lowers on his toes in time to the
expander exercises holding the lips tight
together and carries out a lightly forced
breathing technique in front of an open
window. These myotherapeutic exercises
are indicated for mouthbreathers. They
also help prevent a relapse. The additional
myotherapeutic expander exercise during

bimaxillary treatment help to establish physio­
logical nasal breathing, as well as correcting
maldevelopment of the thorax.
LIP BITING AND LIP SUCKING
Lip sucking may occasionally develop as a
substitute for thumb or finger sucking. BJ
Johnson describes the most common form of
the lip biting habit as follows.
The first motion of the act consists of
wetting the lips with the tongue. The lower lip
is turned inward and tongue goes back into
the mouth. As the tip of the tongue passes the
incisal edges of maxillary incisors, the lower lip
is caught between maxillary and mandibular
teeth and pressure is exerted as the lip slowly
returns to its original position.
The force produced by lower lip as it
slides around the teeth moves maxillary
incisor labially and mandibular incisors
lingually. The deformity reaches maximum
when discrepancy between the maxillary and
mandibular incisors become equal to the
thickness of lower lip.
In severe cases the lip itself shows the
effects of abnormal habit. The vermilion border
becomes hypertrophic and redundant during
the rest. The mentolabial sulcus becomes
accentuated. In some cases chronic herpes
and cracking of lips appears. Occasionally
the lip sucking habit becomes a compulsive
and gratification activity particularly during
the sleeping hours. The redness and irritation
extending from mucosa or to the skin below the
lower lip which occurs due to lip biting can be
seen by an observant dentist.
Differential Diagnosis
In Class II division 1 malocclusion lip sucking
may be purely compensatory or adaptive to
the dento-alveolar morphology.
Etiology 151
Management
Correction of lip biting or lip sucking is by lip
bumper or lip plumper; the effects of appliance
permit the tongue to move the mandibular
incisors labially. This not only improves the
axial inclination, but frequently the overbite
is reduced. In some instances where there
seems to be functional activity, the placing of
lip appliance at this time allows the incisors
to come forward and the mandible may also
do the same. This is the same effect as seen in
frankel type appliance.
BRUXISM
[Synonyms: Neuralgia traumatic (Karolyi),
Karolyi effect (Weski), Occlusal habit neurosis
(Tisher), Parafunction (Drum)].
The term bruxism is derived from the
French work La bruxomanie suggested by
Marie and Pietkiewicz in 1907. Karolyi did not
use the term Bruxism but introduced most of
the concepts of this condition in 1901.
Bruxism is commonly defined as a gnashing
and grinding of the teeth for nonfunctional
purposes.
Miller suggested differentiation between
nocturnal grinding of the teeth, which he
called Bruxism and habitual grinding of the
teeth in day time which he called Bruxomania.
Ramjford (1961) defined bruxism as
nocturnal, subconscious activity but can occur
during the day or night and may be performed
consciously.
Etiology
Psychological and emotional stresses have
been attributed as one of the causes of bruxism.
The vicious cycle of self-perpetuating increase
in tension, related to functional disturbances
in teeth, periodontium other oral tissues,
TMJ and masticatory muscles is the basis for
152 Essentials of Orthodontics
bruxism in persons with psychic or emotional
stresses. Occupational factors are also found to
be one of common cause for bruxism.
Occlusal interference or discrepancy
between centric relation and centric occlusion
can predispose to grinding. In addition
working side or balancing side interferences
can also trigger bruxism.
Local factors other than occlusal inter­
ferences may contribute to hypertonicity of
muscles and initiate abnormal jaw move­
ments such as Pericoronitis, periodontal
disease, surface irregularities of lips, cheek and
tongue and pain or discomfort in TMJ and jaw
muscles.
Organic diseases such as chorea, epilepsy,
meningitis and gastrointestinal disorders may
also cause bruxism.
Clinical Features
1. Occlusal or incisal attrition patterns that
do not conform to or coincide with normal
masticatory or swallowing wear patterns.
a. Such wear facets are seen at the incisal
tip of maxillary cuspids; these facets of
wear are often rounded over to the labial
surface of cusp tip instead of blending
into the lingual attrition facets that
occur from mastication.
b. Wear pattern of long-standing bruxism
is often very uneven and usually more
sever on anterior than on posterior teeth
in natural dentition.
c. In patients who have denture, the wear
may be more sever on the posterior
teeth than the anterior teeth since
the stability of the denture allows for
the greatest pressure in the posterior
regions.
2. Unexpected fractures of teeth or restor­
ations.
3. Unexpected mobility of teeth. Increased
mobility is often associated with bruxism
and is especially significant when found
in teeth with very little or no evidence of
periodontal disease.
4. Increased tonus and hypertrophy and
masticatory muscles.
5. Soreness of masticatory muscles:
a. Masticatory muscles are tender to
palpation.
b. Tender spots are more common along
the anterior and lower border of the
masseter and medial pterygoid muscles
but may also be found in temporal
regions.
c. Sometimes patients with bruxism com­
plain of tired feeling in the jaws when
they wake up in the morning
d. They experience a locking of jaw and the
masseter and temporal muscles have
to be massaged before the jaws can be
opened.
e. Patients with hypertonicity of jaw
muscles, and bruxism may bite their
cheeks and lips and tongue accidentally
as a result of sudden contraction of these
muscles.
f. Sometimes headaches of the type
usually called tension of emotional are
associated.
6. TMJ discomfort and pain. Patients with
TMJ discomfort and pain of a traumatic
nature usually grind their teeth.
7. Maxillary and mandibular exostosis.
8. Audible occlusal sounds of nonfunctional
grinding.
Diagnosis
History and clinical examination: The classical
clinical features are noted.
Electromyograph: Electromyograph shows
abnormally high muscle tonus in the jaw
muscles, especially as an inability to relax
between occlusal contacts is highly indicative
of bruxism.

Occlusal analysis: Occlusal analysis is done
to detect any occlusal prematurities. Use of
temporary bite planes or occlusal splints
to achieve muscle relaxation is needed for
diagnosis of the occlusal trigger factors of
bruxism.
Management
Since bruxism has a dual cause that includes
psychic and local occlusal factors, a rational
treatment should include the elimination of
both disturbing etiologic factors.
Psychotherapy: Psychoanalysis should be
carried out and appropriate treatment should
be given by clinical psychologist.
Autosuggestion and hypnosis: They have been
suggested as a favorite therapy for bruxism by
several authors.
Relaxing exercise and physiotherapy: Relaxing
exercises both general and local nature may
serve to decrease the muscle tension and
bruxism. Electrogalvanic stimulation for relax­
ation is found to be effective.
Exercises, massage, heat and other forms
of physiotherapy will provide some relief for
bruxism as for myalgias of postural or other
nature, but since it does not cure the bruxism
it should be used only to support other forms
of therapy.
Acupressure: Accupressure and transcutaneous
electrical nerve stimulation is found to be
effective in bruxism.
Ultrasound : Ultrasound provides analgesic
effect for masticatory muscles and reduces
pain.
Drugs: Drugs like vaso-coolants for pain, local
anesthetic drugs in TMJ area, tranquilizers
and sedatives and muscle relaxants are used
for bruxism.
Elimination of oral pain and discomfort:
Elimination of oral pain and discomfort
associated with periodontal disease or
pathologic conditions in the lip, cheek and
Etiology 153
tongue as well as pain or irritation elsewhere
in the masticatory system will lower the muscle
tonus and have a favorable effect upon bruxism
both from the stand point of local factors and
from the standpoint of the central nervous
system.
Occlusal therapy: Occlusal therapy is one of
the main treatment modalities to relieve the
local etiologic factors and to provide reduction
in tooth attrition. They include, occlusal
adjustments like removal of sharp edges and
equilibration of occlusion, bite raising crowns
on molars or bite raising appliances, cap splint,
onlays, acrylic anterior or posterior bite planes
either removable or fixed and soft or hart
rubber splints.
The purpose of bite plate and splints are
to stop bruxism by elimination of occlusal
interferences, to let the patient grind the teeth
against acrylic or two occlusal splints and
thereby avoid occlusal wear and to restrict
the jaw movements and break the habit of
bruxism.
Main requirements of the bite plates are
that it should eliminate occlusal interferences
with minimal amount of bite opening and to
maintain a stable position of the teeth while
the appliance is in use.
Others: Other causes for bruxism are to be
explored and treated like desensitizing agents,
occlusal correction, nutritional counseling and
nutritional supplements.
FINGER NAIL BITING
Nail biting does not produce gross maloc­
clusion. It is commonly absent in childrens
less than 3 years of age. There is rapid increase
at 6 years of age; there is a constant trend to
10 years of age in girls and 12 years in boys
followed by a sharp two years rise at puberty
11 to 12 years in girls and 13 to 14 years in
154 Essentials of Orthodontics
boys followed by a rapid decline after the age
of 16 years.
This habit is usually replaced at adolescent
by lip biting, gum chewing or smoking which
is more common in boys. Habit shows a high
correlation with stuttering but is present among
well-adjusted as well as poorly adjusted children.
On examination nail biters disclose crow­
ding, rotation and attrition of incisal edges of
mandi­bular incisors. Malocclusion is due to
untoward pressure introduced during nail biting.
Management includes application of nail
polishes in girls and cutting of nails.
TONGUE SUCKING
It is an activity similar to thumb sucking and
usually disappears by about 2nd year of life.
If per­sisting in later childhood there may be
an organic causation such as oral irritation
or allergy.
Tongue sucking may be a substitute habit
when thumb sucking is prohibited to the child.
PILLOWING HABITS
Postural defects during sleep have been
considered as an etiologic factor in maloc­
clusion. Children and adults do not lie in
one position during sleep, but move about
at frequent intervals these movements are
involuntary and are produced by nervous
reflexes in order to obviate pressure inter­
ferences with circulation.
Deformity, flattening of the skull and facial
asy­­m­metry may occasionally develop during
the first year, in infants who habitually lie in
supine position with the head turned towards
right or left.
Face leaning is a habit where lateral pressure
face leaning which is unintentional, extrinsic
pressure habit, may cause lingual movement
of maxillary teeth on that side. Mandible is less
affected as it does not have a rigid attachment
and can slide away from the pressure.
Chin popping is an extrinsic pressure,
unin­­ten­t ional habit which causes a deep
anterior closed bite. It may cause retrusion of
mandible.
NUTRITION IN
ORTHODONTICS
A review of basic principles of nutritional
science indicates its applicability to orthod­
ontics at many levels. For example, nutritional
considerations are most critical during growth
and development and during environmental
challenges. Such chall­e nges characterize
the growing orthodontic patient, especially
the adolescent facing the physiologic and
psychologic stresses of puberty. The literature
suggests that the nutritional status of the
orthodontic patient can affect the biologic
response of the periodontal ligament and
bone to orthodontic bends and brackets.
Furthermore, the orthodontic patient is in
special need of dietary coun­­seling in view of
the additional plaque reten­tive areas provided
by the orthodontic appliances. Also, the patient
undergoing orthognathic surgery presents
special nutritional considerations. Additi­
onally, nutritional imbalances or defici­encies
may be involved in the etiology of cranio­facial
anomalies.
EFFECT OF NUTRITIONAL STATUS
ON TOOTH MOVEMENT AND TISSUE
RESPONSE TO APPLIANCES
Orthodontic tooth movement relies on the
biologic response of the periodontal ligament
and alveolar bone to applied force systems.

This tissue response is analogus to healing in
that it represents an environmental challenge
to the patient. Additionally, the orthodontic
patient is usually selectively treated during the
adolescent growth spurt, which provides an
additional challenge to his nutritional status.
During growth or healing, some nutrients
that are otherwise nonessential become
essential or are required at higher levels for
optimal growth and/or healing. An example
is asparagine which, although categorized as
a nonessential amino acid, has been shown
when deficient to inhibit growth in the rat and
healing in demineralized bone matrix implants
in the rat. Thus, in an individual subjected
to the demands of growth and healing the
requirements for some nutrients would be
expected to be elevated. Other challenges
accompanying the adolescent period are
increased emotional stress, a higher level of
physical activity, and the unbalanced diet that
typifies this age group.
Ascorbic acid is a classic example of a
nut­r ­i­e nt that may influence the biologic
response to orthodontic forces. Several studies
in animals have documented its effect in
orthodontics. Also, it has been reported that
between 17 and 72% of orthodontic patients
may have suboptimal levels of ascorbic acid,
depending on the type of ascorbic acid test
and the amount of ascorbic acid considered
suboptimal.
The rationale for the effect of ascorbic
acid is based in part on the fact that a lack of it
interferes with collagen synthesis by preventing
hydroxyl­ation of praline to hydroxyproline,
thus affecting both the periodontal ligament
and the formation of osteoid.
A study using lateral forces on guinea pig
incisors showed that this stress during ascorbic
acid deficiency resulted in alterations in the
period­ontal ligament and supporting alveolar
Etiology 155
bone that were more pronounced when
compared to animals only on the deficient
diet or only receiving the orthodontic force.
The animals receiving orthodontic forces
during ascorbic acid deficiency demonstrated
many histologic alterations including enlarged
endosteal spaces with osteoclasts, an uneven
periosteal surface with osteoclastic activity,
and periosteal hemorrhages. Additionally, the
middle area of the periodontal ligament on the
stretched side was extremely stretched, with
large edematous spaces and disorientation of
fibroblasts and collagen fibers. The alveolar
wall demonstrated no osteoblasts but did
show edematous spaces and osteoclastic
acti­vity. The compressed side showed hyalini­
zation, undermining resorption and frontal
resorption.
If involved in the biologic response to tooth
movement, ascorbic acid may also influence
retention. In a study using separation of
guinea pig incisors, the group that had an
ascorbic acid deficiency experienced a more
rapid relapse. It would be expected that these
results could be extrapolated to some degree to
orthopedic forces acting at craniofacial sutures
since similar biologic responses are involved.
Nutritional status may also play a role in
the gingival response to orthodontic bands and
brackets. Since bands and brackets present a
stress to the periodontium, especially in regard
to increased exposure to retained debris, tissue
tolerance needs to be maximized. Dusterwinkle
et al banded one mandibular lateral incisor
and provided a multivitamin trace mineral
supple­ment or a placebo to this group and
to a nonbanded group. After 30 days the
nonbanded group receiving a supplement
showed an improved gingival score, decreased
tooth mobility, and decreased labial debris.
The banded groups not receiving a supplement
deteriorated in overall evaluation of the
156 Essentials of Orthodontics
clinical state, whereas there was no significant
change in the handed group that received the
supplement. Dusterwinkle interpreted these
findings in view of a continuum of health or
disease, which is a function of the product
of the degree of host resistance and the
magnitude of the environmental challenges.
Thus, a nutritional status adequate to support
a healthy period­o ntium in a nonbanded
situation may provide suboptimal host
resistance in a banded condition.
DIETARY COUNSELING FOR PLAQUE
CONTROL AND GENERAL HEALTH
IN THE ORTHODONTIC PATIENT
As noted above, the orthodontic patient is
subject to a number of challenges that will
require a certain host response, which is
partially dependent on nutritional status.
These stresses include the requirement for
tissue response to orthodontic forces in
periodontal ligament and bone, the increased
irritation to the periodontium, the physical
and emotional stresses characteristic of
adole­scence, the increased requirements of
adolescent growth, and the often poor quality
of the diet during this period. Additionally, the
use of alcohol or drugs may further increase
nutritional requirements. For example,
oral contraceptive steroids increase the
need for pyridoxine, foliates and ascorbic
acid. The use of phenytoin by orthodontic
patients with epilepsy represents another
example of drug induced vitamin requirement.
An anticonvulsant induced osteomalacia
with increased osteocytes and osteoclastic
resorption was shown to exist in epileptic
orthodontic patients and was reversed with
vitamin D therapy. The increased amount
of unmineralized new bone may result in a
tendency for increased indirect bone resorption
in these patients. Thus, while classic deficiency
syn­d romes are not common, suboptimal
levels of nutrients probably are common in
the adolescent popul­ation. Furthermore, in
most cases, probably more than one nutrient
is involved since deficiency of one implies
that the circumstances exist which would
lead to other deficiencies. Also, a deficiency
of one element often affects the metabolism
of others. Thus, multiple suboptimal levels of
some nutrients probably exist in a considerable
portion of the orthodontic population, if
optimal is interpreted to mean ability to
respond maximally to environmental stresses.
Incremental increases in height and weight
as compared with standards are one of the
best measures of satisfied nutritional needs,
although they are not diagnostic for borderline
nutritional states. Thus, the orthodontist, who
usually uses these data for growth prediction,
is able to estimate past nutritional status.
Additionally, the presence of such orthodontic
appliances as bands and brackets should alert
the orthodontist to the cariogenecity of the diet.
Perhaps the best method for patient
education is the dietary history. Proper
instructions on how to keep a dietary history
for several days can provide the basis of a brief
educational session with the orthodontist
or an auxillary. Cariogenic foods as well as
their frequency of intake can be identified.
Additionally, a general evaluation of the
patient’s diet in regard to its balance of nutrients
and food groups can be made.
NUTRITIONAL CONSIDERATIONS
IN THE ORTHOGNATHIC SURGICAL
PATIENT
Postoperatively the orthognathic surgical
patient is confronted with increased nutritional
requirements and difficulty in proper nutrients

intake. Suboptimal levels of some nutrients
could be responsible for decreased resistance
to infection as well as delayed soft and hard
tissue repair.
The prevalence of protein calorie malnutr­
ition was shown to be approximately 50%
in a population of general surgery patients.
The degree of this problem in orthognathic
surgical patients would be expected to be
substantially less owing to the elective timing
of the orthognathic surgery and the lower
incidence of preoperative disease conditions
in these patients. The focus is on achieving
optimal nutritional status for optimal host
response rather than on preventing classic
deficiency syndromes.
Although the postoperative patient appears
to be at rest, the metabolic responses to the
surgery can increase the caloric requirements
by 50% or more. It is important that this
increased caloric requirement be met by
sources other that needed proteins. Besides
being a potential source of energy, proteins
are essential to the regulation of osmotic
pressure, lipid transport, the formation of
antibodies, and the repair of injured tissue.
Thus, if a high calorie diet, especially one that
is high in carbohydrates is instituted for a few
days preoperatively, liver glycogen stores and
possibly spare protein will be increased for
a short time postoperatively, when caloric
requirements are high and the patient is not
able to eat an adequate diet. In contrast, the
time to boost protein intake appears to be
during convalescence, not preoperatively.
Jones concluded that while the normal
requirement for protein is about 65 gm per
day, this should be increased to approximately
150 gm per day during convalescence.
Other nutrients important during tissue
repair are reviewed by Hunt. Vitamin A known
to be important in cell differentiation and
Etiology 157
protein synthesis is known to be important
for repair but is also one of the more common
deficiency states. Ascorbic acid, essential
for collagen formation, is important for soft
tissue healing as well as osteoid formation.
Subclinical deficiencies of vitamin C are fairly
common and could be converted to a clinically
evident deficiency during stress. Calcium and
vitamin D have been shown to be essential for
repair of fractures and thus are of importance
in maxillofacial surgery. The level of these
and other nutrients required to achieve the
optimal healing response is in most cases not
established. However, there are studies that
suggest that supplements of vitamins and
micronutrients improve healing. For example,
a vitamin and zinc supplement was shown
to improve the healing response in 88% of
patients undergoing oral surgery, as compared
with oral surgery on the other side of the mouth
during non-supplementation.
Because all the essential nutrients and
their required levels have not been estab­
lished, the difficulty with the use of arbitary
formulas is obvious. Thus, it would seem
preferable when­­ever possible to administer
whole foods. Furthermore, Jones has pointed
out that an oversupply of one amino acid
either may reduce the efficiency of another,
caus­ing a paradoxical deficiency, or may
increase the requirement for another amino
acid.
NUTRITIONAL FACTORS IN THE
ETIOLOGY OF CRANIOFACIAL
ANOMALIES
Craniofacial anomalies pose formidable
challenges to the dental profession. Certainly,
attention to the etiologic factors and possible
prevention of these conditions is warranted.
158 Essentials of Orthodontics
Cleft lip and palate is an example of a
cranio­facial anomaly of particular interest to
orthodontists. This condition can be induced
in animals by nutritional deficiencies such as
those of folic acid, riboflavin, and zinc.
Suboptimal levels of these nutrients may
potentiate other teratogenic factors. The
possibility of vitamins and trace minerals
being suboptimal during pregnancy is great.
The mother may be unaware of the pregnancy
during certain critical periods of development.
Furthermore, the use of alcohol and other
drugs may increase the requirement for certain
nutrients. For example, the administration of
riboflavin or pyridoxine to mice reduced the
incidence of cortisone induced cleft palate. The
teratogenic effect of cortisone in mice has also
been appreciably increased by a low calorie
diet.
Zinc provides an example of a nutrient for
which even a short-term dietary deficiencies
could be teratogenic. No mobilizable store
exists for zinc, necessitating that it be regularly
present in the diet. Animal studies have shown
that even a moderate deficiency during a
critical embryologic period can be teratogenic.
Although data for humans are limited,
retrospective studies of the histories of
pregnancies resulting in clefts suggest that
vitamin and trace metal levels have an
influence. In one study of 78 mothers who had
previously given birth to a child with a cleft,
the 39 who were given vitamin supplements
during a subsequent pregnancy had no
incidence of reported congenital anomalies,
whereas 4 of 48 mothers who did not receive
vitamin therapy had children with clefts.
Nanda has reviewed a number of environ-
mental factors such as diet, infection,
irradiation, and drugs that affect embryonic
development. It should be realized that
nutritional factors represent only one of these
environmental influences and that interactions
between some of these factors occur. Thus,
although the influence of one teratogenic
factor may be marginal, the combination of
several may be significant.
Conclusion
This discussion emphasizes that nutrition is an
important factor, influencing the general health
and tissue tolerance of orthodontic patients on
many levels. While orthodontists will rarely see
frank manifestations of nutritional deficiencies,
it should be recognized that suboptimal levels
of certain nutrients are common and have
an effect on the biologic responses of the
tissues influenced by orthodontic treatment.
Additionally, the age group typically involved
in orthodontic treatment has particularly high
nutritional demands and particularly poor
dietary behavior.
GENETICS IN ORTHODONTICS
Genetics is the science concerned with the
structure and function of all genes in different
organ­isms.
Ray E Stewart medical geneticist, Spence a
psychiatrist both of university of California, Los
Angeles list malocclusion as the most common
hereditary deviation in dentistry, followed by
periodontal disease and dental caries. But it is
not clear to what extent phenotype characters
are of genetic origin or of environmental origin.
Genetic traits in craniofacial region are
known to undergo change. Children who
strongly resemble parents may no longer show
such resemblances as they grow older or on the
contrary the resemblances may become more
positive in later years.
It is important for the dentist to recognize
genetic aberrations in the early stages before
their full establishment and thus practice
preventive dental medicine. For the orthod­
ontist, the aware­ness of genetic expression

in the dentofacial maldevelopment of their
patients, in addition to aiding correction of
malocclusion will be an important factor in
their practice of dentofacial orthopedics in
clinical practice.
Genetics is a rapidly developing science
that has reached an advanced level of genetic
selection and cloning.
HISTORY
Studies of genetic interest can be traced back to
6000 BC in certain stone carvings of Babylon.
Genetic theories and concepts were influenced
by the hypothesis of various prominent
philoso-phers. Among them the forerunners
were Pythogoras, Empedocles, Aristotle,
Harvey, Adams Darwin, etc. In 1814, Joseph
Adams proposed many of the basic principles
of medical genetics. He is even termed by some
authors as the founder of human genetics.
The studies regarding genetics had break
through when an Austrian monk Gregor Mendel
made his far reaching discoveries by carefully
analyzing the results of his experiments on
cross breeding garden pea (Pisum sativum).
Mendel adopted the simplest methods and
studied a single characteristic through many
generations. He is aptly named the “Father
of modern Genetics” for his outstanding
contribution in the field of genetics. Mendel
put forward the Law of segregation according
to which every individual possess two factors
which determine a specific characteristic.
Among these two, one pair is transmitted from
each parent. This is called Mendel’s first Law
or the Law of segregation.
After Mendel’s studies and discoveries
there was a renewed awareness in the field of
genetics. In 1903, Soulton and Boveri proposed
the Chromosome Theory of Inheritance.
Thomas Hunt Moran et al in 1935, were
awarded the Nobel prize for their extensive
Etiology 159
studies on the arrangement of genes along
the chromosomes. Watson and Crick in
1953 demonstrated the structure of the DNA
molecule. The complexity of the chromosome
was further unveiled when the solenoid model
of chromosome structure was proposed by
Finch and Klung.
MOLECULAR BASIS OF
INHERITANCE
Cell
The cell is the basic unit of any living body.
It is made up of different organneles, i.e. the
cell wall, cytoplasm, endoplasmic reticulum,
ribosomes, mitochondria, nucleus, etc.
Chromosome
Within the nucleus of each cell are threads like
structures of different lengths and shapes called
chromosomes. The number of chromosomes
present in every cell of an organism is constant
but it changes from one species to another.
DNA
Chromosomes are made up of long chains
of Deoxyribonucleic acid (DNA) molecules,
twisted and twined in a specific manner.
Each long strand of a DNA molecule is a
chain of nucleotides. The basic nucleotide
unit comprises of a deoxy sugar, a phosphate
molecule and one protein either purine or
pyrimidine. The nucleotides form a pair by a
weak hydrogen bond between the proteins.
At the same time, the sugar molecules on
both sides get attached to an adjacent pair
by means of phosphate bonds. The structure
hence resembles a step ladder.
The complex structure of a chromosome
can more clearly be explained by the solenoid
model of Chromosome structure as proposed
by Finch and Klung. The ladder like structure
160 Essentials of Orthodontics
of DNA according to them undergoes coiling
of the DNA duplex itself, secondary coiling of
these twisted duplex around spherical protein
beads called histones, to form nucleosomes,
tertiary coiling of nucleosomes to form
chromatin fibers and quaternary coiling to
form the chromatic loops. These loops are then
tightly wounded to form the chromosome.
Gene
The gene forms the basic unit of inheritance
by determining the make up and structure
of a particular characteristic in an organism.
A gene consists of a portion of the double
stranded DNA molecule with 300 to 1000
nucleotide pairs. Each chromosome consists
of hundreds of thousands of nucleotide pairs,
which can be considered as a sequence of
genes.
Transcription
Transcription is the process by which
information is transmitted from DNA to
the messenger RNA at the initial stage of
replication.
Translation
Translation is the process in which the genetic
information is actually converted into protein
synthesis.
Patterns of Genetic Transmission
The pattern of genetic transmission within
the dentofacial complex can generally be of
three types:
Repetitive: It is characteristic by recurrence of
a dentofacial deviation within the immediate
family and its progenitors.
Discontinuous: It is characterized by the recurr­
ence of a malocclusion trait that reappears
within the family background over several
generations but not continuously.
Variable: It is characterized by the occurrence
of different but related types of malocclusion
within several generations of the same family.
Modes of Genetic Transmission
1. Mutation
2. Selection
3. Mixture
4. Drift.
Gene Mutations
Protein synthesis for the process of replication
is controlled by genes. A change induced by
certain agents in the composition of the base
pair of the DNA molecule may lead to the
synthesis of an altered protein. This may result
in a gross reduction or even a complete loss of
the biological activity resulting in an altered
expression of certain specific characters of
the individual.
Gene mutations can be of different types
like, visible mutations, detrimental mutations,
lethal mutations, etc.
Mutagens are agents that induce genetic
mutations. They are of different types:
i. Ionizing radiations
ii. Certain drugs, chemicals and food
additives
iii. Certain viruses
iv. High temperature.
Although genetic mutations are usually
associated with a specific mutagen, sometimes
spontaneous mutations take place. Although
we do not have any supporting evidence, some
resear­c hers attribute it on the basis of
Darwinian evolution and adaptive mutation
to the environ­ment.
Chromosomes in Man
In 1956, Tjio and Levan and independently
Ford and Hamerton demonstrated that the
number of chromosomes in man is 46, i.e. 23

pairs. Among these, 44 (22 pairs) are auto­
somes and a pair of sex chromosomes.
The autosomes in the male and female
cells are identical while the sex chromosomes
are different. Males have one X and one
Y chromosome while females have two X
chromosomes. This forms the basis of sex
determination in the offspring. Normal human
cells have 46 chromosomes while the gametes
have only 23 chromo­somes, i.e. haploid cell.
During fertili­zation, the union of 2 haploid
cells from each parent results in an offspring
with 46 chromo­somes (Fig. 4.4).
Genetic Disorders
Genetic disorders in a general aspect can
be considered to be of two types, numerical
disorders and structural disorders.
Numerical Disorders
Numerical disorders are those in which there
is a change in the number of chromosomes
within the cell. The following are some
examples of numerical disorders:
1. Polyploidy: A condition where there is an
additional full set of chromosomes.
Figure 4.4: Human chromosomes
Etiology 161
2. Monosomy: A condition where one auto­
some is missing.
3. Trisomy: A condition when there is an
addition of a single chromosome only.
4. Klinefelter’s syndrome: It is a sex chromo­
some abnormality in males where there are
additional X chromosomes.
5. Turner’s syndrome: A sex chromosome
abnor-mality in females with one X-chro­
mo­some missing.
Structural Disorders
Structural disorders are those in which there
is a change in the basic composition and stru­
cture of the chromosome. Structural disorders
can be of the following types:
1. Translocation: An exchange of segments
between nonhomologous chromosomes.
2. Deletions: Loss of segment of the chromo­
some.
3. Ring chromosomes: Deletion at both the
ends of the chromosome. Later the deleted
ends stick together to form a ring.
GENETICS IN ORTHODONTIC
PERSPECTIVE
The significance of genetic studies in the field
of medicine and related branches cannot be
over-emphasized. Hereditary predisposition
of certain diseases like Hemophilia, the
importance of ‘Rh’ factor in pregnancy and
childbirth, congenital abnormalities like
Down’s syndrome, etc. are few examples that
highlight the importance of genetic studies and
genetic counseling (Fig. 4.5).
Like any other discipline in medicine, the
importance of genetic influence within the
dentoalveolar complex and related structures
were recognized quite early. In 1836, Fredrick
G Kussel after extensive study reported that
162 Essentials of Orthodontics
Figure 4.5: Genetic causes for malocclusion
malocclusion, both skeletal and dental can be
transmitted from one generation to another.
Later many investi­gators followed his path
and came up with their observations which
attributed malocclusion more to an inherited
trend than the result of any environmental
influences.
Dentofacial disturbances of genetic origin
can briefly be listed as follows:
1. Micrognathia
2. Macrognathia
3. Cleft lip and palate
4. Down’s syndrome
5. Gardner’s syndrome
6. Marfan’s syndrome
7. Cherubism
8. Cleidocranial dysplasia
9. Mandibulofacial dysostosis
10. Osteogenesis imperfecta
11. Bimaxillary protrusion
12. Bimaxillary atresia
13. Retarded eruption of teeth
14. Hypodontia, anodontia, oligodontia,
etc.
15. Abnormal overjet and over bite
16. Open bite
17. High arched palate
18. Abnormal number and arrangement of
teeth
19. Arch length to tooth size discrepancy
(Crowding and Spacing)
20. Ectodermal dysplasia
21. Tooth shape and tooth form
22. Upper facial height, nose height, head
height, bigonial width.
Research into the genetic influence of the
dentofacial complex have thrown light on
new vistas of thoughts and at the same time
disproved some of the misconceptions within
the subject. For example, previously, racial
crossing among humans was considered to be
one of the factors of malocclusion. Later this
was disproved by studies stating that human
racial crossing presented little or negligible risk
to dental occlusion.
Similarly another study on relapse of
treated cases showed that relapse can be
caused by hereditary tendencies that come
into play and upset the results after treatment
has been completed. Occlusal mannerisms,
jaw positioning and abnormal pressure habits
which induce untoward forces that tend to
move the orthodon­tically treated teeth back
into malocclusion also be of genetic origin.
Methods and Criteria in Genetic
Identification
Neel and Chull enumerated some of the
criteria that would permit this recognition of
genetic factor as follows:
1. Occurrence of the disease in definite
num­­erical proportions among individuals
related by descent.
2. Failure of the disease to spread to nonrel­
ated individuals. The consanguinity effect is
often seen in genetic disorders testimonies
to the role of relatedness.

3. Onset of the disease at a characteristic age
without a known precipitating event.
4. Greater concordance of the disease in
identical than in fraternal twins.
Methods of Studying Role of Genes
Twin Studies
The genetic influence of inheritance has
always been a cause of controversy. Some of
the pioneers in the medical field proposed
the possibility of some genetic components
which helped in transmission of certain trains.
However others believed that the make of an
individual is entirely due to environmental
influences. Twinning of human embryo
seems to be nature’s answer to this heated
controversy. Human twins can be of two types:
Monozygotic twins (Monovular): They are two
individuals developed from a single fertilized
ovum, which divides into two at an early stage
of development. Monozygotic twins thus have
a genetic make up identical to each other.
Monozygotic twins are either males or both
females.
Dizygotic twins (Fraternal twins or Diovular):
They are two individuals developed from two
separate ova, ovulated and fertilized at the
same time. The two ova are fertilized by two
different sperms. They are not genetically
identical as they develop from two different
embryos. They are analogous to siblings except
that they have an almost similar prenatal
developmental life. Dizygotic twins can be
combination of one male and one female child.
Twin studies are done by analyzing
monozygotic and dizygotic twins in a specific
manner. In case of monozygotic twins, they
have similar genetic make-ups, but postnatally
some of them have different environmental
conditions. This helps us to study the expression
of the genetic factors and at the same time,
the environmental influences on this genetic
Etiology 163
expression. Similarly in the case of dizygotic
twins who have a similar environmental
condition the influence of genetic as well as the
environmental factors in the expression and
development of an individual can be studied.
Although twin studies have several limita­
tions like identification of different types
of twins as well as their developmental
environment, the work of many researchers
has thrown light into the understanding
of genetic contribution in the growth and
development of an individual.
Triplet and quadruplet studies : They are similar
to twin studies in that the number of children
born is three or four. They may be either
monozygotic or bizygotic or combinations.
Pedigree Studies
Pedigree studies are the most common among
genetic studies. Here a definite trait of an
individual is studied along his ‘family tree’ so
as to find any hereditary influence. Many of
the family traits like bimaxillary protrusion,
missing teeth, high arched palate, etc. can be
readily be attributed to hereditary inheritance.
While doing these studies one should be aware
of the dominant and recessive traits and their
expressions. Larger the number of generations
the better a trait can be traced by repetitive
occurrence.
Inbreeding
The mode of transmission of certain traits can
be studies and their dominant and recessive
characteristics determined by analyzing
certain communities where practices like
polygamy and marriages within the family
still exist.
Age of Onset
The age of onset of a disease may be genetic
but this determination is negative in nature.
164 Essentials of Orthodontics
If all possible causes of the disease have been
eliminated the genetic hypothesis knowledge
available for a given disease.
Problems associated with the role of
heredity of dentofacial complex in humans:
The principles of genetics have been
applied with different degree of success to the
general field of dental and facial structures. The
human population is not the best for genetic
studies because of:
i. Slow generation
ii. Long growth period
iii. Constant hybridization.
The above-mentioned factors will blur the
genetic hypothesis. To this should be added
the fact, the characteristics studied, i.e. facial
form, malocclusion and jaw size are present
continuous variables rather than disease of an
all or none nature.
Butler’s Field Theory
In 1939 Butler an English paleontologist
proposed this theory.
According to this theory, mammalian
dentition can be divided into several develop­
mental fields. The developmental fields
include the molar/premolar fields, the canine
and the incisor fields. Considering each
quadrant separately molar/premolar field
would consist of first molar as key tooth and
second and third molar on distal ends of this
field, first and second premolar on mesial
and would be most variable in size and shape.
Most clinicians agree on third molar but not
with first premolar. Actually earlier mammals
had four premolars, some higher primates
including man lost the first two premolars so
that the premolars which we are referring to
are actually third and fourth premolars. The
point is that as Butler’s theory predicted. The
premolars farthest from the first molar were
the first to be lost in the evolutionary sense
and therefore can be considered as the least
stable. Among the fields, dental variability
manifests itself strongly in the distal than in
the mesial direction. For example the lateral
incisor is more prone to variation than the
central incisor.
Adapting Butler’s theory to human
dentition Dehlbergt suggested the following
fields and gradients of stability among teeth.
Max CI → LI Canine I Pm→ IIPm IM → IIM
→ IIIM
Mand CI→ LI Canine I Pm → IIPm IM → IIM
→ IIIM
Principal Polygenic Variation
Most research date suggest that normal vari­
ation in the dentition is the result of multiple
rather than single genes unlike ectodermal
dysplasia or odontogenesis imper­fecta which
result from segregation of single gene, the size
or shape of the teeth is determined by many
genes interacting with each other and the
environment.
Relapse is not an uncommon phenomenon
in orthodontics. While treating a patient
ortho­dontically, we do change the genetic
expression of the patient. Once the treatment is
completed and the appliance is removed, there
is always a chance that the genetic expression
of the patient reestablishes. Ruling out all
other possibilities like misdiagnosis, defective
appliance therapy, and improper patient
care, a great variety of relapse can possibly be
attributed to these genetic factors.
Eugenics
Eugenics is the applied aspect of human
genetics. It aims at the improvement of
humanity by altering the hereditary qualities in

future generations of man. Genetic counseling
and genetic engineering are the two important
aspects of eugenics.
Genetic counseling is the act of educating
the prospective parents who are either suffer­
ing from the diseases or suspected to be hete­
ro­zygous for some specific genetic diseases.
Once genotypes of parents are known then
the chances of inheriting the diseases can be
reduced. Genetic counseling and antenatal
diagnosis are essential in preventing the
genetic syndromes.
Genetic engineering is the manipulation
of genetic system within the cell in order to
Etiology 165
alter the genetic mechanism for reducing the
genetic disorders.
Negative eugenics is concerned with the
elimination of undesirable genes from the
population. Thus, by reducing the progeny of
defective individuals, deterioration of human
race can be prevented. Consangenous marri­
ages are also genetically undesirable, as the
frequency of the production of defective child­
ren is likely to be higher for such marri­ages.
This is because of simple reason that most of
the harmful traits are recessive, so they tend
to express in the children of parents who are
related very closely.
166 Essentials of Orthodontics
CHAPTER
Orthodontic
5 Diagnosis
ORTHODONTIC DIAGNOSIS
Orthodontic diagnosis deals with recognition
of the various characters of the malocclusion.
It involves collection of pertinent data in a
systemic manner to help in identifying the
nature and cause of the problem. Orthodontic
diagnosis 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 infor­
mation. The data is derived from case, history,
clinical examination and other diagnostic
aids such as study casts, radiographs and
photographs. A systematic approach to the
examination is essential to ensure that nothing
is overlooked. Then the task of treatment
planning is to synthesize the possible solutions
to these specific problems into a specific
treatment strategy that is best for this particular
patient.
Diagnosis must be made scientifically,
treatment planning cannot be science alone,
judgment by the clinician is required as
problems are prioritized and as alternative
treatment possibilities are evaluated. Compre­
hensive orthodontic diagnosis is established
by use of certain clinical implements called
diagnostic aids.
ESTHETICS IN ORTHODONTICS
Most patients seek orthodontic treatment in
order to improve their appearance. Most often
the demand for correction of malocclusion is
based on psychological or sociopsychological,
rather than somatic factors. In an effort to
establish treatment priorities, the World
Health Organization (WHO) suggested that
an anomaly should be regarded as requiring
treatment if the disfigurement or functional
defect is likely to be an obstacle to the patient’s
physical and emotional well­being.
Esthetics is the study of beauty and together
with ethics, logic, politics and metaphysics is
a branch of basic philosophy. Man has been
aware of facial esthetics for a long time. As early
as 35,000 years ago man developed his esthetic
awareness and sensitivity. The brilliant Greek
philosophers Plato and Aristotle introduced
esthetics as a study of beauty and philosophy.

Divine Proportions
It is now an accepted face that beauty respects
certain geometric laws and proportions. The
proportion of 1:1.618 is called the divine or
the golden proportion or Fibonacci series.
This proportion has been found extensively in
nature and is believed to be the basis of beauty,
harmony and balance. The divine proportion
has for long been used by artists and architects
in their work. Objects exhibiting the divine
proportion are said to be attractive, exhibiting
beauty and harmony. The human face exhibits
numerous golden proportions. The normal
human face is one of the most beautiful
works of nature. Though esthetics is a maker
of individual opinion there is a considerable
agreement among humans regarding the
concept of beauty.
Concern about the appearance of teeth
and face is believed to the most impor­tant
motivating factor for orthodontic treatment.
Obvious malocclusion and facial disfigurements
can be a major handicap. It is widely believed
that attractive children are recognized as
more intelligent than nonattractive children.
Malocclusion can thus affect the mental
well-being of an individual leading to an
inferiority complex or introversion. Thus the
orthodontist should have as one of his goals
the esthetic portion of the dentofacial region
so as to improve the overall well-being of the
individual.
Fibonacci Numbers
In 1202, Filius Bonacci (alias Leonardo of Pisa)
published his work, Liber Abaci, which was
to change the Roman numerical world to the
Hindu-Arabic numeral system. He proposed
that the numbers could be demonstrated in the
multiplication. It occurs by adding the last two
numbers together in a series. Hence, starting
with 0 and 1, the total is 1. Adding those last
two gives the sum of 2. Two and 1 are 3, 2 and
Orthodontic Diagnosis 167
3 total 5, and thus the numbers increase as
follows: 0, 1, 1, 2, 3, 5, 8, 13, 21, 34, 55, 89, 144,
etc. When about this level is reached, each new
addition is precisely 1.618 times the previous
number, and this ratio of addition continues
on to infinity. The Fibonacci numbers have
been studied extensively by mathematicians,
and groups and societies have been formed
by scholars of this unique relationship of
numbers.
GOLDEN SECTION
That which is known as the golden section
has been known at least since the time of
the Egyptians and was popular in the art
and architecture of the Greeks. It starts with
a basic proposition that enters many of our
minds as children. Where is there a place
to section a line so that the small portion is
a ratio, compared to the larger part, as the
larger part would be to the complete line? This
can be arrived at geometrically quite easily.
By bisecting the line and erecting a vertical
from one end, a 90° angle is constructed. The
connection of the two ends forms a triangle. By
marking off the dimension of original bisection
on the hypotenuse and swinging an arc of the
remaining distance down to the original line,
a “golden section” is constructed.
Properties of Phi (φ)
This golden sectioning seems to have some
marvelously unique properties. It is a quality
which, for some reason, attracts the attention
and is recorded in the limbic system as beauty,
harmony, and balance. Static symmetry
consists of absolute even balance on both sides
and will be monotonous or become boring.
There is a certain quality of the golden section
which stimulates the viewer, and this value has
been called “dynamic symmetry”, meaning that
168 Essentials of Orthodontics
it portrays action and a continuum. Examples
of this relation can be found throughout nature,
which has always attracted the art, satisfaction,
serenity, and euphoria of mankind. The artist
almost always is taken by the beauty of nature
and tries to put it on canvas.
Actual measurement of the line division
for the cut results in the longer section being
1.618 times the length of the shorter one! The
shorter line is 0.618 the length of the larger.
This astonishing number is the only one in
mathematics which, when subtracted by unity
(1.0), yields its own reciprocal. Strangely, this
quality is exactly the same as the Fibonacci
quantum jump! Because a famous Greek
sculptor, Phidias, used the golden proportion
so much, it was called phi, the Greek letter for
the first part of his name. The label phi is so
common that it is used similarly to pi which, as
any grammar school student knows, is for the
analysis of circles and spheres. Phi was related
to so many aspects of beauty that Kepler, in
about 1600, called it the “divine proportion.”
Thus, we see the relation of Fibonacci to
the golden section. Of final charm for the
intellect, a measurement of the sound waves
also corresponds to the phi value in harmonic
chords picked up by the ear.
Golden Rectangle
If the altitude of a rectangle is constructed in
the proportion as 1.0, and the base is made
1.618 times the altitude, this is called the
golden rectangle. It was on such a scale that
the Parthenon was built, and it has endured for
two millenniums as a world attraction.
It is rare to see a square picture frame.
Golden rectangular stationery, writing pads,
and 3 by 5 inch cards are known to be most
popular. For example, examine the typical
credit card. The golden section even entered
commercial design and became a part of art,
if not directly, certainly intuitively, probably
since man first started to scratch forms on the
walls of caves. It has harmony and balance
yielding comfort and pleasure to the senses.
Pentagon Analysis
The five-pointed star has also been a striking
symbol. The base of this star is the pentagon.
If two corners of the pentagon are connected
with a line and two more are connected to
cross the line, each line will be sectioned
in a golden section, that is, 1.0 and 1.618
lengths proportionately. When a third line is
connected to two corners, one of the crossing
lines will be sectioned from both ends in a
sort of reciprocal division. This produces a
smaller section in the middle that is a common
smaller divine proportion to both ends. It is an
overlapping “area of congruence’’ balanced
between other parts.
Golden Triangle
Further analysis of the intersected pentagon
reveals that the sections are the same length
as the sides and a unique triangle is formed
by the construction.
In mathematics phi is given its Greek
symbol f, and a series of phi relations has been
called an additive series. Starting with a value
represented by 1.0, the f’ is 0.618, f’2 is 0.3819
and f’3 is 0.2360, going to smaller dimensions.
Larger numbers are f’2 at 2.6189, f’3 at 4.2358,
and f’4 at 6.853. The value 1.618 plus 0.618
equals 2.236, which is the square root of 5. The
mathematical formula is:
Solving for X leads to these numbers form a
natural progression, with each value a multiple
of the phi proportion.
Measured geometrically, the golden
triangle is a 72° 72° 36° isosceles triangle and
also has several unique properties. It can easily
be constructed from the golden section. When

the longer section of the golden sectioned
line is marked off from each end of the short
section, a point is found to which each end of
the shorter section is connected. This forms
the golden triangle.
If one of the base angles is bisected (72°
= 36° + 36°), the bisection will intersect the
opposite side and, in so doing, will section
that side into the golden section. The areas
produced likewise are golden to each other.
Thus, an infinite series of triangles can be
constructed by adding 36° to each 36° angle.
When the base of each triangle is connected to
each succeeding base with a smooth tangent,
the connection forms a logarithmic spiral.
Genetic Implications of the Logari­
thmic Spiral and the Golden Section
The logarithmic spiral is found in the simplest
of primitive life forms, the snails. The nautilus
has long been selected for adornment and
amusement. The same pattern may be found
in the sunflower, with two reversed spirals to
make it more intriguing. It is interesting to find
the three-leafed clover, the five-petaled daisies,
and so many flowers with eight or thirteen
petals illustrating the interesting Fibonacci
numbers in nature.
Of even greater interest is the proportion of
the fingers and toes of species of animal, being
1, 2, 3, and 5. Man’s usual five fingers and toes
are significant, but of even greater interest is
the relation of the phalanges in the hand and
fingers in the span. By the construction of a
“golden divider”, an increase will always occur
in the exact same proportion. When examined
with the golden divider, it is observed that each
phalange is a f relation to the next, and each
two are a f relation to the last two segments
in the fingers. In fact, the body as a whole
has been studied, and the total height can be
sectioned into the golden proportion and it
Orthodontic Diagnosis 169
comes out to be the umbilicus. With all these
relations, it causes one to ponder the possible
link with basic cellular phenomena.
Facial Analysis with the
Golden Proportion
With the foregoing biologic facts in mind, it was
only natural to examine faces for alternative f
relationships. With calculator handy, several
photographs of male and female models were
explored and a hypothesis was formed relative
to proportions of facial component.
Divine Proportions in the
Human Dentition
With the foregoing findings, it was natural to
seek divine proportions in the dentition.
The lower incisor became a basic unit. The
upper incisor was golden to the width of the
lower incisor. Taking both the upper and lower
central incisors as a unit, the f relationship is a
mark of dynamic symmetry. A progression is
seen as the two upper incisors are compared to
the four upper incisors—not in a straight line,
but as they appear to the eye in the chord of the
arc of the arch form. Taking data from charts,
the next progression is the width of the upper
first premolars as also viewed from the anterior.
Thus, a rhythm is seen in the natural normal
ideal occlusion with the lower incisor as a basic
unit and f for the upper central incisors, f2 for
the lateral incisor widths, and f3 for premolars.
It can be imagined what happens to esthetics
and beauty with teeth missing and collapsed
arches in the first premolar areas.
A second series of divine proportions was
discovered in the teeth. Starting with the widths
of all four lower incisors (across the arch) as 1.0
value, a f relation to the tips of the upper canine
widths was found. A f2 relationship to the four
lower incisors was found at the widths of the
upper second molars. Therefore, the molar
170 Essentials of Orthodontics
width for the upper molars is 2.618 times the
width of the arc of the four lower incisors in
great beauty. Thus, in the broad smile, there
is harmony from the lower to the upper arch
and harmony within the upper arch itself.
A third golden proportion was seen from
the distal aspect of the lower canines. This
measurement as a base revealed the lower
first molars at the mesial cusps to be in the
f relationship. Thus, the normal human den­
ti­t ion represents a concert of harmony—
undoubtedly a factor in natural selection at
the subliminal level.
Association of Divine Relations with
Denture and Face
Any magazine will show smiling faces to
portray happiness with the product advertised.
Ten photographs were studied to test possible
association. By dropping vertical lines from the
lateral margin of the nose during the smile, the
nasal width was found almost consistently to
be the same as the upper intercanine width
at the canine tips. However, the ala are drawn
slightly outward in a broad smile. If this is true
(and ten patients do not prove a complete
theory), then the four lower incisors form a
basic unit of 1.0 with f relations going to the
nose to the mouth f2 to the eyes f3 and the
head f4. Lower incisor width would be 0.2360
the width of the eyes.
Analysis of the Cephalometric Matrix
Extensive computer research and clinical
analysis kept pointing to the use of certain
points and planes for reference, not only for
convenience but also for biologic significance.
With all these golden associations in the soft-
tissue face and hard-tissue teeth, the next issue
was the possible skeletal and dental relations.
It will be remembered that the large unit
used as a unit of 1.0 will show the smaller unit
as 0.618 or 61.8 percent of the length of the
original dimension. It is still a golden relation,
but termed a negative value. It may be more
convenient to describe the longer side first.
The findings are as follows:
1. Corpus axis length f to condyle axis length
(to condyle tip).
2. Anterior cranial fossa length SN to posterior
cranial fossa length S Ba.
3. Basal or cranial anterior base length (cc to
NO f to cranial center to articulare [ar]).
4. Length of the hard palate ANS-PNS f to
depth of nasopharynx and point A to PNS
to posterior margin of the condyle neck.
5. Anterior length of Frankfort plane (PtV to
orbitale) f to PtV to glenoid fossa (GL).
6. Vertical height of point A to Pm f to A to the
Frankfort plane.
7. Palate at incisive canal to menton f to
canthus of eye.
8. Height of the lower incisor tip from Pm f to
distance of incisor tip to point A.
Divine Proportions in the Frontal
Cephalometric View
The frontal proportions were determined from
a computer composite of the adult sample. The
width of transverse dimensions would apply
for the teeth except for greater enlargement
in structures more distant from the film in
the posteroanterior exposure. Certain golden
relationships were found in the upper, middle,
and lower face.
In the upper face, the distance from point
Z at the lateral border of the orbit at the zygo­
matofrontal suture to the medial border of the
orbit (or point dacryon) was golden to the inter­
dacryon distance. This makes the bridge of the
nose a congruent area between the two orbits.
In the midface the distance between the
widest points on the piriform aperture (at
the anterior rim of the nasal cavity) formed

a congruent area between the width of the
mandible at a level which was called lateral
articular (Lar), at the crossing of the condyle
neck with the outline of the zygoma. Thus, a f
relationship was found from the nose to each
lateral part of the face. In turn, the maxilla
between J points was f2 or 2.618 to the piriform
aperture, which made the interarticular
distance f3 or 4.236 times the nasal width.
A golden rectangle was observed from the
maximum width of the nose (NC) as related to
the floor of the nose to the zygomaticofrontal
suture line which approximates dacryon and
is close to nasion.
Visual Esthetic Examination
The routine examination carried out prior to
orthodontic treatment should include esthetic
evaluation of the patient. The following
factors should be considered in the esthetic
examination of a patient.
Examination of Symmetry
The patient is examined for overall facial
symmetry. Almost all individuals exhibit mild
asymmetry where in the left and the right side
of the face may not be perfectly identical. Thus
some amount of asymmetry is considered
normal. But major asymmetries constitute
esthetic impairment.
Examination of Facial Proportions
An esthetically pleasing face is usually propor­
tional. Such a face can be divided into three
equal vertical thirds using four horizontal
planes. The planes used are at the level of the
hairline, the supraorbital ridge, the base of the
nose and the lower border of the chin.
In the vertical plane the intercanthal dis­
tance is equal to the alar nasal base width and
the margin is as wide as the distance between
Orthodontic Diagnosis 171
the left and right medial limbs. Face is divided
into fifths all being equal.
Examination of Lips
Ideally at rest, 2 mm of upper incisors should
be exposed and on smiling only a small
amount of gingival is exposed. An excessive
vertical development of the maxilla or a short
upper lip leads to a gummy smile.
Examination of Facial Profile
Examination of the facial profile helps in
diag­nosing gross deviation in the maxillo-
mandibular relation; profiles can be straight,
con­vex or concave. Convex profiles are usu­­
ally a result of maxillary prognathism or
mandibular retrognathism. Concave pro­files on
the other hand are usually due to mandibular
prognathism or a retrognathic maxilla. Major
discrepancies in the profile can affect the
esthetics of the patient.
DIAGNOSTIC AIDS IN
ORTHODONTICS
Comprehensive orthodontic diagnosis is
esta­bli­­­shed by use of certain clinical imple­
ments called diagnostic aids. Orthodontic
diagnostic aids are of two types. They are the
essential diagnostic aids and the supplemental
diagnostic aids.
ESSENTIAL DIAGNOSTIC AIDS
1. Case history
2. Clinical examination
3. Study models
4. Certain radiographs:
i. Intraoral periapical radiographs
ii. Bite wing radiographs
172 Essentials of Orthodontics
iii. Panoramic radiographs (OPG)
5. Facial photographs.
SUPPLEMENTAL DIAGNOSTIC AIDS
1. Specialized radiographs:
i. Cephalometric radiographs
ii. Occlusal intraoral films
iii. Lateral oblique views
iv. Cone shift technique.
2. Electromyography
3. Hand wrist radiographs
4. Endocrine tests
5. Estimation of basal metabolic rate
6. Diagnostic setup
7. Occlusograms
8. Physioprints.
CASE HISTORY
Case history involves and recording of relevant
information from the patient and parent to
aid in the overall diagnosis of the case. The
information is gathered from the patients and
parents.
Personal Details
Name: The patients name should be recor­
ded for the purpose of communication,
identification, and referral and recalling.
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
conditions. In addition, there is certain
treatment modalities that are best carried out
during the growing ages. Growth modification
procedures using functional and orthopedic
appliances are carried out during the growth
period. Surgical resective procedures are best
carried out after the cessation of growth.
Sex: The patient 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 and females. Females usually precede
males in onset of growth spurts, puberty and
termination of growth.
Address: Recording of the address helps
in evaluation of the socioeconomic status
of the patient and parents. This helps in
selection of an appropriate appliance. The
address and phone number also helps in
future correspondence such as to intimate
appointments.
Occupation: Recording of occupation helps in
evaluation of the socioeconomic status of the
patient and parents. Occupation also helps in
diagnosis of occupational diseases.
Chief Complaints
The patient’s chief complaint should be
recorded in his or her own words. This helps
the clinician in identifying the priorities and
desires of the patient. Most patients seek
orthodontic care for reasons of either esthetics
or impaired function. The duration of the
chief complaints is also important in that the
duration of the existing malocclusion could
be ascertained.
Medical History
Before orthodontic treatment is undertaken
a full medical history is recorded. Fortunately
very few medical conditions contraindicate the

use of orthodontic appliances. Most of these
conditions may require certain precautionary
measures to be taken 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 management if extractions are planned.
Diabetic patients can undergo orthodontic
therapy if it is under control. Patients having
rheumatic fever or cardiac anomalies require
antibiotic coverage. Children who are severely
handicapped either mentally or physically may
require special management.
The medical history should include infor­
mation on drug usage. The use of certain drugs
like aspirin may impede orthodontic tooth
movement. Patients who are suffering from
acute, debilitating conditions such as viral
fever should be allowed to recover prior to
initiating orthodontic treatment.
Dental History
The dental history of the patient should
include information on the age of eruption of
the deciduous and permanent teeth history
of extraction, decay, restorations and trauma
to the dentition. The past dental history helps
in evaluation of patients and parents attitude
towards orthodontic treatment.
Prenatal History
The prenatal history should be asked to the
parents. It should include information on the
condition of the mother during pregnancy and
the type of delivery. The use of certain drugs
like thalidomide or affectation with some
infections during pregnancy like German
measles can result in congenital deformities
of the child. Information should be gathered
on the type of delivery. Forceps delivery predi­
sposes to tem­poro­mandibular joint injuries
Orthodontic Diagnosis 173
which can manifest as marked mandi­bular
growth retar­dation.
Postnatal History
The postnatal 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 other
members of the family.
CLINICAL AND GENERAL
EXAMINATIONS
The general examination comprises of the
general assessment of the patient. An obser­
vant clinician usually begins his general
examination as soon as the patients enter the
clinic.
Height and Weight
The height and weight of the patient are recor­
ded. They provide a clue to the physical growth
and maturation of the patient which may have
dentofacial correlation.
Gait
It is the way a person walks. Abnormalities of
gait are usually associated with neuromuscular
disorders which may have a dental correlation.
Posture
Posture refers to the way a person stands.
Abnor­­mal postures can predispose to maloc­
clusion due to alteration in maxillo-mandibular
relationship.
174 Essentials of Orthodontics
Body Built (Physique)
It is possible to classify the physique into one
of the following three types:
i. Esthetic: They have a thin physique and
usually posses narrow dental arches.
ii. Plethoric: They are persons who are
obese. They generally have large, square
dental arches.
iii. Athletic: They are considered normally
built, being neither thin nor obese. They
have normal sized dental arches.
Sheldon has classified the general body
build into three types:
i. Ectomorphic: Tall and thin physique.
ii. Mesomorphic: Average physique.
iii. Endomorphic: Short and obese phy­
sique.
Extraoral Examination
Shape of the Head
Cephalic index: Cephalic Index (Fig. 5.1) is the
ratio of maximal width of head and maximal
depth of head.
Figure 5.1: Cephalic index
The head can be classified into one of the
following three types based on cephalic index
as:
i. Mesocephalic: Average shape of head.
They have normal dental arches.
ii. Dolichocephalic: Long and narrow head.
They have narrow dental arches.
iii. Brachycephalic: Broad and short head.
They have broad dental arches.
Classification
Dolichocephalic (long skull) x – 75.9
Mesocephalic 76 – 80.9
Brachycephalic (short skull) 81– 85.4
Hyperbrachycephalic 85.5 – x
Facial form: A simple way of describing the face
is to classify it as either round, oval, or square.
A more scientific classification is to classify face
into the following three types:
i. Mesoprosopic: It is an average or normal
face form.
ii. Euryprosopic: This type of face is broad
and short.
iii. Leptoprosopic: It is long and narrow face
form.
Assessment of Facial Symmetry
The patient’s facial symmetry is examined
to determine disproportions of the face in
transverse and vertical planes. In most people
the right and left sides are not identical. Thus
mild degree of asymmetry is considered
normal.
Asymmetries that are gross and are
detected easily should be recorded. Gross
facial asymmetries can occur as a result
of congenital defects, hemifacial atrophy/
hypertrophy, unilateral condylar ankylosis and
hyperplasia.
Facial Profile (Figs 5.2A to C)
The facial profile is examined by viewing
the patient from the side. The facial profile

A B C Assessment of Anteroposterior
Figures 5.2A to C: Facial profile
helps in diagnosing gross deviations in the
maxillomandibular relationship. The profile is
assessed by joining the following two reference
lines:
1. A line joining the forehead and the soft
tissue A point (deepest point in curvature
of upper lip).
2. A line joining soft tissue point A and the
soft tissue pogonion (most anterior point
of the chin).
Based on the relationship between these
two lines, three types of profiles exist.
Straight profile: The two lines form a nearly
straight line.
Convex profile: The two lines form an angle
with the concavity facing the tissues. This
kind of profile occurs in prognathic maxilla or
retrognathic mandible as seen in Class II cases.
Concave profile: The two reference lines
form an angle with the convexity towards the
tissues. This type of profile is associated with a
prognathic mandible or a retrognathic maxilla
as in a Class III malocclusion.
Facial divergence: Facial divergence is defined
as an anterior or posterior inclination of the
lower face relative to the forehead. Facial
divergence can be of three types.
Anterior divergent: A line drawn between
forehead and chin is inclined anteriorly
towards the chin.
Orthodontic Diagnosis 175
Posterior divergent: A line drawn between the
forehead and chin slants posteriorly towards
chin.
Straight or orthognathic: The line between the
forehead and chin is straight or perpendicular
to the floor.
The facial divergence is to a large extent
influenced by the patients’ ethnic and racial
background.
Jaw Relationship
The anteroposterior relationship between
the upper and lower jaw can be assessed to a
certain extent clinically. Ideally the maxillary
skeletal base is 2 to 3 mm forward compared
to 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 patients, the index finger is sufficiently
anterior to the middle finger or the hand points
upwards. In a skeletal Class III patient the
middle finger is ahead of the forefinger or the
hand points downwards. In a normal patient
with Class I skeletal pattern the hand is at an
even level.
Assessment of Vertical Skeletal
Relationship
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 bite.
The vertical skeletal relationship can also
be assessed by studying the angle formed
between the lower border of the mandible and
176 Essentials of Orthodontics
the Frankfort horizontal plane (a line between
the most superior point of external auditory
meatus and inferior border of orbit). Normally
the two planes intersect at the occipital region.
In case the two 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.
Evaluation of Facial Proportions
A well­proportioned face can be divided
into three equal vertical thirds using four
horizontal planes at the level of the hairline,
the supraorbital ridge, the base of the nose and
the inferior border of chin. Within the lower
face, the upper lip occupies one­third of the
distance while the chin occupies the rest two­
thirds (Figs 5.3A and B).
B
Figures 5.3A and B: Facial proportions
Examination of Nose
The nose to a large extent contributes to the
esthetic appearance of the face.
Nose size: Normally the nose is one­third of the
total facial height (from hairline to the lower
border of chin).
Nasal 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.
Fomon and Bell described three major
categories of nasal features according to racial
background:
1. Leptorrhine: Usually found in whites and
characterized by a long, high, narrow nose
and nostrils.
2. Mesorrhine: Usually found in Asians and
characterized by lack of dorsal height and
collumellar support.
3. Platyrrhine: Usually found in blacks and
characterized by a flat broad nose and wide
nostrils.
Examination of Chin (Fig. 5.4)
Mentolabial sulcus: The mentolabial sulcus
is a concavity seen below the lower lip. Deep
mentolabial sulcus is seen in Class II division 1
malocclusion while it is shallow in bimaxillary
protrusion.
Mentalis activity: Normally the mentalis mus­
cle does not show any contraction at rest.
Figure 5.4: Mentolabial sulcus

Figure 5.5: Nasolabial angle
Hyperactive mentalis muscle activity is seen in
some malocclusions such as Class II division 1
cases. It causes puckering of the chin.
Chin position and prominence: Prominent
chin is usually associated with Class III malo­
cclusion while recessive chins are common in
Class II malocclusion.
Nasolabial Angle (Fig. 5.5)
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 superioris). This angle is
normally 110°. It reduces in patients having
proclined upper anteriors or prognathic maxilla.
It increases in patients with retrognathic maxilla
or retroclined maxillary anteriors.
Examination of Lips (Fig. 5.6)
Normally the upper lip covers the entire labial
surface of upper anteriors except the incisal 2
to 3 mm. The lower lip covers the entire labial
surface of the lower anteriors and 2 to 3 mm
of the incisal edge of the upper anteriors. Lips
can be classified into the following four types:
Competent lips: The lips are in slight contact
when the musculatures are relaxed.
Incompetent lips: They are morphologically
short lips which do not form a lip seal in a
relaxed state. The lip seal can only be achieved
Orthodontic Diagnosis 177
Figure 5.6: Lips examination
by active contraction of the perioral and men­
talis muscles.
Potentially incompetent lips: They are normal
lips that fail to form a lip seal due to proclined
upper incisors.
Everted lips: They are hypertrophied lips with
weak muscular tonicity.
Intraoral Examination
Examination of Tongue
Abnormalities of the 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.
A patient whose tongue can reach the tip
of the nose is said to have a long tongue. The
lingual frenum should be examined for tongue
tie. In patients having tongue tie there is an
alteration in the resting tongue position as well
as impairment of tongue movements.
Gag reflex is the next factor. It is elicited by
tongue depression. Individuals extremely
sensitive to tongue depression are often found
178 Essentials of Orthodontics
to have inflamed tonsils which may not be
enlarged. But it still causes a lower and forward
tongue posture eliminating support for
development of normal maxillary arch width.
Examination of Palate
The palate should be examined for the follow­
ing findings:
i. Variation in palatal depth occurs in
asso­ci­ation with variation of facial form.
Most dolichofacial patients have deep
palates.
Palatal vault: The height and contour
of palatal vault is the most important
feature. It is determined in order to
decide whether to treat the case with
expansion procedure or not.
ii. Presence of swelling in the palate can be
indicative of an impacted tooth presence
of cysts or other bony pathologies.
iii. Mucosal ulceration and indentations is
a feature of traumatic deep bite.
iv. Presence of clefts in the palate is asso­
ciated with discontinuity of the palate.
v. The third rugae is usually in line with the
canines. This is useful in the assessment
of maxillary anterior proclination.
Examination of Gingiva and Periodontium
The gingival should be examined for inflam­
mation, recession and other muco­gingival
lesions. Presence of poor oral hygiene is
usually associated with generalized marginal
gingivitis. It is very common to find anterior
marginal gingivitis in mouth breathers due
to dryness of the mouth caused by the open
lip posture. Presence of traumatic occlusion
is indicated by localized gingival recession.
Abnormally hyperplastic gingival is seen in
patients using certain drugs like Dilantin.
Examination of Frenal Attachments
The maxillary labial frenum can at times be
thick, fibrous and attached relatively low. Such
an attachment prevents the two maxillary
central incisors from approximating each other
thereby predisposing to maxillary midline
diastema.
Abnormal frenal attachments are diagnosed
by blanch test where the upper lip is stretched
upwards and outwards for a period of time.
The presence of blanching in the region of the
inter-dental papilla is diagnostic feature of an
abnormal frenum.
An abnormally high attachment of the
mandibular labial frenum can cause recession
of the gingival in that area.
Examination of Tonsils and Adenoids
The size and degree of inflammation if any of
the tonsils should be examined. Abnormally
inflamed tonsils cause alteration in tongue
and jaw posture thereby upsetting the orofacial
balance to malocclusion.
Adenoid tissue can be examined clinically
by moving the uvula to one side using a dental
mirror. The dental mirror is then tilted above
the posterior level of hard palate. But it is best
viewed in a lateral cephalograms which are
routinely used by orthodontists.
Assessment of the Teeth and Dentition
The dental system is examined and the
following details are recorded:
i. Number of teeth present.
ii. Teeth unerupted, impacted and missing.
iii. Presence of dental caries, restorations,
malformations, hypoplasias, wear and
discoloration.
iv. The patient is asked to close the jaws in
centric occlusion and the molar relation
 Orthodontic Diagnosis 179

is determined. This is described as

Angle’s Class I, II, III (Figs 5.7 to 5.11).
v. The overjet (Fig. 5.12) and overbite
(Fig. 5.13) which represent the hori­
zontal and vertical overlap of the upper
and lower anterior teeth are recorded.
Variations such as increased overjet,
deep bite, open bite and cross bite
should be recorded.

Figure 5.8: Angle’s Class II

Figure 5.7: Angle’s Class I Figure 5.9: Angle’s Class II division 1

Figure 5.10: Angle’s Class II division 2

180 Essentials of Orthodontics
Figure 5.11: Angle’s Class III
Figure 5.12: Overjet is the horizontal relation of upper
and lower incisors
Figure 5.13: Overbite is the vertical relation of upper
and lower incisors
vi. Transverse malrelations such as poster­
ior cross bite and shift in the upper or
lower midlines should be looked for.
vii. Individual tooth irregularities such as
rotations, displacements, intrusion and
extrusion are noted.
viii. The upper and lower arches are examined
to study their arch form and symmetry
(Fig. 5.14). Arch forms can be normal,
narrow (V­shaped) or square.
ix. Curve of Spee should be measured with
scale in the lower arch (Fig. 5.15).
FUNCTIONAL EXAMINATION
It is now established that normal function of
the stomatognathic system promotes nor­
mal growth and development of the orof­
acial complex. Improper functioning of the
stomatognathic system can result in various
malocclusions.
Orthodontic diagnosis should not be restri­
cted only to static evaluation of the teeth and
their supporting structures but should include
the examination of the various functional units
Figure 5.14: Examination of symmetry
 Orthodontic Diagnosis 181

space exists between the upper and lower jaws.

Figure 5.15: Curve of Spee
of the stomatognathic system. The functional
examination should include the following:
Assessment of Postural Rest Position
and Interocclusal Clearance
The postural rest position is the position of the
mandible at which the muscles that close the
jaws are those that open them are, in a state of
minimal contraction to maintain the posture
of the mandible. At the postural rest position, a
This space is called the interocclusal 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 position:
Phonetic method: The patient is asked to repeat
some consonants like ‘M’ or ‘C’ or repeat a
word like ‘Mississippi’. The mandible returns
to the postural rest position 1 to 2 seconds
after the exercise. The patient is told not to
change the jaw, lip or tongue position after the
phonation, as the dentist parts the lips to study
the interocclusal space.
Command method: The patient is asked to
perform certain functions such as swallowing.
The mandible tends to return to rest position
following this act.

Features Class II division 1 Class II division 2

1. Profile Convex Straight to mild convexity
2. Lips
a. Upper Short Normal
b. Lower Everted Normal
c. Competency Incompetent Competent
3. Mentolabial sulcus Deep Deep or normal
4. Mentalis muscle Hyperactive ­
5. Malar process Not prominent Prominent
6. Lower facial height Normal or increased Decreased
7. Arch form “V” shaped Square, “U” shaped
8. Palate Deep Normal
9. Incisors Proclined Centrals are retroclined
10. Overjet Increased Decreased
11. Overbite Deep overbite Closed bite
12. Crown root Normal angulation Axis of crown and root are bent and
is referred to as column angle
13. Path of closure Normal Backward
14. Interocclusal clearance Normal/increased/decreased Increased
182 Essentials of Orthodontics

Noncommand method: The patient is observed

as he speaks or swallows. The patient is not
aware that he is being examined. This is usually
carried out by talking about topics unrelated
to the patient while carefully observing him
or her. There are various methods employed
to measure the interocclusal clearance. The
following are some of them:
Direct intraoral method: Vernier calipers can
be used directly in the patients’ mouth in the
canine or the incisor region to measure the
freeway space.
Direct extraoral method: Two marks are placed
A B
one on the nose and other on the chin in the
Figures 5.16A and B: Difference between true and
mid­sagittal plane. The distance between pseudo Class III
these two points is measured after instructing
the patient to remain at rest position. Later
True Pseudo
the patient is asked to occlude the teeth and Features
Class III Class III
the distance between the two points is again
1. Profile Concave Straight to concave
measured. The difference between the two 2. Etiology Hereditary Habitual/ develop­
readings is the freeway space. mental
Indirect extraoral method: The interocclusal 3. Premature Absent Present
space is determined in a radiograph or by contacts
Kinesiography. Two lateral cephalograms, at 4. Path of closure Forward Deviated
5. Gonial angle Increased/ Normal
rest position and other in centric occlusion can
decreased
help establish the freeway space. 6. Retrusion Not possible Possible
of mandible
Evaluation of Path of Closure further
The path of closure is the movement of the 7. Treatment Orthopedic Elimination of
or surgical prematurities,
mandible from rest position to habitual replacement of lost
occlusion. Abnormalities of the path of closure posterior teeth
are seen in some forms of malocclusions. 8. Left untreated No further Becomes
Forward path of closure: A forward path of changes established into
true Class III
closure occurs in patients with mild skeletal
prenormalcy or edge to edge incisor contact
as in cases of pseudo Class III cases (Figs 5.16A Backward path of closure: Class II division 2
and B). In such patients, the mandible is gui­ cases exhibit premature incisor contact due
ded to a more forward position to allow the to retroclined maxillary incisors. Thus the
mandibular incisors to go labial to the upper mandible is guided posteriorly to establish
incisors. occlusion.

Lateral path of closure: Lateral deviation of
the mandible to the left or the right side is
associated with occlusal prematurities and a
narrow maxillary arch.
Smile Analysis (Fig. 5.17)
Smile is one of important emotions of face.
Smile is produced by the elevation of the
upper lips.
The upper and lower lips frame the display
zone of the smile. Within this framework, the
components of the smile are the teeth and the
gingival scaffold.
Frontally smile can be visualized in 2
dimension—vertical and transverse:
1. Vertical characteristics:
a. Incisor display
b. Gingival display
Figure 5.17: Smile analysis
Orthodontic Diagnosis 183
c. Smile arc
d. Relation between gingival margins of
maxillary incisors and upper lip.
2. Transverse characteristics:
a. Arch form
b. Buccal corridor
c. Transverse cant of maxillary arch.
Assessment of Respiration
Humans may exhibit three types of breathing
nasal, oral and oronasal.
A number of simple tests exist that can be
employed to diagnose the mode of respiration.
Observation: Study the patients breathing
pattern unobserved. Nasal breathers usually
hold the lips touching lightly during relaxed
breathing. Whereas in the mouth breathers
lips are parted during breathing.
184 Essentials of Orthodontics
Mirror test: A double sided mirror is held
between the nose and the mouth. Fogging on
the nasal side of the mirror indicates nasal
breathing while fogging towards the oral side
indicates oral breathing.
Mouth mirror test: Hold a mouth mirror infront
of the nostrils and in the mouth, in nasal
breathers the mirror gets clogged when shown
in front of nose and it clogged near mouth in
mouth breathers.
Cotton test: A butterfly shaped piece of cotton
is placed over the upper lip below the nostrils.
If the cotton flutters down it indicates nasal
breathing. This test can be used to determine
unilateral nasal blockage.
Water test: The patient is asked to fill his mouth
with water and retain it for a period of time.
While nasal breathers accomplish this with
ease, mouth breathers find the task difficult.
Deep breath exercise: In nasal breathers the
external nares dilate during inspiration. In
mouth breathers, there is either no change in
the external nares or they may constrict during
inspiration.
Examination of Temporomandibular
Joint
The functional examination should routinely
include auscultation and palpation of the
temporomandibular joint (TMJ) and the
musculature associated with mandibular
opening.
The condyle and fossa are palpated with
index finger during opening and closing
maneuvers. The posterior surface can be
palpated by inserting the little finger in the
external auditory meatus. The condyles can
thus be checked for tenderness, synchrony of
action and coordination of relative position in
the fossae.
Palpation of the lateral pterygoid muscle
area is done by placing the forefinger behind
the maxillary tuberosity right above the
occlusal plane and the palmar surface of the
finger directed medially towards the pterygoid
hamulus.
A stethoscope is used to check for signs
of clicking and crepitus. A stereostethoscope
is better because it allows the operator to
determine the magnitude and timing of
abnormal sounds for each joint simultan­
eously.
The examinations are performed by having
the patient open and close the jaw into full
occlusion. If clicking or crepitus is noted, the
patient is asked to bite forward into incision
and then repeat the opening and closing
movements. Most often sounds disappear in
the protruded position.
The patient is examined for symptoms
of temporomandibular joint problems such
as clicking, crepitus, pain of the masti­
catory muscles, limitation of jaw movement,
hypermobility and morphological abnor­
malities.
The maximum mouth opening is deter­
mined by measuring the distance between the
maxillary and mandibular incisal edges with
the mouth wide open. The normal interincisal
distance is 40 to 45 mm (Fig. 5.18).
Figure 5.18: Maximum mouth opening

Evaluation of Swallowing
In newborn, the tongue is relatively large and
protrudes between the gum pads and takes
part in establishing the lip seal. This kind
of swallow is called infantile swallow and is
seen till 1½ to 2 years of age. Infantile swallow
is replaced by the mature swallow as the
buccal teeth start erupting. The persistence
of the infantile swallowing can be cause for
malocclusion. Thus the swallowing pattern
of the individual should be examined. The
persistence of infantile swallow is indicated
by protrusion of tip of tongue, contraction of
perioral muscles during swallowing and no
contact at the molar region during swallowing.
Normally the tongue rests on the occlusal
level within the arches, dorsum touching the
palate and the tip of the tongue rest in lingual
fossa.
Methods of examination of swallowing:
Observe the posture of the tongue while the
mandible is in postural position unnoticed.
In normal swallow the mandible rises as the
teeth are brought together during swallow and
the lips tough lightly without any contraction
of facial muscles.
Place a hand over temporalis muscle, give
a little water to the patient ask him to swallow,
contraction of temporalis is felt in normal
swallow no temporalis contraction is present
in tongue thruster.
Retract the lower lip using tongue depressor
or mouth mirror ask the patient to swallow.
Normal swallowers can complete command,
but those with tongue thrusting habit will have
the swallow inhibited by depression of the lips
since strong mentalis and lip contractions are
needed for mandibular stabilization in the
teeth apart swallow.
Speech
Certain malocclusions may cause defects in
speech due to interference with movement of
Orthodontic Diagnosis 185
the tongue and lips. This should be observed
while conversing with the patient. The patient
can be asked to read out from a book or asked
to count from 1 to 20 while observing the
speech. Patient can also be asked to read loud
or repeat a sentence. Patient can be asked to
play song of six pence and sound and tongue
are observed.
Patients having tongue thrust habit tend to
lisp while cleft palate patients may have a nasal
tone.
ORTHODONTIC STUDY MODELS
(FIGS 5.19A TO D)
Orthodontic study models are accurate plaster
reproduction of the teeth and their surrounding
soft tissues. They are an essential diagnostic aid
that makes it possible to study the arrangement
of teeth and the occlusion from all the three
dimensions. Lingual occlusion can only be
viewed from study models.
The uses of study models include:
1. They enable the study of the occlusion from
all aspects.
2. They enable accurate measurements to
be made in a dental arch. They help in
measurement of arch length, arch width
and tooth size.
3. They help in assessment of treatment
progress by the dentist as well as the
patient.
4. They help in assessing the nature and
severity of malocclusion.
5. They are helpful in motivation of the patient
and to explain the treatment plan as well
as progress to the patient and parents.
6. It makes it possible to simulate treatment
on the case such as mock surgery.
7. Study models are useful to transfer records
in case the patient is to be treated by
another clinician.
186 Essentials of Orthodontics
A B
D
Figures 5.19A to D: Orthodontic study models
Ideal Requirements of an
Orthodontic Study Model
Orthodontic study models should fulfill the
following criteria:
i. The models should accurately reproduce
the teeth and their surrounding soft
tissues without any distortion.
ii. The models are to be trimmed in such a
manner that they are symmetrical and
pleasing to the eye. This enables instant
identification of asymmetries in the arch
form.
iii. The models are to be trimmed in such
a way that when placed on their backs,
they are accurately reproducing the
occlusion.
iv. The study models should have a clean,
smooth and nodule­free surface.

v. The study models should not only depict
the teeth but should also reproduce as
much of the alveolar process as possible.
Parts of a Study Model
Orthodontic study models consists of two
parts:
1. Anatomic portion: Anatomic portion is
that post of the study model which is the
actual impression of the dental arch and
its surrounding structures. This portion is
usually made of stone plaster.
2. Artistic portion: Artistic portion of the
study model consists of a plaster base that
supports the anatomic portion. This portion
of the study model helps in depicting the
actual orientation and occlusion of the
study models and also gives a pleasing and
symmetrical appearance to the models.
In a well-fabricated the ratio of the anatomic
portion to artistic portion should be 3:1.
Steps in Construction of
Orthodontic Study Models
1. Impression making: Obtaining a good
impression of the hard and soft tissues of the
dentoalveolar region is an important factor
in the proper fabrication of orthodontic
study casts. The impressions should extend
to the limits of the buccal sulcus and into
the lingual sulcus of the lower arch. The
maxillary impression should cover the hard
palate but should not extend on to the soft
palate.
It is recommended to use high flange
orthodontic trays that extend deep into
the buccal and lingual sulcus. This is an
important consideration as orthodontic
study models should reproduce as much
of the supporting structures as possible.
The trays selected should include the
last erupted molars and a clearance of
around 3 mm should exist between the
Orthodontic Diagnosis 187
teeth and the tray. Use of trays that are too
wide or too narrow invariably causes soft
tissue distortion and therefore results in
inaccurate study models.
Irreversible hydrocolloids (Alginate)
are widely used for impression making.
During the procedure, the patient is seated
in a vertical position to avoid entry of the
impression material into the pharynx.
2. Disinfecting the impression: The impre­
ssions are rinsed thoroughly in water and
are disinfected to free them of micro­
organisms, plaque and other oral secretions
that may be present on them. Disinfection
can be done by soaking the impression
in a disinfectant solution such as Biocide
(Glutaraldehyde). After disinfection the
impressions are once again rinsed in water
to clear them of any residual disinfectant.
3. Casting the impression: The impressions
obtained are casted using orthodontic
stone or model stone. It is beneficial to
use some form of vibrator to eliminate
incorporation of air bubbles.
4. Basing and trimming of the cast: Once
the anatomic area of the study models
are poured, the artistic portion of the
study casts is built to form a base over the
anatomic portion. To help in making the
base, rubber base formers are available.
Once the anatomic portion of the model
is poured, the impression tray is turned
upside down and pushed into the plaster
filled into the base former. The plaster
base is allowed to set for 30 to 60 minutes.
The trimming of the base is a meticulous
task that contributes to the beauty of the
models. The trimming of the orthodontic
model is done on an electric plaster
trimming machine having a medium grit
carborundum wheel.
Step I: The base of the mandibular case
should be parallel to the occlusal plane.
188 Essentials of Orthodontics
The lower model is inverted over a ‘T’
shaped piece of rubber and a marking
is circumscribed all around the base of
the model using a marker mounted on a
vertical stand. Once the marking is made,
the base of the cast is trimmed upto the
marking.
Step II: The mandibular model is trimmed
perpendicular to the midline. The back of
the model should also be 90° to the base of
the model. While trimming the back care
should be taken to leave 5 mm of the plaster
base distal to the most posterior teeth.
Step III: Occlude the upper and lower
models together and trim the maxillary
backs surface, so that the maxillary back
is in flush with the mandibular back.
Step IV: The upper and lower models are
occluded together and are placed on their
backs on the model trimmer. The base of
the maxillary cast is trimmed to that it is
parallel to the base of the lower model.
At the end of this step, the bases of the
maxillary and the mandibular casts are
parallel to each other and to the occlusal
plane and the back of both the upper and
lower casts are at right angles to the bases.
Step V: The buccal cuts are made on the
mandibular cast 5 to 6 mm away from the
buccal surface of the posterior teeth. The
buccal cuts are to be made 60° to the back
of the model.
Step VI: The anterior segment of the lower
arch is trimmed into a curve that follows
the curvature of the lower anterior teeth.
The anterior curve should be 5 to 6 mm
away from the labial surface.
Step VII: The posterior cuts of the
mandibular model are trimmed at approxi­
mately 115° to the back of the model. The
linear measurement of the posterior cuts
should be 13 to 15 mm.
Step VIII: The buccal cuts are made on the
maxillary cast 5 mm away from the buccal
surface of the most posterior teeth. The
buccal cuts should be 65° to the back of the
maxillary cast.
Step IX: The anterior cuts are made on
the maxillary cast. The cuts on either side
should be of equal length and should lie 5
to 6 mm ahead of the labial surface of the
anterior teeth. The anterior cuts on either
side should meet at the midline of the cast
and should extend till the midline of the
canine. The anterior cuts are made 30° to
the back of the cast.
Step X: The posterior cuts of the maxillary
cast are made in such a way that they
are in flush with the posterior cuts of the
mandibular cast. This is done by occluding
the models and trimming the maxillary
posterior cuts till they are in line with the
mandibular posterior cuts.
5. Finishing and polishing: The artistic por­
tion of the dental cast is polished using fine
grained sand paper. Care should be taken
not to round off the edges of the models.
The final polishing of the casts is done
by placing them in soap solution for one
hour. The casts are removed from the soap
bath and are rinsed under warm water.
The casts are then allowed to dry and are
buffed so that they acquire a smooth and
shiny appearance.
Gnathostatic Models
Gnathostatic models were devised by Simon in
1926 for the purpose of Simon’s classification
of malocclusion.
They are orthodontic study models where
the base of the maxillary cast is trimmed
to corr­e s­p ond to the Frankfort horizontal
plane. Gnathostatic model allows us readily
to visualize the angulation of teeth to the
 Orthodontic Diagnosis 189

Frankfort horizontal plane. Special equipment Pont’s Analysis

called Gnathostat is required to fabricate these
models.
Model analysis involves the study of the
maxillary and mandibular dental arches in
all the three planes of space and is a valuable
tool in orthodontic diagnosis and treatment
planning (Fig. 5.20).
Classification
Pont in 1909 suggested a method for deter­
mination of the dental arch width from
combined mesiodistal width of upper central
and lateral incisors 21|12.
Pont’s analysis helps in determining
whether the dental arch is narrow or is normal.
It also helps in determining the need for lateral
arch expansion and how much expansion
possible in premolar and molar regions.

Permanent Dentition Model Analysis Procedure

1. Pont’s analysis i. Measure the mesiodistal width of four
2. Linderharth’s analysis maxillary incisors. They are summed up
3. Korkhaus analysis this value is called sum of incisors (SI)
4. Arch perimeter analysis ii. Measure the arch width in premolar
5. Bolton tooth size ratio region from distal pit of right premolar
6. Carey’s analysis to distal pit of left premolar. This is the
7. Ashley Howe’s analysis measured premolar value (MPV) (Fig.
8. Peck and Peck index. 5.21)
iii. Measure the arch width in first molar
Mixed Dentition Model Analysis region from mesial pit of right molar
1. Moyer’s mixed dentition analysis to mesial pit of left molar. This is the
2. Huckaba’s analysis measured molar value (MMV) (Fig.
3. Hixon and Oldfather’s analysis 5.21)
4. Tanaka Johnston analysis iv. Calculate arch width in premolar region
5. Nance Carey’s analysis using the formula:
6. Total space analysis. SI 100
80

Figure 5.20: Model analysis Figure 5.21: Intercanine and intermolar width
190 Essentials of Orthodontics
v. Calculate arch width in molar region
using the formula:
SI 100
64
vi. Inference: If the calculated value is
greater than measured value then the
arch is narrow for the sum of incisors
width and needs expansion.
If the measured value is greater than the
calculated value then the arch is wider for the
sum incisor width and there is no scope for
expansion (Fig. 5.22).
Drawbacks
i. This is done for French population
ii. Does not consider alignment of teeth
iii. Does not consider the malformations of
teeth (e.g. peg lateral incisors).
Linderharth’s Analysis
This analysis is very similar to Pont’s analysis
except that a new formula has been proposed
Figure 5.22: Measurement of arch circumference
to determine the calculated premolar and
molar value.
SI ¥ 100
Arch width in premolar region:
80
SI ¥ 100
Arch width in molar region:
64
Korkhau’s Analysis
This analysis is also similar to Pont’s analysis.
It makes use of the Linderharth’s formula
to determine the ideal arch width in the
premolar and molar region. In addition, this
analysis utilizes a measurement made from
the midpoint of the interpremolar line to a
point in between the two maxillary incisors.
According to Korkhaus, for a given width of
upper incisors a specific value of the distance
between the midpoint of interpremolar 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 retroclined
upper anteriors.
Carey’s Analysis
Many malocclusions occur as a result of
discrepancy between arch length and tooth
material. Carey’s analysis helps in detemining
the extent of the discrepancy. It is performed
on the lower cast. The same analysis on the
upper cast is called archperimeter analysis.
Determination of Arch Length
The arch length anterior to the first permanent
molar is measured using a soft brass wire. The
wire is placed touching the mesial surface of
the first permanent molar of one side and is
passed over the buccal cusps of the premolars
and along the anteriors and is continued on the
opposite side in the same way upto the medial
surface of the opposite first permanent molar.
In case of proclined anteriors the wire is passed
along the cingulum of anterior teeth. If the
 Orthodontic Diagnosis 191

anterior teeth are retroclined, the brass wire

in the anterior segment passes labial to the
teeth. If the anterior teeth are well­aligned the
wire passes over the incisal edge of anteriors.

Determination of Tooth Material

The mesiodistal width of the teeth anterior to
the first molars (second premolar to second
premolar) is measured and summed up.

Determination of the Discrepancy

A
The discrepancy refers to the difference
between the arch length and tooth material.

Inference
i. If the discrepancy is 0 to 2.5 mm, it
indicates minimal tooth material excess.
In such cases, proximal stripping can be
carried out to reduce the tooth material.
ii. If the discrepancy is between 2.5 to
5 mm, it indicates the need to extract the
second premolars.
B
iii. A discrepancy of more than 5 mm
Figures 5.23A and B: Bolton’s index
indicates the need to extract the first
premolars.

Bolton’s Analysis second permanent molars is measured and

Tooth size is an important factor to be taken
into consideration in orthodontic diagnosis
and treatment planning. According to Bolton
there exists a ratio between the mesiodistal
widths of maxillary and mandibular teeth.
Many malocclusions occur as a result of abnor­
malities in tooth size. The Bolton’s analysis
helps in determining disproportion in size
between maxillary and mandibular teeth (Figs
5.23A and B).
Sum of mandibular 12 teeth: The mesiodistal
width of all the teeth mesial to the mandibular
second permanent molars is measured and
summed up.
Sum of maxillary 12 teeth: The mesiodistal
width of all the teeth mesial to the maxillary
summed up.
Sum of mandibular 6 teeth: The mesiodistal
width of all the teeth mesial to the mandibular
first premolars is measured and summed up.
Sum of maxillary 6 teeth: The mesiodistal
width of all the teeth mesial to the maxillary
first premolars is measured and summed up.
Determination of Overall Ratio
According to Bolton, the sum of mesiodistal
widths of the mandibular teeth anterior to the
second permanent molars is 91.3 percent the
mesiodistal width of the maxillary teeth mesial
to the second molars.
The overall ratio is determined using the
formulas
192 Essentials of Orthodontics
Sum of mandibular 12 teeth
Overall ratio = 100
Sum of maxillary 12 teeth
If the overall ratio is less than 91.3 percent,
it indicates maxillary tooth material excess or
mandibular tooth material deficient.
The amount of maxillary excess is deter­
mined by using the formula:
Sum of maxillary 12 teeth – sum of
mandibular 12 teeth × 100
19.3
If overall ratio is more than 91.3%, it
indicates mandibular tooth material excess of
maxillary tooth material deficient. The amount
of mandibular excess can be determined by the
formula:
Sum of mandibular 12 teeth – sum
of maxillary 12 teeth × 91.3
100
Determination of Anterior Ratio
The sum of mesiodistal width of the mandibular
anteriors should be 77.2 percent of the
mesiodistal width of the maxillary anteriors.
The anterior ratio is determined using the
following formula:
Sum of mandibular 6 teeth
Anterior ratio = × 100
Sum of maxillary 6 teeth
If the anterior ratio is less than 77.2 percent,
it indicates maxillary anterior excess or
mandibular anterior deficient. The amount of
maxillary anterior excess is determined by the
following formula.
Sum of maxillary 6 teeth – sum of
maxillary 6 teeth × 100
77.2
If the anterior ratio is more than 77.2
percent it indicates mandibular anterior excess
or maxillary anterior deficient. The amount
of anterior excess is determined using the
formula:
Sum of mandibular 6 teeth –
Sum of maxillary 6 teeth
× 77.2
100
Moyer’s Mixed Dentition Analysis
The purpose of a mixed dentition analysis is
to evaluate the amount of space available in
the arch for the erupting permanent canines
and premolars. In this analysis the size of the
unerupted permanent cuspids and premolars
are predicted from the knowledge of the sizes
of certain permanent teeth already erupted
in the mouth. The Moyer’s mixed dentition
analysis predicts the combined mesiodistal
width of Permanent canine, first premolar
and second premolar based on the sum of the
widths of the four lower permanent incisors.
The mesiodistal widths of the four lower
incisors are measured and summed up. The
amount of space available for the permanent
canine, first premolar and second premolar
after incisor alignment is determined by
measuring the distance between the distal
surface of lateral incisor and the mesial surface
of first permanent molar.
Based on the mesiodistal widths of the
four mandibular incisors, the expected width
of the canines, first and second premolars
are predicted by referring the probability
chart. While doing so, the 75 percent level of
probability is considered reliable.
The predicted tooth size of permanent
canine, first premolar and second premolar
is compared with the arch length available for
them so as to determine the discrepancy. If the
predicted value is greater than the available
arch length, crowding of teeth can be expected.
If the predicted value is less than available arch
length, spacing of teeth can be expected.
Mixed Dentition Analysis—
Radiographic Method
This technique makes use of a radiograph as
well as a study models to determine the width
of the unerupted teeth.
Radiographic measurements of unerupted
teeth are by themselves unreliable due to

the distortion that can occur. It is possible to
determine the measurements of the unerupted
teeth by studying the teeth that have already
erupted in a radiograph and on a cast. The
following formula is used:
X1 ´ Y2
Y1 =
X2
Where,
Y 1 = width of unerupted tooth whose
measurement is to be determined.
Y 2 = width of unerupted tooth on the
radiograph.
X1 = width of a tooth that has erupted
measured on the cast.
X2 = width of a tooth that has erupted
measured on the radiograph.
TOTAL DENTITION SPACE
ANALYSIS
Since the original diagnosis and treatment plan
must accept the dimensions of the denture
presented in the original malocclusion when
musculature is normal (i.e. Class I), a total
dentition space analysis allows the clinician to
develop a differential diagnosis that respects
the dimensions of the denture concept during
the treatment planning process. Available
space can neither be created nor destroyed by
tooth movement. Orthodontics therefore is a
space management procedure. It is an attempt
to balance tooth material most advantageously
with present and future space available.
All 32 teeth must be considered, as well as
the anterior, posterior, vertical, and lateral
dimension of the denture.
Total dentition space analysis is divided
into three parts: (1) anterior, (2) midarch, and
(3) posterior. This division is made for two
reasons: (1) simplicity in identifying the area of
Orthodontic Diagnosis 193
space deficit or space surplus, and (2) a more
accurate differential diagnosis.
Anterior Space Analysis
Anterior space analysis includes the measure­
ment in millimeters of the space available in
the mandibular arch from canine­to­canine
and a measurement of the six anterior teeth
mesiodistally. The difference is referred to
as a surplus or a deficit. Tweed’s diagnostic
facial triangle is also used to further analyze
this area. A head film discrepancy, based on
the amount of mandibular incisor uprighting
that is needed to restore facial balance, is
added to the anterior space measurement.
The total, if a deficit, is referred to as anterior
discrepancy. Anterior discrepancies are most
easily resolved, if they are the overriding
consideration of the malocclusion, by removal
of the first premolar teeth and by using the
resulting space to move the canines distally
to obtain the space to upright and align the
incisors.
Midarch Analysis
The midarch area includes the mandibular first
molars and the second and first premolars.
Careful analysis of this area can show mesially
inclined first molars, rotations, spaces, deep
curves of Spee, cross bites, missing teeth,
habit abnormality, blocked out teeth, and
occlusal disharmonies. This is an extremely
important area of the denture. Being in the
center of the arch, this area allows the easiest
and most direct method of space management
for malocclusion correction when it can be so
used. Crowding, deep curves of Spee, end­on,
and Class II occlusions not accompanied by
anterior discrepancy, all indicate a need for
second premolar extraction in the lower arch.
Careful measurement of the space from the
distal of the canine to the distal of the first
194 Essentials of Orthodontics
molar should be recorded as available midarch
space. An equally accurate measurement of
the mesiodistal width of the first premolar,
the second premolar, and the first molar must
also be recorded. To this is added the space
required to level the curve of Spee. From these
measurements one can determine the space
deficit or surplus in this area.
Many diagnosticians have suggested that
they extract second premolar teeth to eliminate
facial retrusion. This is faulty reasoning. These
cases have, as a rule, very little anterior discre­
pancy, and the second premolars are removed
because their space is most advantageously
used for the midarch problems that these
cases usually demonstrate. The midarch
space analysis is critical in proper differential
diagnosis.
Posterior Space Analysis
The posterior denture area has great impor­
tance, and has at times been ignored or
mistreated by our specialty. The required
space in the posterior space analysis is the
mesiodistal width of the second molars and
the third molars in the mandibular arch. The
available space is more difficult to ascertain
on the immature patient. It is a measurement
in millimeters of the space distal to the
mandibular first molars along the occlusal
plane to the anterior border of the ramus, plus
an estimate of posterior arch length increase,
based on both age and sex.
There are certain variables that must
be considered in estimating the increase in
posterior space available. These variables are
as follows:
1. Rate of mesioocclusal migration of the
mandibular first molar.
2. Rate of resorption of the anterior border of
the ramus.
3. Time of cessation of molar migration.
4. Time of cessation of ramus resorption.
5. Sex.
6. Age.
A review and study of the literature reveals
that a consensus of researchers suggests
3 mm of increase in the posterior denture area
occurs per year until age 14 years for girls and
age 16 years for boys. This is a 1.5 mm increase
on each side per year after the full eruption of
the first molars. In the mature patient, girls
beyond 15 years and boys beyond 16 years, one
can measure from the distal of the first molar to
the anterior border of the ramus at the occlusal
plane and have an accurate determination
of the space available in the posterior area.
It is of extreme importance to know whether
there is a surplus or deficit of space in this area
during diagnosis and treatment planning. It is
imprudent to create a posterior discrepancy
while making adjustments in other areas—the
midarch, or in the anterior area. It is equally
imprudent not to use a posterior space surplus
to help alleviate midarch and anterior deficits.
The most easily recognizable symptom of a
posterior deficit on the young patient is the late
eruption of the second molar. If space is not
available for this tooth by the age of its normal
eruption, then one can pretty well ascertain
that there is a posterior space problem. A
good lateral jaw radiograph can immediately
confirm the clinical observation by using the
above-mentioned guidelines.
In summary, a total space analysis that
analyzes the anterior, midarch, and posterior
denture areas is a valuable diagnostic tool.
It enables the orthodontic specialist to treat
within the dimensions of the denture in the
case with normal muscular balance. A total
dentition space analysis, used within the
dimensions of the denture framework, enables
the orthodontist to make correct differential
diagnostic decisions.

Diagnosis, by definition, is both subjective
and objective. Webster defines diagnosis
as a “deter­mination of a disease from sym­
ptoms, data, or tests and the decisions and
judgments made prior to treatment”. Thus the
determination made in regard to whether,
when, and which teeth need to be eliminated
for proper space management is a differential
diagnostic process. When diagnostic guide­
lines or decisions are suggested, they can
appropriately be called “one man’s opinion”.
The following diagnostic space management
guide­lines are suggested for use and should
not be considered as rules. These space
management suggestions are based on space
analysis only. Any complete diagnostic scheme
has to consider the facial pattern and the
skeletal pattern.
INFERENCE TO DEFICITS AND
DECISIONS
Space management guidance:
A. Anterior surplus or deficit: + to -2 mm space
management nonextraction
3 to 5 mm without crowding.
Extract: All third molars
3 to 5 mm with crowding.
Extract: All second premolars
5 to 7 mm with less than 3 mm anterior
crowding.
Extract: Upper 4s and Lower 5s
5 to 7 mm with more than 3 mm anterior
crowding.
Extract: All first premolars
7 to 15 mm anterior deficit.
Extract: All first premolars
16 mm and above.
Extract: All first premolars and any one
molar on each side.
B. Midarch surplus or deficit: An anterior
deficit or surplus overrides a midarch
Orthodontic Diagnosis 195
deficit so the first determination is a
decision on the anterior deficit.
+ to 3 mm
Nonextraction
3 to 5 mm without crowding.
Extract: All third molars
3 to 5 mm with Class II molar.
Extract: Upper 4s and Lower 5s.
5 to 7 mm with upper anterior protrusion.
Extract: Upper 4s and Lower 5s.
5 to 7 mm
Extract: All second premolars
8 to 15 mm
Extract: Upper 4s and lower 5s and any one
molar on each side.
Over 15 mm
Extract: Upper 4s and lower 5s and any one
molar on each side.
C. Posterior surplus or deficit: The space
analysis in this area is of great importance,
although in corrective procedures, anterior
and midarch deficits are overriding. The
posterior space must be carefully measured
and protected. No orthodontic treatment is
complete until all decisions and treatment
procedures are completed in this area.
+ to -5 mm with good position of the third
molars. Await full development of the third
molars.
+ to -5 mm with poor position of third
molars. Extract: All third molars.
Note: Wait for maxillary third molars until
age 16 years. Have the mandibular third
molars removed immediately if other
treatment is necessary.
5 to 15 mm.
Extract: All third molars.
(Determine the timing of these third molar
extractions in relationship to symptoms and
other treatment that is necessary).
Consistent, quality orthodontic treatment
results are based on fundamental concepts.
The concept of dimensions of the denture is
196 Essentials of Orthodontics
predicated on the conviction that the teeth
and their supporting structures should be in
a state of maximum environmental harmony
(dynamic equilibrium). Total dentition space
analysis, based on the dimension of the
denture concept, is a valuable tool that can
help the orthodontic specialist produce a
consistently high quality result that meets the
needs and expectations of the patient.
RADIOGRAPHS USED IN
ORTHODONTIC DIAGNOSIS
William Conrad Roentgen discovered X-rays
in 1895. There is no aspect of the medical
field that is not influenced by this discovery.
Orthodontics is no exception. Radiographs
have established them­selves as a valuable tool
in orthodontic diagnosis. Radiographs are used
for the following purposes in orthodontics:
1. To assess general development of the
dentition; presence, absence and state of
eruption of the teeth.
2. To establish the presence or absence of
supernumerary teeth.
3. To determine the extent of root resorption
of deciduous tooth.
4. To study the extent of root formation of the
permanent teeth.
5. To confirm the presence and extent of
pathological and traumatic conditions.
6. To study the character of alveolar bone.
7. They are a valuable aid in craniodentofacial
analysis.
8. To confirm the axial inclination of the roots
of teeth.
9. To assess teeth those are morphologically
abnormal.
Radiographs routinely used for diagnosis in
orthodontics can be classified into two types:
1. Intraoral radiographs
2. Extraoral radiographs.
Intraoral Radiographs
Three types of intraoral radiographs are comm­
only used. They are periapical, bitewing and
occlusal projections.
Intraoral periapical radiographs (IOPA): They
are radiographs that are used to view the teeth
and their supporting structures. Two intraoral
projection techniques are used for periapical
radiography they are:
i. Paralleling technique: This technique
is also called right angle or long cone
technique. In this technique, the X-ray
film is placed parallel to the long axis of
the teeth and the central ray of the X-ray
beam is directed at right angles to the
teeth and film. This method is believed
to reduce geometric distortions and is
therefore the preferred technique.
ii. Bisecting angle technique: In this tech­
nique, the central ray is directed at right
angles to a plane bisecting the angle
between the long axis of the teeth and
the film.
Uses of intraoral periapical radiographs: Full
mouth intraoral periapical radiographs routi­
nely taken prior to initiation of orthodontic
treatment. The following are some of the uses
of intraoral periapical radiographs:
1. To confirm the presence or absence of teeth.
2. To establish the presence or absence of
supernumerary teeth.
3. To assess the extent of calcification and root
formation of teeth.
4. To confirm the presence and study the
extent of periapical pathology and root
fractures.
5. To study the alveolar bone and periodontal
ligament space.
6. To study the height and contour of alveolar
bone crest.
7. To assess the axial inclination of roots.
8. To detect retained root fragments and root
stumps.

9. To detect the size and shape of unerupted
teeth.
Disadvantages of Intraoral
Periapical Radiographs
The following are some of the disadvantages
of intraoral periapical films:
1. Assessment of the entire dentition requires
too many radiographs.
2. Children may not allow placement of
intraoral films.
3. They cannot be used in patients having
high gag reflex and trismus.
Advantages
Although intraoral films have a number of
drawbacks they offer some advantages as
follows:
1. Low radiation dose.
2. Possible to obtain localized views of the
area of interest.
3. They offer excellent clarity of teeth and their
supporting structures.
Bite Wing Radiographs
Bite wing radiographs record the coronal part
of the upper and lower dentition along with
their supporting structures. The following are
some of the uses of bite wing radiographs:
1. To detect proximal caries.
2. To study the height and contour of inter­
dental alveolar bone.
3. To detect secondary caries below restor­
ations.
4. To detect overhangings proximal restor­
ations.
5. To detect periodontal changes.
6. To detect interproximal calculus.
Occlusal Radiographs
Intraoral occlusal radiographs enable viewing
of a relatively large segment of the dental
Orthodontic Diagnosis 197
arch, including the palate or floor of the
mouth. Occlusal radiographs are also useful
in patients who are unable to open the mouth
wide enough for periapical radiographs. It is
possible to obtain occlusal projection of the
upper as well as the lower arches.
The following are the uses of occlusal
radiographs:
1. To locate impacted or unerupted teeth.
2. To locate supernumerary teeth.
3. To locate foreign bodies in the jaws and
stones in salivary ducts.
4. To study buccolingual expansions of
cortical plate due to pathology of the jaws.
5. To diagnose the presence and extent of
fractures.
6. They are useful in orthodontics to study the
effects of arch expansion procedures.
Extraoral Radiographs
Extraoral radiographs include all views made
of the orofacial region with the film positioned
extra­orally. They are useful whenever large
areas of the face and skull are to be visualized.
Panoramic Radiographs
(Orthopantomograms, OPG) (Fig. 5.24)
Panoramic radiographs enable viewing of both
maxillary and the mandibular arches with their
supporting structures. Thus a single image
covers a major part of the facial region. Uses
of panoramic radiographs include:
Figure 5.24: Panoramic radiograph
198 Essentials of Orthodontics
1. They are useful in assessing the dental
deve­lop­m ent by studying deciduous
root resorption and root development of
permanent teeth.
2. They can be used to view ankylosed and
impacted teeth.
3. To study the path of eruption of teeth.
4. To diagnose the presence or absence of
multiple supernumerary teeth.
5. To diagnose the presence and extent of
pathology and fractures of the jaws.
6. They are useful aids in serial extraction
procedures to study the status of erupting
teeth.
7. They are useful in the mixed dentition
period to study the status of unerupted
teeth.
The advantages of panoramic radiograph
include:
1. A broad anatomic area can be visualized.
2. The patient radiation exposure is low.
3. It can be used in patients who are unable
to tolerate intraoral films or unable to open
the mouth.
The following are the disadvantages of
panoramic radiographs:
1. Distortions, magnifications and overl­
apping of the structures occur.
2. The teeth and the supporting periodontal
structures are not as clear as in periapical
films.
3. Inclination of anterior teeth cannot be
visualized.
4. Requires equipment that is expensive.
5. Whenever details of a particular area are
needed they have to be supplemented by
other radiographs.
Cephalometric Radiographs
They are specialized skull radiographs in which
the head is positioned in a specially designed
head holder called cephalostat by means of ear
rods. Thus it is standardized technique where
in the head is held in a predetermined position.
Cephalograms are also used for comparison of
serial radiographs.
Cephalometric radiographs are of two
types:
1. Lateral cephalogram.
2. Posteroanterior cephalogram.
CEPHALOMETRICS
The assessment of craniofacial structures forms
a part of orthodontic diagnosis. The earliest
method used to assess facial proportions was
by artistic standards with harmony, symmetry
and beauty as key points. Craniometry can be
said to be the forerunner of cephalometry.
Craniometry involved measurements of
craniofacial 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 and
far less reliable.
The discovery of X-rays in 1895 by Roent­
gen revolutionized dentistry. It pro­vided a
method of obtaining the inner craniofacial
measurements with quite a bit of accuracy
and reproducibility. In 1922, Paccini stand­
ardized the radiographic head images
by positioning the subjects against a film
cassette at a distance of 2 meters from the
X-ray source. In 1931, Broadbent of USA and
Hofrath in Germany simultaneously presented
a standardized cephalometric technique using
a high powered X-ray machine and a head
holder called Cephalostat.
Types of Cephalograms
Cephalograms can be of two types:
i. Lateral cephalogram: This provides
lateral view of the skull.
ii. Frontal cephalogram: This provides an
anteroposterior view of the skull.

Uses of Cephalograms
Cephalometrics has established as one of
the pillars of comprehensive orthodontic
diagnosis. It is also a valuable tool in treatment
planning and follows up of patients undergoing
orthodontic treatment. The following are
some of the applications of cephalometrics in
orthodontics:
1. Cephalometrics helps in orthodontic
diagnosis by enabling the study of skeletal,
dental and soft tissue structures of the
craniofacial region.
2. It helps in classification of the skeletal and
dental abnormalities and also helps in
establishing facial type.
3. Cephalometrics helps in planning treat­
ment for an individual.
4. It helps in evaluation of the treatment
results by quantifying the changes brought
about by treatment.
5. Cephalometrics help in predicting the
growth related changes and changes
associated with surgical treatment.
6. Cephalometrics is a valuable aid in research
work involving the craniodentofacial
region.
Cephalostat (Fig. 5.25)
The cephalometric radiographs are taken using
an apparatus that consists of an X­ray source
and a head holding device called cephalostat.
Figure 5.25: Cephalostat
Orthodontic Diagnosis 199
The cephalostat consists of two ear rods that
prevent the movement of the head in the
horizontal plane. Vertical stabilization of the
head is brought about by an orbital pointer
that contacts the lower border of the left orbit.
The upper part of the face is supported by the
forehead clamp positioned above the region
of the nasal bridge. The distance between the
X­ray source and the midsagittal plane of the
patient is fixed at 5 feet or 60 inches (152.4 cm).
Thus the equipment helps in standardizing
the radiographs by use of constant head
position and source film distance so that serial
radiographs can be compared.
Film Interpretation
The information content of a radiograph is a
complex function of film/screen selection,
technique factors, processing, and patient
anatomy. The first three of these parameters
can be controlled and should be optimized
to ensure the best radiographic image with
the least patient exposure. However, once
a radiograph is processed the amount of
information recorded in the image does not
change, but the amount of information that
can be retrieved from each image is greatly
affected by the circumstances under which
the film is viewed. Reduced ambient lighting,
quiet surroundings, and the elimination of
peripheral light improve visual acuity.
Kundel and Nodine have described two
modes of visual perception of radiographs.
First is “global perception” resulting from
rapid parallel processing of the entire retinal
image by means of pattern recognition and
rapid association with previously acquired
visual concepts. The second is “analytic
perception”, which is based on the extraction
of features from the incoming visual data and
the use of logical rules to combine them in
a meaningful way. This technique results in
a gradual buildup of the perception. They
200 Essentials of Orthodontics

suggest that experienced radiologists perceive cell nervous syndrome. Although the first two
abnormalities in a global manner and that observations had little impact on the patients’
specific features are perceived secondarily. health, the latter two findings could have had
The experienced orthodontist can often rapidly a serious negative effect on the patients’ well­
scan a cephalometric film and tell whether being if they had been overlooked (Fig. 5.26).
a patient has a dental or skeletal problem or
a combination of the two and what part of Cranium
the anatomy is contributing the most to the In evaluating the cranium, the method sugg­
problem. The cephalometric analysis usually ested by Meschan is recommended:
corroborates this global impression and 1. Calvarium and base: Initially, the size and
quantitates a qualitative judgment. shape of the calvarium and base should
Christensen and associates evaluated the be evaluated. Gooding reviews some
effect of search time on perception and found of the common morphometric indices
that obvious abnormalities are detected almost available and concludes that they are
instantaneously but that the overall number most valuable for following changes once
of abnormalities identified increased as the an abnormality has been identified and
viewing time increased. The number of visual that “with experience normal craniofacial
images that are immediately recognizable proportions at different age levels are
is a function of experience and the analytic appreciated, and deviation is recognized as
approach is necessary to evaluate those images an indication of intracranial abnormality”.
that represent uncommon findings. Even The calvarium is divided into three layers;
the experienced radiologist can be seriously the inner and outer tables are compact
misled and draw the wrong conclusion if bone and the middle table is cancellous.
pattern recognition is the primary mode of Thickness varies widely in individuals
radiographic interpretation. and this will be demonstrated as varying
Bisk and Lee reviewed 513 lateral cephalo­
metric head films. Eighteen films (3.5%)
were classified as having abnormalities or
pathosis present as follows: enlarged aden­
oids—5, failure of segmentation C4­CS—1,
impacted canine—1, interstitial emphy­
sema—1, osteoma—1, sinus polyp—1, and
sinusitis—8. Because abnormalities occur
infrequently, the orthodontist should carefully
search the cephalometric films for features that
would suggest disease and warrent further
investigation. Nanda, Merow, and Martin
reported four cases of significant abnormalities
that were incidental findings: (1) a foreign
object in the right nostril, (2) bilateral retention
cyst in the maxillary sinuses, (3) unusual
intrasellar cyst with a tooth or dermoid and,
(4) multiple cysts of the jaws as part of the basal Figure 5.26: Cephalogram

radiodensities on the radiograph. The
thickest part of normal vault should not
exceed 1 cm, after which some degree of
cerebral underdevelopment or systemic
disease should be suspected.
2. Lines, impressions, channels and sutures.
Exam­ination of the inner surface of the
calvarium will show numerous lines,
impressions, and channels that reflect the
structure of the brain and its meningeal
covering.
a. Meningeal vessel grooves: The arteries
and veins of the meninges are closely
adapted to the inner table of the calvar­
ium resulting in lines readily identifiable
by their well-defined borders; smooth
undulating course, and characteristic
location. The middle meningeal vessels
are usually the most prominent; they
begin at foramen spinosum and branch
out, tapering along the way.
b. Diploic vein channels: The diploic veins
are contained in channels within the
cancellous bone of the middle table or
diplöe. They will appear as radiolucent
channels 2 to 3 mm wide, coursing in
an irregular pattern over the calvarium;
they do not appear to taper as the
meningeal vessels do. When two or more
of these veins anastomose, a diploic lake
may be present. The diploic venous
lakes are irregular, usually less than 2
cm in size and have multiple diploic
veins running into them. Awareness of
the existence of diploic venous lakes
and the observation of diploic channels
associated with them will usually allow
the clinician to recognize these for
what they are and not mistake them
for osteolytic lesions, such as bone
metastasis, meningoceles, fibrous
dysplasia or histiocytosis X.
Orthodontic Diagnosis 201
c. Sutures: The sutures form the articulation
of the cranial bones. Many of the sutures
are closed by the second year of life.
The sphenooccipital synchondrosis
begins to ossify at puberty; the coronal,
lambdoidal, and sagittal sutures persist
through early adulthood. Premature
closure of the sutures may be a primary
defect, a component of other known
head and neck syndromes, or associated
with metabolic, osseous, or hematologic
disorders. Sutural widening is usually
a result of increased intracranial pre­
ssure or destruction of bone at the
suture margins. Observation of any of
these findings warrants further studies
and consultation with the patient’s
physician is recommended. The coronal,
lambdoidal, and squamosal sutures can
be seen on the lateral cephalograph;
the sagittal and lambdoidal sutures
and their junction, lambda, are seen on
the posteroanterior (PA) cephalogram.
The sutures appear as radiolucent
serpentine lines in their anatomically
expected location. Occasionally, there
are small independent bones that
persist within a suture; these are called
wormian bones and the lambda region
is a common location for them. Multiple
wormian bones may be associated with
cleidocranial dysplasia, cretinism, or
osteogenesis imperfecta.
It is important to recognize the
radi­­o­l u­c ent lines that represent the
meningeal vessel grooves, the diploic
vein channels, and the sutures, and to be
able to distinguish them from fractures
of the calvarium, especially given a
history of recent trauma.
d. Arachnoid (pacchionian) granulation
impressions: The arachnoid granul­
202 Essentials of Orthodontics
ations are an out-pocketing of the arach­
noid membrane and subarachnoid
space that may extend into the dural
sinuses or the adjacent lacuna laterales.
When found in the latter region, they
may present as irregularly rounded,
sharply radiolucent depressions of the
inner table of the skull. They are most
commonly found just lateral to the
superior sagittal sinus, although they
can be located in proximity to any of the
dural sinuses. They may also calcify and
this presentation will be described in a
later section.
e. Dural sinuses: The sinuses of the dura
mater are the channels by which the
blood from the cerebral veins and some
of the meningeal and diploic veins
drain into the internal jugular veins.
The superior sagittal, sphenoparietal,
transverse, and sigmoid sinuses groove
the inner table of the calvarium produ­
cing broad radiolucent channels.
f. Convolutional markings: Also called
digital markings or brain markings, the
convolutional markings are impressions
or thinning of the inner table of the
calvarium caused by pressure from
the convolutions or gyri of the growing
brain. They are most prominent in
the 3-to 12-year age group and tend
to regress with age. Absence of these
markings in the young or persistence
into adulthood, especially when
accompanied by neurologic signs and
symptoms or other cranial morphologic
abnormalities, is a significant pathologic
finding.
g. Artifacts: If the patient’s hair is parti­
cularly thick, wet, or pulled taut, it may
cause linear streaks to appear over the
calvarium.
3. Calcification within the calvarium: There
are a number of intracranial structures
that may calcify in the absence of any
disease. Reiskin has stressed the impor­
tance of multiple right-angle views for
the localization and evaluation of these
structures as a necessary component to
distinguish between those structures that
are normal or physiologic and those that
are pathologic. Meschan has described
the normal structures within the calvarium
that may calcify. They can be summarized
as follows:
a. Pineal gland: The incidence of pineal
calcification varies from 33 percent to
76 percent in the North American white
population; there is a considerably
lower incidence in Japanese (10%),
Indians (8%) and Nigerians (5%). The
size of the calcification averages 5 mm
in length and 3 mm in height and width.
When seen in the frontal projection, the
pineal gland is a midline structure and
a shift of 3 mm or more from midline
is considered significant. Numerous
methods have been described to
localize the pineal gland in the lateral
radiograph ; in general, it will be
found above and slightly behind the
petrous portion of the temporal bone.
Calcification of the pineal in children is
not as common as in adults, but it is not
a rare phenomenon. It may be observed
in approximately 5 percent of white
children under 10 years of age.
b. The habenular commissure may cal­
cify and it will appear as a C-shaped
radiodensity located a few millimeters
anterior to the pineal gland in about 30
percent of the adult population.
c. Meningeal calcifications: The falx
cerebri is calcified in approximately

7 percent of adults and is usually
shown to best advantage in the frontal
projection where it appears as a linear
midline radiopacity. Calcification of
the arachnoid granulation appears
as uniform radiopacities near the
corresponding granulation impression
in the calvarium.
d. Petroclinoid ligament and diaphragma
sellae: Calcification of the petroclinoid
ligament occurs in approximately 12
percent of adults and appears as a
radiopaque line extending from the
posterior clinoid process to the petrous
ridge. Calcification of the diaphragma
sellae may give the appearance of
a separate enclosed pituitary fossa.
However, it must be remembered that
we are only seeing a two-dimensional
representation and, in fact, there
is a space between the interclinoid
calcifications to accommodate the
pituitary stalk. Radiographically, this
appearance is described as “roofing” or
“bridging” of the sella.
In the absence of any clinical neurologic
signs or symptoms, these calcifications may be
considered normal; however, it is important
to remember that many pathologic processes
can be associated with these calcifications. A
patient with a calcified pineal gland who is
experiencing headaches, nausea and vomiting
should not be ignored; appropriate referral and
follow-up are warranted.
Once again, the patient’s hairstyle may
create artifacts that mimic real findings.
For example, if the hair is gathered on the
lateral surface of the skull into pigtails, it may
resemble intracranial calcification on the
lateral skull film.
Size and shape of the sella turcica. The
sella turcica is a saddle-shaped formation
of the sphenoid bone in the middle cranial
Orthodontic Diagnosis 203
fossa. When viewed in the lateral radiograph,
the anterior clinoid processes are usually
superimposed; the hypophyseal fossa appears
as a single dense curved line that merges
posteriorly with the posterior clinoid processes
of the dorsum sellae. The clinoid process may
range from short and rounded to long and
pointed. Normal variants include: (1) a middle
clinoid process, (2) extension of the sphenoid
sinus into the dorsum sellae, posterior clinoid
process or anterior process, and (3) bridging
as previously described. Because the sella
turcica is a midline structure, the floor of
the hypophyseal fossa usually appears as a
single line. A double-contoured appearance
may represent a variant of normal, an artifact
of positioning, or a significant pathologic
change. When viewed in the sagittal plane, the
normal range for the greatest anteroposterior
dimension is 5 to 16 mm (average 10.6 mm),
and the depth as measured from a line between
the anterior and posterior clinoid processes
to the floor of the hypophyseal fossa ranges
from 4 to 12 mm (average 8.1 mm). Significant
variation in the size, area, or volume of the sella
associated with a variation of two standard
deviations in height and weight as compared
to age-matched cohorts suggests a pituitary
abnormality and the patient’s physician should
be alerted to this finding. Expansion or erosion
of the borders of the pituitary fossa, especially
if accompanied by neurologic findings such
as headaches, blurred or double vision, or
dizziness, is a significant finding and the
patient should be referred for a thorough
evaluation. The sella turcica is also seen in
the PA view where it is superimposed over the
superior aspect of the nasal cavity. In this view
the floor of the sella is usually convex upward.
Paranasal Sinuses
The paranasal sinuses develop as outpouchings
of the mucous membrane of the fetal nasal
204 Essentials of Orthodontics
cavity that extend into the maxillary, sphenoid,
frontal, and ethmoid bones and subsequently
enlarge. In adulthood the sinuses communicate
with the nasal cavity through ostia, thus
reflecting their common embryologic origin.
The maxillary, sphenoid, and ethmoid sinuses
begin to enlarge in utero and may occasionally
be detected radiographically at birth. The
frontal sinuses do not begin to pneumatize
until the second year and are not usually visible
on the radiograph until the sixth year. Hence,
all four sets of paranasal sinuses should be
evident in the average orthodontic patient.
The variation in size of the normal sinus may
be great.
1. Maxillary sinuses are seen in the PA, base,
and lateral views. In the standard PA view,
the petrous portion of the temporal bone is
superimposed over the superior one-third
of the sinus. If disease is suspected, the best
view of the maxillary sinuses in the frontal
plane is obtained with Water’s projection.
The lateral view will show the borders in
the sagittal plane; however, the right and
left sinuses will be superimposed and often
indistinguishable. On films obtained in
the erect position, soft-tissue swelling can
usually be differentiated from free fluid in
the sinus by the nature of the air-shadow
interface. The air-fluid line will be straight
and parallel to the floor; a soft-tissue
swelling will produce a shadow that follows
the bony contours or is convex. Bone
destruction is an important radiographic
sign that requires biopsy and/or culture.
2. Frontal sinuses are seen to best advantage
in the PA and lateral views. They vary
greatly in size, are usually asymmetric, and
may even be absent. An osteoma of the
frontal sinus is not a rare finding; it may be
an isolated finding or part of a generalized
process such as Gardner’s syndrome. If
osteomas are identified in association
with the sinuses or anywhere else, inquiry
into family history and examination of the
skin for sebaceous cysts are required. The
patient’s physician should be informed of
any positive findings.
3. Sphenoid sinuses appear as a single cavity
in the sphenoid bone, inferior to the
sella turcica in the lateral film. Although
identifiable in the frontal projection, the
superimposition of the nasal septum,
lateral nasal wall, and the medial wall of
the orbits makes evaluation difficult. The
lateral extension of the sphenoid sinuses
is easily seen on the base projection; it is
known to vary greatly and, in the absence
of any other pathologic findings, should
be considered an insignificant incidental
finding.
4. The ethmoid sinuses, also known as
the ethmoid air cells, form the medial
wall of the orbit and the lateral wall of
the upper half of the nose. The ethmoid
sinuses are divided by numerous septa
resulting in multiple compartments. Of the
radiographic projections typically obtained
for orthodontic treatment planning, the
ethmoid sinuses are best seen on the lateral
and base views. In the frontal view, they are
seen as radiolucency between the medial
rim of the orbit and the nasal septum.
When evaluating the paranasal sinuses,
the integrity of the bony borders and adjacent
structures and the degree of aeration must
be established. In health, the thin mucous
membrane lining is not visible on the radio­
graph.
Mastoids
The mastoid air cells communicate indirectly
with the nasal cavity via the middle ear; how­
ever, embryologically they develop separately
from the paranasal sinuses. Nonetheless, the
radiographic appearances of air-filled cavities

within the bone resemble the ethmoid air
cells. The distribution and pneumatization of
the mastoid air cells are extremely variable;
the cells are located in the mastoid process
and periauricular region and may extend as
far forward as the zygomatic process of the
temporal bone.
Cervical Spine
The upper vertebrae are often visible on the
lateral and PA cephalometric radiographs.
The atlas has no body or spinous process
and has the form of a ring. The axis has the
fundamental structure of the cervical vertebra
with the addition of an upward projection
called the dens or odontoid process. The dens
occupy the space where the body of the atlas
would have developed; it articulates with
the posterior surface of the anterior arch of
the atlas and provides a pivot around which
the atlas and skull rotate. The bodies of the
axis and the odontoid process have separate
ossification centers and often do not fuse until
age. Therefore, a transverse radiolucency at
the base of the odontoid process in a young
ambulatory patient with no history of trauma
should not be mistaken for a fracture.
The C-spine has a gentle curvature and
is convex anteriorly when viewed from the
side. This normal lordotic curve is position-
dependent and can be altered as a result of
failure to achieve natural head position when
placing the patient in the cephalometric head
holder or as a result of muscle spasm that
causes the patient to posture the head in an
effort to reduce pain and discomfort.
Lines drawn along the anterior and post­
erior margins of the vertebral bodies should
be practically parallel. A straight line drawn
along the front of the odontoid process meets
the anterior margin of the foramen magnum
and lies approximately 1 mm behind and
Orthodontic Diagnosis 205
away from the posterior border of the anterior
arch of the atlas. The normal dimension of the
spinal canal ranges from 18 to 27 mm at the first
cervical vertebra to 15 to 20 mm at the seventh
cervical vertebra for children 15 years of age
and less. For adults, the ranges are 16 to 30 mm
and 13 to 24 mm, respectively. In the PA view,
the lateral border of the vertebral body will be
in alignment and the spinous process will be
visible. Frank displacement of a vertebra is
a serious abnormality that demands further
investigation.
The intervertebral disk is a fibrocartilaginous
anulus with a gelatinous center and is not
visible on a conventional radiograph. However,
we can make inferential observations about
the intervertebral disk by evaluating the
surrounding anatomy. The intervertebral
disk space appears as radiolucency between
the vertebral bodies defined by the relatively
parallel inferior and superior cortical margins.
If the cortical margins appear convergent or
the disk space is narrowed, this may suggest a
herniated disk.
Upper Airway and Neck
The upper air passages—the nasal cavity,
oral cavity, pharynx, and larynx—appear
radiolucent on the skull film. When sufficiently
thick, the soft tissues of the region will have an
intermediate radiodensity between the airway
and skeleton.
The nasal air passages usually conform to
the bony architecture as the mucosal lining
of the nasal cavity is usually less than 1 mm
thick and does not cast a radiographic shadow.
Thickened membranes or linings can be seen
as an intermediate density between bone and
air with proper exposure factors. The cigar-
shaped nasal conchae will be superimposed
over the airway; this will be discussed in greater
detail in the next section.
206 Essentials of Orthodontics
The dimensions of the oral airway will vary
depending on the position of the tongue. If the
tongue is elevated, it may contact the soft palate
and their radiographic shadows will merge.
The palatine tonsils are situated between the
palatoglossal and palatopharyngeal folds in
the lateral fauces. These can sometimes be
distinguished on the lateral film, especially if
they are inflamed and enlarged.
On the superior aspect of the posterior
wall of the nasopharynx, there is a collection
of lymphatic tissue (the nasopharyngeal
tonsils or adenoids) that may be quite large
in children. This is usually easy to identify on
the lateral cephalometric film. Changes in
breathing patterns caused by hypertrophied
adenoids may affect facial growth patterns.
The lymphatic tissue tends to atrophy with
age and will not be as prominent in adult
patients. The opening of the eustachian
tubes on the lateral wall of the nasopharynx
just behind the inferior nasal conchae may
be evident as a round, relatively radiolucent
area. These structures are difficult to see, but
may be discerned with certain anatomic and
exposure factors. The soft palate separates the
nasopharynx from the oropharynx. At rest, it
extends from the posterior borders of the hard
palate and arches inferiorly.
In the lateral projection, the hyoid bone
is seen just below the angle of the mandible.
The thyroid, cricoid, and tracheal ring cartilage
are usually not visualized but may on occasion
have areas of calcification that appear on the
radiographs. The epiglottis and the laryngeal
folds are also seen.
The prevertebral soft tissue and muscles
can be seen separating the airway from the
vertebral column. The retropharyngeal shadow
at the line of C2 varies from 2 to 7 mm in
children less than 15 years of age and from 1
to 7 mm in adults; the retrotracheal shadow at
the level of the C6 varies from 5 to 14 and 9 to
22 mm, respectively. The soft-tissue shadow
should have a smooth anterior outline. In the
PA view, the lateral wall of the laryngopharynx
and the larynx are seen; other parts of the
airway are obscured by superimposition of
bony structures.
Dentomaxillofacial Complex
Orthodontists are most familiar with the
facial portion of the skull as this is the region
they routinely treat. For our purposes we will
consider the dentomaxillofacial complex to
include the orbits, nose, zygomatic arches, and
jaws. The paranasal sinuses have been dealt
with separately in a previous section.
1. Orbits: In the PA view, the rim of the orbit
is seen as a smooth round radiopaque line.
There are a number of structures that appear
within the orbit and these should all be
evaluated. The lesser wing of the sphenoid
contributes to the floor of the anterior
cranial fossa and is seen as a horizontal
convex-down curvilinear radiodensity
in the superior third of the orbit. From
the region where this line intersects the
superolateral border of the orbit, there
is another linear radiopacity running
downward and medially; this is called the
innominate line and represents a curvature
of the greater wing of the sphenoid.
The optic foramen is a round radio­
lucency near the medial orbital wall.
The superior and inferior orbital fissures
can be seen extending from this region
in lateral-upward and lateral-downward
directions, respectively. Occasionally, one
can follow the path of the inferior orbital
fissure as it becomes the inferior orbital
canal and emerges on the front of the face
as the infraorbital foramen. Just medial and
slightly below the infraorbital foramen is

a somewhat larger well-defined circular
radiolucency; this is foramen rotundum
through which the maxillary division of the
trigeminal nerve passes as it leaves the skull
base. This may be a region deserving careful
scrutiny if the patient complains of pain
over the area that this division innervates.
The vertical position of the foramen will
vary depending upon the tilt of the patient’s
head relative to the central ray of the beam.
At the junction of the middle and medial
thirds of the superior rim of the orbit, the
supraorbital foramen may be seen as a
small, round radiolucency. In the lateral
view, the superior and inferior walls of
the orbit are seen. Likewise, the posterior
and anterolateral margins of the orbit are
visualized; however, the superimposition of
structures makes it difficult to distinguish
left from right. The zygomaticofrontal and
maxillofrontal sutures may be seen at the
rim of the orbit and should not be mistaken
for fractures.
2. The nose: In the PA view, the nasal septum,
lateral walls, and conchae are easily defined.
The nasal septum should be positioned
at the midline; displacement from the
midline may represent a congenitally
deviated septum, prior trauma, or the
presence of a pathologic process causing
the displacement. Extending medially from
the lateral walls are the nasal conchae or
turbinates. The inferior and middle conchae
are usually seen, but the superior conchae
may not be visualized. In the lateral views,
the inferior conchae appear as a cigar-
shaped radiopacity. Often the posterior
extent of the conchae extends beyond the
posterior border of the maxillary sinus,
which makes it radiographically difficult
to distinguish from an isolated radiopacity
in the nasal cavity. If there is a question
Orthodontic Diagnosis 207
as to what this radiographic shadow
represents, establishing continuity of the
outer boundary of the radiopacity with the
adjacent turbinate bone should confirm
its identity. Should a question persist, the
posterior nasopharynx can be visualized
by indirect laryngoscopy using an angled
mirror and proper lighting.
3. Zygomatic arches: The zygomatic process
arises from the maxillary bone at the
region of the first molar. The radiodensity,
size, and shape of this structure are
variable and the structure often takes on a
different form, depending upon the angle
of the directed X-ray beam. The zygomatic
process may appear quite radiolucent if
the maxillary antrum extends into it. The
greater the extension of the maxillary sinus
into the zygomatic process, the greater the
contrast of the dark radiolucent air spaces
and the sharply defined cortical walls of the
process. Seen in the lateral cephalogram,
the corticated walls of the zygomatic
process appear as a U-shaped radiopaque
line known as a key ridge. The definition
of the molar apices superimposed on
the zygoma will vary with the amount
of pneumatization that has occurred. If
aeration is minimal, molar apical and
maxillary sinus anomalies may be masked
or ill-defined.
4. The jaws: Details of the teeth and their
surrounding structures are difficult to see
on skull films because of superimposition
of anatomic structures and the inherent
resolution limitation of screen film.
Evaluation of the teeth and periodontium
is best accomplished by a periapical film.
Most orthodontists use these intraoral
films in their diagnostic evaluations and
treatment plans. Misinterpretations can
present problems here also. For example,
208 Essentials of Orthodontics
occasionally a double image of the lamina
dura is seen that reflects the normal
concavities and fluting of the roots or the
superimposition of different roots of a
multirooted tooth such as the maxillary
first molar. Superimposition of the lingual
root surface and periodontal ligament
space of the first premolar onto the distal
surface of the canine in the periapical film
should not be mistaken for a vertical root
fracture of the canine. Care should be taken
to examine carefully for supernumerary
teeth and evidence of small developing bud
follicles. They can be of great consequence
if the clinician is trying to move teeth
into the space they occupy. If initially
overlooked and subsequently noted on
follow-up radiographs, they are a source of
embarrassment at least, and iatrogenesis at
worst.
The trabecular pattern of the anterior
maxilla is fine, granular, and dense. The
posterior maxilla shows a slightly less dense
pattern with larger marrow spaces. The
trabeculae of the anterior mandible are thicker
than the maxilla, presenting a course pattern
with large marrow spaces. The posterior
mandibular periapical trabeculae and marrow
spaces are usually the largest in the jaws. These
can be variable in size and mimic pathologic
lesions. Changes in the density and pattern
of the cancellous bone may result from
inflammation, systemic disease, or tumors.
The mandibular symphysis frequently has
a radiolucent line at the midline suture that
disappears at about 1 year postpartum. If this
radiolucency is found in older children or
adults, it may suggest a fracture or cleft. The
genial tubercles are the bony projections of
attachment of the genioglossus and geniohyoid
muscles. They often have a small radiolucent
area in the center (the lingual foramen) that is
the point of exit of mandibular nerve. Depending
upon its size, this may be mistaken for incipient
pathosis. The mental fossa is a depression
found in the labial aspect of the mandible. The
thinness of the hard tissue in this area may be
mistaken for periapical disease of the incisors.
Similarly, the mental foramen, located between
the first and second premolars, can mimic
periapical pathosis in this area. The mandibular
canal forms a dark linear radiographic shadow
with thin superior and inferior opaque borders
cast by its lamella boundaries. The molar
teeth apices are frequently projected over this
canal, giving the illusion of a discontinuous
lamina dura surrounding these teeth. This
is due to the localized overexposure caused
by this radiolucent linear structure. Finally,
the submandibular fossa is a depression on
the lingual side of the mandible below the
mylohyoid ridge that accommodates the
submandibular gland. It will appear as a local
radiolucency with scant or absent trabeculation.
The anterior and posterior aspects of this
radiolucency will blend into the surrounding
bony pattern.
Cephalometric Landmarks (Fig. 5.27)
Cephalometrics makes use of certain land­
marks or points on the skull which are used
for quantitative analysis and measurements.
The cephalometric landmarks can be of two
types:
Anatomic landmarks: These landmarks repre­
sent actual anatomic structures of the skull.
Derived landmarks: These are landmarks
that have been obtained secondarily from
anatomic structures in a cephalogram.
The landmarks that are used in cephalo­
metrics should fulfill certain require­ments:
i. It should be easily seen in a radiograph.
ii. It should be uniform in outline and
should be reproducible.

Figure 5.27: Cephalometric landmarks
iii. The landmarks should permit valid
quantitative measurements of lines and
angles projected from them.
The landmarks used in cephalometrics can
be classified into:
i. Hard tissue landmarks
ii. Soft tissue landmarks.
Landmarks
Nasion: The most anterior point midway
between tha frontal and nasal, bones on the
frontonasal suture.
Orbitale: The lowest point on the inferior bony
margin of the orbit.
Porion: The highest bony point on the upper
margin of external auditary meatus.
Sella: The point representing the midpoint
of the pituitary fossa or sella turcica. It is a
constructed point in the midsagittal plane.
Point A: It is the deepest point in the midline
between the anterior nasal sping and alveolar
Orthodontic Diagnosis 209
crest between the two central incisors. It is also
called subspinale.
Point B: It is the deepest point in the midline
between the alveolar crest of mandible and the
mental process. It is also called supramentale.
Basion: It is the median point of the anterior
margin of the foramen magnum.
Bolton point: The highest point at the postcon­
dylar notch of the occipital bone.
Anterior nasal spine (ANS): It is the anterior tip
of the sharp bony process of the maxilla in the
midline of the lower margin of anterior nasal
opening.
Gonion: It is a constructed point at the junction
of ramal plane and the mandibular plane.
Pogonion: It is the most anterior point of the
bony chin in the median plane.
Menton: It is the most inferior midline point
on the mandibular symphysis.
Gnathion: It is the most anteroinferior point
on the symphysis of the chin. It is constructed
by intersecting a line drawn perpendicular to
the line connecting menton and pogonion.
Articulare: It is a point at the junction of the
posterior border of ramus and the inferior
border of the basilar part of the occipital bone.
Condylion: The most superior point on the
head of the condyle.
Prosthion: The lowest and most anterior point
on the alveolar bone in the midline, between
the upper central incisors. It is also called
supradentale.
Infradentale: The highest and most anterior
point on the alveolar process, in the median
plane between the mandibular central incisors.
The key ridge: The lower most point on the
contour of the anterior wall of the infra­
temporal fossa. It is a radiographic anatomical
landmark commonly appearing on a lateral
cephalometric radiograph. It represents the
lower contour of the zygomatic bony ridge,
situated between the maxillary tuberosity and
the canine fossa.
210 Essentials of Orthodontics

Posterior nasal spine (PNS): The intersection

of a continuation of the anterior wall of the
pterygopalatine fossa and the floor of the nose,
marking the distal limit of the maxilla.
Broadbent registration point: It is the midpoint
of the perpendicular from the center of sella
turcica to the Bolton plane.
Ptm point: It is the intersection of the inferior
border of the foramen rotundum with the
posterior wall of the pterygomaxillary fissure.
Glabella: It is the most prominent point of the
forehead in the midsagittal plane.
Chelion: It is the lateral terminus of the oral slit
on the outer corner of the mouth.
Subnasale: The point where the lowest border Figure 5.28: S-N plane
of the nose meets the outer contour of the
upper lip.

Lines and Planes in Cephalometrics

Cephalometrics makes use of certain lines or
planes. These lines are obtained by connecting
two landmarks. Based on their orientation the
lines or planes can be classified into horizontal
and vertical planes.

Horizontal Planes
S-N plane: It is the cranial line between the
center of sella turcica (sella) and the anterior
Figure 5.29: Frankfort horizontal plane
point of the frontonasal suture (nasion) (Fig.
5.28).
Frankfort horizontal plane: This plane conn­
ects the lowest point of the orbit (orbitale)
and the superior point of the external auditory
meatus (porion) (Fig. 5.29).
Occlusal plane: It is a denture plane bisecting
the posterior occlusion of the permanent
molars and premolars (or deciduous molars
in mixed dentition) and extends anteriorly
(Fig. 5.30).
Palatal plane: It is a line linking the anterior
nasal spine of the maxilla and the posterior
nasal spine of the palatine bone. Figure 5.30: Occlusal plane

Figure 5.31: Mandibular plane
Mandibular plane: Several mandibular pla­
nes (Fig. 5.31) are used in cephalometrics,
based on the analysis being done. The most
commonly used ones are:
i. Tangent to the lower border of the
mandible (Tweed).
ii. A line connecting gonion and gnathion
(Steiner).
iii. A line connecting gonion and menton
(Downs).
Basion-Nasion plane: It is a line connecting
the basion and nasion. It represents the cranial
base.
Bolton’s plane: This is a plane that connects
the Bolton’s points posterior to the occipital
condyles and nasion.
Vertical planes: A­Pog 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 frontonasal suture (nasion) to the most
anterior point of the mandible (pogonion).
Facial axis: A line from ptm point to cephalo­
metric gnathion.
Y-axis: A line from sella to gnathion.
Ramal plane: The plane from articulare to
gonion.
Orthodontic Diagnosis 211
Long Axis of Upper and Lower Incisors
A-B plane: Plane drawn from point A to point B.
Cephalometric Tracing Technique
The facial profile is customarily placed on the
right side of the tracing sheet. Masking tape is
used to attach the tracing acetate to the X­ray.
The tracing is made on the frosted surface of
the acetate sheet. An X­ray view box providing
adequate illumination and a sharpened pencil
are essential for tracing.
The tracing is begun by marking the points
needed for the analysis on the tracing sheet.
The soft tissue profile is traced and then the
sella turcica going forward to the planum
sphenoidale along the floor of the anterior
cranial fossa and the shadows of the greater
wings of the sphenoid bone are traced. The
anterior surfaces of the frontal and nasal bones
are then traced followed by tracing the outline
of the maxilla from the anterior nasal spine
along the floor of the nasal cavity back to the
posterior nasal spine. The pointed end of the
pterygomaxillary fissure is directed toward the
posterior nasal spine and is, therefore, a guide
to the anteroposterior position of the posterior
nasal spine. Frp, the posterior nasal spine,
trace forward along the palatal surface of the
maxilla to the lingual alveolar bone around the
incisors. The anterior surface of the maxilla is
then traced. The most anterior central incisor
are outlined, and after referring to the models
or diagnostic record, the first molars are traced
in their correct occlusal relationship. If the
molar relationship is different on the right and
left sides, the relationship for both sides should
be written on the tracing. The symphysis and its
inner cortical bone should be traced, and the
lower and posterior borders of the mandible
should be bisected until the borders intersect
the posterior cranial base. The orbital rims are
212 Essentials of Orthodontics
often difficult to trace. Both rims may be traced
and bisected. The ear rod is traced unless
anatomic porion is used.
Superimposition of Serial
Cephalograms
Clinicians and researchers are interested in
studying the growth and treatment changes
seen in patients from the study of facial
growth, techniques have been developed
that allow accurate superimposition of lateral
cephalograms taken from the same person at
two or more different times. It is important that
the serial cephalograms be made from the same
cephalometric machine. Superimposition is
more accurate in nongrowing adults that in
growing patients (Fig. 5.32).
Sequence of Color Code in
Cephalometric Superimposition
1. Pretreatment (initial) = Black
2. Progress = Blue
3. End of treatment = Red
4. Retention = Green.
Cephalometric Analysis
Cephalometric analysis is used to assess,
express and predict the spatial relations of soft
Figure 5.32: Registration point
(used for superimposition)
tissues, craniofacial and dentofacial complexes
at one point or over time. The analysis is either
objective or subjective. Objective evaluation
involves quantification of spatial relationships
by angular or linear measurements. Subjective
evaluation involves the visualization of changes
in spatial relationships of areas or anatomical
landmarks within the same face and relating to
a common point or plane over time.
Classification
1. Methodological
Angular: Dimensional analysis, propor­
tional analysis, analysis to determine posi­
tion.
Linear: Orthogonal analysis, dimensional
linear analysis, proportional linear analysis.
2. Normative
Mononormative analyses: Arithmetical or
geometrical.
Multinormative analyses: Correlative Anal­
yses.
3. According to area of analysis
Dentoskeletal analyses: Facial skeleton,
maxillary and mandibular base.
Dentoalveolar analyses: Position and
angulation of upper and lower incisors.
Soft tissues analyses.
Down’s Analysis (Fig. 5.33)
One of the most frequently used cephalometric
analysis is the Downs analysis. Down’s
had based his findings on 20 Caucasians
individuals of 12 to 17 years age group
belonging to both the sexes. Down’s analysis
consists of 10 parameters of which five are
skeletal and five are dental.
Skeletal Parameters
Facial angle: It is the inside inferior angle
formed by the intersection of nasion pogonion
plane and the FH plane. The average value is
87.8° while the range is 82° to 95°. This angle
 Orthodontic Diagnosis 213

since point B is positioned behind point A. In

case of Class III malocclusions a positive angle
may be found.
Mandibular plane angle: The mandibular
plane angle is formed by the intersection
of the mandibular plane with the FH plane.
The mean value is 21.9° while the range is
17° to 28°. An increased mandibular plane
angle is suggestive of a vertical growers with
hyperdivergent facial pattern.
Y-axis (Growth axis): This angle is obtained
by joining the sella­gnathion line with the FH
plane. The mean value is 59° with a range of
53° to 66°. The angle is larger in Class II facial
patterns than in patients exhibiting Class III
pattern. In addition, the Y axis indicates the
Figure 5.33: Down’s analysis growth pattern of the individual. If the angle
is greater than normal, it indicates greater
gives us an indication of the anteroposterior vertical growth of mandible. If the angle is
positioning of the mandible in relation to smaller than normal, it indicates greater
the upper face. The magnitude of this value horizontal growth of mandible (Fig. 5.34).
increases in cases of skeletal Class III with Dental parameters: Cant of occlusal plane:
prominent chin while it decreases in skeletal This angle is formed between the occlusal
Class II cases. plane and the FH plane. Downs constructed
Angle of convexity: This angle is formed by
the intersection of a line from nasion to point
A and a line from point A to pogonion. This
angle reveals the convexity or concavity of the
skeletal profile.
The average value if 0° while the range
is between –8.5° to 10°. A positive angle or
an increased angle suggests a prominent
maxillary denture base relative to mandible.
A decreased angle of convexity or a negative
angle is indicative of a prognathic profile.
A-B plane angle: This angle is formed between
a line connecting point A and point B and
a line joining nasion to pogonion (facial
plane). The mean value is –4.6° while the
range if –9° to 0°. This angle is indicative of the
maxillomandibular relationship in relation to
the facial plane. It is usually negative in value Figure 5.34: Y-axis
214 Essentials of Orthodontics

the occlusal plane by bisecting the occlusion

of the first permanent molars and the incisal
overbite. The mean value is 9.3° while the range
is 1.5° to 14°. The angle gives us a measure of
the slope of the occlusal plane relative to the
FH plane.
Interincisal angle: This angle is formed bet­
ween the long axes of the upper and lower
incisors. The average reading is 135.4° while the
range is 130° to 150.5°. The angle is decreased
in Class I bimaxillary protrusion and Class II
division 1 malocclusion whereas it is increased
in a Class II division 2 case.
Incisor occlusal plane angle: This is the inside
inferior angle formed by the intersection
between the long axis of lower central incisor
Figure 5.35: Steiner’s analysis
and the occlusal plane and is read as a plus or
minus deviation from a right angle. The average
value is 14.5° while the range is 3.5° to 20°. An Skeletal Analysis
increase in this angle is suggestive of increased SNA angle: It is the angle formed by the
lower incisor proclination. intersection of SN plane and a line joining
Incisor mandibular plane angle: This angle nasion and Point A. This angle indicates the
is formed by intersection of the long axis of relative anteroposterior positioning of the
the lower incisor and the mandibular plane. maxilla in relation to the cranial base. The
The mean angulation is 1.4° while the range is mean value is 82° (+ 2°). A larger than normal
between –8.5° to 7°. An increase in this angle is value indicates that the maxilla is prognathic
indicative of lower incisor proclination. (Class II) while a smaller value is suggestive of
Upper incisor to A-Pog line: This is a linear a retrognathic maxilla.
measurement between the incisal edge of the SNB angle: It is the angle between the AN plane
maxillary central incisor and the line joining and a line joining nasion to point B. This angle
point A to pogonion. This distance is on an indicates the anteroposterior positioning of
average 2.7 mm (Range –1 to 5 mm). The the mandible in relation to the cranial base. Its
measurement is more in patients presenting average value is 80°. An increase in this angle
with upper incisor proclination. indicates a prognathic mandible (Class III)
whereas a less than normal angle indicates a
Steiner’s Analysis retrusive mandible (Class II).
Cecil C Steiner in the year 1953 developed this ANB angle: This angle is formed by the
analysis with the idea of providing maximal intersection of lines joining nasion to point A
clinical information with the least number of and nasion to point B. It denotes the relative
measurements (Fig. 5.35). position of the maxilla and mandible to each
The Steiner analysis is divided into three other. The mean value is 2°. An increase in
parts: this angle is indicative of a Class II skeletal

tendency while an angle that is less than
normal or a negative angle suggests a skeletal
Class III relationship.
Mandibular plane angle: It is the angle formed
between SN plane and the mandibular plane.
The mandibular plane used in this analysis
is a line connecting gonion and gnathion.
The average value is 32°. This angle gives
an indication of the growth pattern of an
individual. A lower angle is indicative of a
horizontal growing face while an increased
angle suggests a vertical growing individual.
Occlusal plane angle: The occlusal plane
angle is formed between the occlusal plane
and the SN plane. In this analysis the occlusal
plane represents a line passing through the
overlapping cusps of first premolars and first
molars. It has a mean value of 14.5°. This angle
indicates the relation of the occlusal plane
to the cranium and face. It also indicates the
growth pattern of an individual.
Dental Analysis
Upper incisor to NA (angle): It is the angle
formed by the intersection of the long axis of
the upper central incisors and the line joining
nasion to point A. The normal angle is 22°. This
angle indicates the relative inclination of the
upper incisors. An increased angle is seen in
patients who have proclined upper incisors as
in Class II division 1 malocclusion.
Upper incisor to NA (linear): It is a linear
measurement between the labial surface of
upper central incisor and the line joining
nasion to point A. This measurement also helps
in determining the upper incisor position.
Normal value is 4 mm. It increases in cases
with proclined upper incisors.
Lower incisor to NB (angle): This angle is
formed between the NB plane and the long
axis of the lower incisor. This angle indicates
the inclination of the lower central incisor
and has a mean value of 25°. An increased
Orthodontic Diagnosis 215
value indicates proclination of lower incisors
whereas a decreased value indicates upright
or retroclined lower incisors.
Lower incisor to NB (linear): It is the linear
distance between the labial surface of lower
central incisor and the line joining nasion to
Point B. This measurement helps in assessing
the lower incisor inclination. An increase in
this measurement indicates proclined lower
incisors. The normal value is 4 mm.
Interincisor angle: This is the angle formed
between the long axis of the upper and lower
central incisors. A reduced interincisor
angle is associated with a Class II division
1 malocclusion or a Class I bimaxillary
protrusion. A larger than normal angle is seen
the Class II division 2 malocclusion. The mean
value is 130° to 131°.
Soft Tissue Analysis
S-line: According to Steiner the lips in a well­
balanced face should touch a line extending
from soft tissue contour of the chin to the
middle of an ‘S’ formed by the lower border
of the nose. If the lips are located beyond this
line then the lips are believed to be protrusive
and are interpreted as a convex profile. If the
lips are behind this line they are said to be
retrusive and the patient may have a concave
profile (Fig. 5.36).
Figure 5.36: S-line
216 Essentials of Orthodontics
Figure 5.37: Wits appraisal
Wits Appraisal (Fig. 5.37)
The purpose of Wits appraisal is to identify
instances in which the ANB reading does not
accurately reflect the extent of anteroposterior
jaw dysplasia.
It emphasizes an awareness of the relation­
ship of the jaws to each other and to the cranial
base. Wits appraisal is a linear measurement
and not an analysis in itself. The Wits appraisal
of a­p jaw disharmony is a measure of the
extent of which jaws are related to each other.
Method of assessing the degree of extent of
disharmony is by dropping perpendicular lines
from points A and B onto the occlusal plane to
form points AO and BO respectively.
The distance between AO and BO is noted
to infer the relationship between the jaws.
For males BO ahead of AO by 1 mm.
For females BO coincides with AO.
Tweed Analysis (Fig. 5.38)
The Tweed’s analysis makes use of three planes
that form a diagnostic triangle. The planes
used are:
i. Frankfort horizontal plane
Figure 5.38: Tweed’s triangle
ii. Mandibular plane
iii. Long axis of lower incisor.
The objectives of the analysis include:
i. Determination of the position of the
lower incisor.
ii. Evaluation of prognosis.
The angles formed by these three planes
are:
Frankfort mandibular plane angle (FMA):
It is the angle formed by the intersection
of the Frankfort horizontal plane with the
mandibular plane. The mean value is 25°.
Incisor mandibular plane angle (IMPA): It is
the angle formed by the intersection of the long
axis of the lower incisor with the mandibular
plane. It indicates the relative inclination of the
lower incisor. The mean value is 90°.
Frankfort mandibular incisor angle (FMIA): It
is the angle formed by the intersection of the
lower incisor with the FH plane. The mean
value is 65°.
Sassouni Analysis
It was the first cephalometric method to
emphasize vertical as well as horizontal
relationships and the interactions between
vertical and horizontal proportions. Sassouni
pointed out that the horizontal anatomic

planes­—the inclination of the anterior cranial
base, Frankfort plane, palatal plane, occlusal
plane and mandibular plane-tend to converge
toward a single point in a well-proportioned
face. The inclination of these planes to each
other reflects the vertical proportionality
of the face. If the planes intersect relatively
close to the face and diverge quickly as they
pass anteriorly, the facial proportions are
long anteri­orly and short posteriorly which
predisposes the individual to an open bite
malocclusion. Sassouni coined the term
Skeletal Open Bite for this anatomic relation­
ship, the opposite of which is Skeletal Deep
Bite.
Mcnamara Analysis
This analysis was originally published in
1983, and still represents the state of the art
in cephalometric measurement analysis
reasonably well. It combines elements of
previous approaches (Ricketts and Harvold)
with original measurements to attempt a more
precise definition of tooth and jaw positions.
This analysis has two major strengths: (1) it
relates the jaws via the nasion perpendicular,
in essence projecting the difference in
anteroposterior position of the jaws to an
approximation of the true vertical line, (2)
the normative data are based on well-defined
Bolton sample, which is also available in
template form, meaning that the McNamara
measurements are highly compatible with
preliminary analysis by comparison with
Bolton templates.
Wylie Analysis
This analysis was introduced by Wylie in 1947.
The terms “orthognathism” and “prognathism”
were selected to categorize facial types, in
preference to “Class II faces” and “Class III
faces”.
Orthodontic Diagnosis 217
“Prognathism” and “orthognathism”, when
used by others, may apply either to the maxilla
or the mandible or both. As it is used here it
applies mainly to the mandible in relation to
the maxilla. A method is presented whereby
discrepancies in size of facial bones occurring
in the anteroposterior plane of space may be
assessed quantitatively in terms of millimeters.
The method of assessment presented makes
possible a net score of anteroposterior dysplasia
which is approximately zero where such
dysplasia is either nonexistent or compensated
for by variation in different parts and which
is negative in the type of face where relative
mandibular insufficiency exists and positive
in cases of mandibular prognathism.
Cephalometrics for Orthognathic
Surgery (COGS by Burstone)
It was developed by Burstone and Legan.
Normally during orthodontic treatment the
alveolar base is stable. But during orthognathic
surgery, the alveolar base also changes
position. The COGS system describes the
horizontal and vertical position of facial bones
by use of a constant coordinate system.
1. The chosen landmarks and measurements
can be altered by various surgical proced­
ures.
2. The comprehensive appraisal includes
all of the facial bones and a cranial base
reference.
3. Rectilinear measurements can be readily
transferred to a study cast for mock surgery.
4. Critical facial skeletal components are
examined.
5. Standards and statics are available for
variations in age and sex.
6. Systematized approach to measurements
that can be computerized.
7. COGS appraisal describes dental, skeletal
and soft tissue variations.
218 Essentials of Orthodontics
Posteroanterior Cephalometric
Analysis
Frontal view is particularly important in cases
of dentoalveolar and facial asymmetry, cross
bites and functional mandibular displacements
(Fig. 5.39).
There are different methods of analysis:
1. Rickett’s: It measures the nasal cavity
width, maxillary, mandibular, intermolar
and intercuspid widths by connecting
bilateral identical points and measuring
the distance between them. Symmetry is
measured from the midsagittal plane and
relating the points pogonion and ANS to it.
2. Svanholt and Solow analysis: It measures
the relationships between the midlines of
the jaws and dental arches. It measures
the transverse maxillary and mandibular
positions, transverse jaw relationship and
position of upper and lower incisors and
Figure 5.39: PA cephalometric landmarks
the compensation of upper and lower
incisors. It incorporates variables that will
be zero in symmetrical subjects.
3. Grayson analysis: It uses multiple planes at
selected depths to analyze facial asymm­
etry.
4. Hewitt analysis: It is performed by dividing
the craniofacial complex into constructed
triangles­triangulation of face.
5. Chierici analysis: It focuses on asymmetry
of upper face.
6. Grummon’s analysis: Explains the asymm­
etry of lower­third of face.
Cephalometric Superimpositions
Serial superimposition of cephalograms reveals
the rate, amount and relative directions of
the growth and treatment changes of facial
structures, including the changes in maxillary
mandibular relationships, and the relative
changes in the soft tissue integument. It however,
does not reveal either the sites or mode of growth
of bone. 2D information was interpreted of a
3D process. It demonstrates the sum total of
apposition and resorption at that particular time
without detailed intervening changes.
FACIAL PHOTOGRAPHS
Facial photographs offer a lot of information
on the soft tissue morphology and facial
expression. Photographs should be taken in a
standardized manner so that they can readily
be compared with similar photographs taken
during or after the treatment.
Both extraoral as well as intraoral photo­
graphs are useful. Extraoral photographs are
taken by positioning the patient in such a
manner that the FH plane is parallel to the
floor.
The commonly taken intraoral and extraoral
photographs are:
 Orthodontic Diagnosis 219

I. Extraoral Photographic Analysis

1. Frontal view Photographic analysis can be done in profile
i. Frontal normal or frontal examination of facial photographs.
ii. Frontal smiling
2. Profile view
Profile Examination
i. Right profile
ii. Left profile Profile View
3. Oblique facial view Depending upon the location of subnasal point
i. 45° frontal relative to skin nasion perpendicular there are
ii. Submental. typical profile variations.
II. Intraoral Average face—Subnasal lying on skin nasion
1. Frontal view perpendicular.
2. Lateral view Anteface—Subnasal lying in front of skin
i. Right lateral nasion perpendicular.
ii. Left lateral Retroface—Subnasal lying behind the skin
3. Occlusal view nasion perpendicular.
i. Maxillary
ii. Mandibular. Facial Divergence
Analysis of lateral photograph is based upon
the evaluation of divergence of the face.
Uses of Photographs
The following three profiles types are differ­
Extraoral entiated according to the relationship between
1. They are useful in assessment of facial sym­ these two lines:
m­etry, facial type and profile. 1. Straight profile
2. They serve as diagnostic records. 2. Convex profile
3. They help in assessing the progress of the 3. Concave profile.
treatment.
4. Detection of muscle imbalances. Frontal Examination
5. Monitoring the treatment progress. Examine the face in frontal view for propor­tional
6. Patient identification. width of eyes/nose/mouth. Evaluation of vertical
7. Patient motivation an visualized treatment facial proportion can be done by dividing a well-
objective. proportioned face into vertical third.
8. Photographic mock surgery. Bilateral facial asymmetry can be revealed
by comparing the real full face photography
Intraoral with composite consisting of two right and two
1. Monitoring the treatment progress. left side.
2. Assesment of teeth and surrounding struc­
tures for diagnosis and treatment planning.
Supplementary Diagnostic Aids
3. Patient motivation.
4. Record the structure of enamel or any other Special Radiographs
anomalies. Special X-rays are taken to visualize certain
5. For oral hygiene instructions. areas of interest:
220 Essentials of Orthodontics
1. Occlusal view for canine location and to
see midpalatal suture ossification.
2. Tube shift technique for locating impacted
canines.
3. Posteroanterior cephalogram to assess the
symmetry of face.
4. Cephalogram with wide open mouth to
study TMJ disorders.
5. Cephalogram with radiopaque media to
study velopharynges, activity in cleft lip
and palate patients.
6. 45o lateral projection for studying
development of dentition.
7. Lateral oblique X-ray for assessment of
dentition.
8. Hand wrist X-rays for evaluation of skeletal
growth status.
Hand-Wrist Radiographs
Radiographs of the hand and wrist are useful
in estimating the skeletal age of a person. The
hand and wrist region have a number of small
bones whose appearance and progress of
ossification occur in a predictable sequence.
This enables assessment of the skeletal age of
a patient. They are useful in assessing growth
for planning growth modification procedures
and surgical resective procedures.
Skeletal Maturity Indicators
An understanding of growth events is of
primary importance in the practice of clinical
orthodontics. Biologic age, skeletal age,
bone age and skeletal maturation are nearly
synonymous terms used to describe the
stages of maturation of a person. Due to
individual variations in timing, duration and
velocity of growth, skeletal age assessment is
essential in formulating viable orthodontic
treatment plans. Maturational status can have
considerable influence on diagnosis, treatment
goals, treatment planning and the eventual
outcome of orthodontic treatment. Clinical
decisions regarding use of extraoral traction
forces, functional appliances, extraction versus
nonextraction treatment, or orthognathic
surgery are at least partially, based on growth
consi­derations. Prediction of both the time
and the amount of active growth especially in
the craniofacial complex would be useful to
the orthodontist.
In view of the importance of growth in
orthodontic treatment, objective assessment of
maturation is important. The chronological age
based on the date of birth offers little insight
in determining the developmental stage or
somatic maturity of a person. Thus the maturity
indicators provide an objective diagnostic
evaluation of stage of maturity in an individual.
The basis for skeletal age assessment by
radiographs is that the different ossification
centers appear and mature at different
times. The order, rate, time of appearance
and progress of ossification in the various
ossifi­cation centers occurs in a predictable
sequence.
A number of methods are available to
assess the skeletal maturity of an individual.
These include:
i. Use of hand-wrist radiographs.
ii. Evaluation of skeletal maturation using
cervical vertebra.
iii. Assessment of maturity by clinical and
radiographic examination of different
stages of tooth development.
Although a number of methods of skeletal
maturity determination have been described,
the use of hand-wrist radiographs has been the
most widely accepted method.
Hand-Wrist Radiographs
The hand-wrist region is made up of numerous
small bones. These bones show a predictable
and scheduled pattern of appearance,

ossification and union from birth to maturity.
Thus by merely comparing a patient’s hand and
wrist radiograph with standard radiographs
that represent different skeletal ages, we will
be able to determine the skeletal maturation
status of that individual.
Anatomy of hand-wrist: The hand­wrist region
is made up of the following four groups of
bones (Fig. 5.40):
Distal ends of long bones of forearm: The distal
ends of radius and ulna, which are long bones
of the forearm, arm the first group of bones. In
the anatomical position with the palm facing
the front the ulna is on the medial aspect while
the radius is on the distal aspect. The radius
and the ulna give rist to a distal projection on
their respective sides. These are called the ulna
styloid and the radial styloid.
The carpals: They consist of eight small,
irregularly shaped bones arranged in two
Figure 5.40: Anatomy of hand-wrist
Orthodontic Diagnosis 221
rows, a proximal row and a distal row. The
bones of the proximal row are schaphoid,
lunate, triquetral and pisiform. The distal
row of bones include trapezium, trapezoid,
capitate and hamate. Each of these eight carpal
bones ossifies from one primary center, which
appears in a predictable pattern.
The metacarpals: They are 5 miniature long
bones forming the skeletal framework of the
palm of the hand. They are numbered 1 to
5 from the thumb to the little finger. Each
metacarpal ossifies from one primary center
(in its shaft) and a secondary center on the
distal end (except for the first metacarpal
where it appears at the proximal end).
The phalanges: They are small bones forming
the fingers. They are three in number in each
finger, except the thumb which has only two
phalanges.
The three bones are referred to as the
proximal, middle (absent in thumb) and the
distal phalanges. The phalanges ossify in three
stages:
Stage I: The epiphysis and diaphysis are equal.
Stage II: The epiphysis caps the diaphysis by
surrounding it like a cap.
Stage III: Fusion occurs between the epiphysis
and diaphysis.
The sesamoid bone: The sesamoid bone is
a small nodular bone most often present
embedded in tendons in the region of the
thumb.
Indications for Hand­wrist
Radiographs
1. In patients who exhibit major discrepancy
between dental and chronological age.
2. Determination of skeletal maturity status
prior to treatment of skeletal malocclusion
such as a skeletal Class II or class III.
3. To assess the skeletal age in a patient whose
growth is affected by infections, neoplastic
or traumatic condition.
222 Essentials of Orthodontics
4. Serial assessment of skeletal age using
hand-wrist radiograehs helps not only
in assessing the growth of an individual,
but also helps predict future skeletal
maturation rate and status.
5. To predict the pubertal growth spurt.
6. It is a valuable aid in research aimed at
studying the role of heredity, environment,
nutrition, etc. on the skeletal maturation
pattern.
7. It is indicated in patients with skeletal
malocclusion needing orthognathic
surgery, if undertaken between 16 to 20
years so as to assess the growth status.
A number of methods have been described
to assess the skeletal maturity using hand-
wrist radiographs. The following are the most
commonly used methods:
Greulich and Pyle Method
Greulich and Pyle published an atlas
containing ideal skeletal age pictures of the
hand-wrist for different chronological ages and
for each sex. Each photograph in the atlas is
representative of a particular skeletal age. The
patient’s radiograph is matched on an overall
basis with one of the photographs in the atlas.
Tanner and Whitehouse Method
Tanner and Whitehouse suggested three
methods of scoring maturity of individual
bones to determine skeletal age:
1. The RUS (Radius, ulna, short bones) score
rates the radius, ulna, metacarpals of digits
1, 3 and 5, proximal phalanges of digits 1, 3
and 5, middle phalanges of digits 3, 5 and
distal phalanges of digits 1, 3 and 5.
2. The carpal bone method scores capitate,
hamate, triquetral, lunate, scaphoid, trape­
zium, and trapezoid. The problem of using
the carpal bones only is that 97 percent of
the carpal score is reached by age 13 in
males and 11 years in females.
3. The TW-2 method scores all the aforemen­
tioned growth centers. Each growth center
is given a maturity rating on a scale of 8 (A
to H) except the radius, which has 9 (A to
I). Numerical score is then assigned each
center in an attempt to allow for biologic
variability. A total is derived and gives the
overall maturity rating. Females and males
get different scores for the same since the
radiologic appearance of all bones does not
indicate the same maturity in both sexes.
Each is compared to the atlas standards,
consisting of X-rays photographs and
descriptions. Only individual growth centers
are pictured. Correct positioning of the hand
in imperative for this method to succeed.
Standard curves have been developed
plotting total maturity score against
chronologic age. Similar to a standard height
curve, bone age is taken as the age at which
the score is at the 50th percentile.
Taranger Method
Another recent method called the MAT (mean
appearance time of bone stages) set forth by
Taranger utilizes mathematical logarithmic
analysis of Tanner Whitehouse skeletal stages.
Studies of reliability of Greulich Pyle versus
the Tanner Whitehouse method of skeletal age
assessment have shown each to be superior
to the other.
Chapman Method
In addition, Chapman has proposed a radio­­
graphic method using a standard sized
intraoral dental film to assess the development
of the first metacarpophalangeal joint. The
develop­m ent of the adductor sesamoid is
staged accor­ding to ossification. The onset
of ossifi­­cation of the sesamoid occurs at the
beginning of the adole­scent spurt in height,
and maxi­mum velocity usually occurs at the
seed stage.
 Orthodontic Diagnosis 223

Bjork, Grave and Brown Method

They have divided skeletal development into 9
stages. Each of these stages represents a level
of skeletal maturity. Appropriate chronological
age for each of the stages was given by Schopf
in 1978.
Stage I (males 10.6y, females 8.1y): The
epiphysis and diaphysis of the proximal
phalanx of index finger are equal. It occurs
approximately three years before the peak of
pubertal growth spurt (Fig. 5.41A). Figure 5.41A: Stage I—PP2
Stage II (males 12.0y, females 8.1y): The
epiphysis and diaphysis of the middle phalanx
of the middle finger are equal (Fig. 5.41B).
Stage III (males 12.6y, females 9.6y) (Fig.
5.41C): This stage is characterized by presence
of three areas of ossification:
i. The hamular process of the hamate
exhibits ossification.
ii. Ossifcation of pisiform.
iii. The epiphysis and diaphysis of radius
are equal.
Stage IV (males 13.0y, females 10.6y) (Fig. Figure 5.41B: Stage II—MP3

5.41D): This stage marks the beginning of the

pubertal growth spurt. It is characterized by:
i. Initial mineralization of the ulnar sesa­
moid of the thumb.
ii. Increased ossification of the hamular
process of the hamate bone.
Stage V (males 14.0y, females 11.0y) (Fig.
Figure 5.41C: Stage III (H Pisi-R)
5.41E): This stage heralds the peak of the
pubertal growth spurt. Capping of diaphysis
by the epiphysis is seen in:
i. Middle phalanx of the third finger.
ii. Proximal phalanx of the thumb.
iii. Radius.
Stage VI (males 15.0y, females 13.0y): This
stage signifies the end of the pubertal growth
spurt. It is characterized by union between
epiphysis and diaphysis of the distal phalanx
of the middle finger (Fig. 5.41F). Figure 5.41D: Stage IV (5H)
224 Essentials of Orthodontics

Figure 5.41E: Stage V (MP3c, PPIc, Rc)

Figure 5.41G: Stage VII (PP5u)

Figure 5.41H: Stage VIII (MP3u)

Figure 5.41F: Stage VI (DP3u)

Stage VII (males 15.9y, females 13.3y): Union

of epiphysis and diaphysis of the proximal
phalanx of the little finger occurs (Fig. 5.41G).
Stage VIII (males 15.9y, females 13.9y): This
stage shows fusion between the epiphysis and
diaphysis of the middle phalanx of the middle
finger (Fig. 5.41H).
Stage IX (males 18.5y, females 16.0y): This
is the last stage and it signifies the end of
skeletal growth. It is characterized by fusion
of epiphysis and diaphysis of the radius (Fig.
5.41I).
Singer’s Method of Assessment
Julian Singer in 1980 proposed a system
of hand­wrist 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
Figure 5.41 I: Stage IX (Ru)
of hand wrist development are described. The
stages and their characteristics are:
Stage I (Early)
This stage is characterized by absence of the
pisiform, absence of hook of the hamate and
epiphysis of proximal phalanx of second finger
being narrower than its diaphysis.
Stage II (Prepubertal)
Stage two is characterized by initial ossification
of hook of the hamate, initial ossification of
the pisiform and proximal phalanx of second

finger being equal to its epiphysis. Stage two
represents that period prior to the adolescent
growth spurt during which significant amounts
of mandibular growth are possible. Maxillary
orthodontic therapy in conjunction with
mandibular growth might aid correction of a
Class II relationship with considerable speed
and ease.
Stage III (Pubertal Onset)
This stage is characterized by beginning of
calcification of ulnar sesamoid, increased
width of epiphysis of proximal phalanx of the
second finger and increased calcification of
hook of hamate and pisiform.
Stage IV (Pubertal)
Stage four is characterized by calcified ulnar
sesamoid and capping of the diaphysis of the
middle phalanx of third finger by its epiphysis.
Stage V (Pubertal Deceleration)
This stage is characterized by fully calcified
ulnar sesamoid, fusion of epiphysis of distal
phalanx of third finger with its shaft and
epiphysis of radius and ulna not fully fused
with respective shafts. Stage V represents that
period of growth when orthodontic treatment
might be completed and the patient is in
retention therapy.
Stage VI (Growth Completion)
No remaining growth sites seen.
Fishman’s Skeletal Maturity
Indicators
A system for evaluation of skeletal maturation
was proposed by Leonart S Fishman in
1982. This system of evaluating hand-wrist
radiographs makes use of anatomical sites
located on the thumb, third finger, fifth
finger and radius. Eleven discrete adolescent
skeletal maturity indicators (SMI’s) covering
Orthodontic Diagnosis 225
the entire period of adolescent development
have been described. The Fishman’s system
of interpretation uses four stages of bone
maturation. They are:
1. Epiphysis equal width to diaphysis.
2. Appearance of adductor sesamoid of the
thumb.
3. Capping of epiphysis.
4. Fusion of epiphysis.
The eleven skeletal maturity indicators are
as follows (Fig. 5.42):
SMI 1: The third finger proximal phalanx shows
equal width of epiphysis and diaphysis.
SMI 2: Width of epiphysis equal to that
of diaphysis in the middle phalanx of third
finger.
SMI 3: Width of epiphysis equal to that of
diaphysis in the middle phalanx of fifth finger.
SMI 4: Appearance of adductor sesmoid of
the thumb.
SMI 5: Capping of epiphysis seen in distal
phalanx of third finger.
SMI 6: Capping of epiphysis seen in middle
phalanx of third finger.
SMI 7: Capping of epiphysis seen in middle
phalanx of fifth finger.
SMI 8: Fusion of epiphysis and diaphysis in the
distal phalanx of third finger.
SMI 9: Fusion of epiphysis and diaphysis in
proximal phalanx of third finger.
SMI 10: Fusion of epiphysis and diaphysis in
the middle phalanx of third finger.
SMI 11: Fusion of epiphysis and diaphysis seen
in the radius.
Maturation Assessment by Hagg and
Taranger (Fig. 5.43)
Skeletal development in the hand and wrist is
analyzed from annual radiographs, taken bet­
ween the ages of 6 and 18 years, by assessment
of the ossification of the ulnar sesamoid of the
metacar­pophalangeal joint of the first finger
and certain specified stages of three epiphyseal
226 Essentials of Orthodontics
Figure 5.42: Fishman’s method
bones. The middle and distal phalanges of
the third finger (MP3 and DP3) and the distal
epiphysis of the radius.
Sesamoid
Sesamoid is usually attained during the accele­
ration period of the pubertal growth spurt
(onset of PHV).
Third Finger Middle Phalanx
MP3-F: The epiphysis is as wide as the
metaphysic. This stage is attained before onset
of PHV by about 40 percent of the subjects and
at PHV by many others.
MP3-FG: The epiphysis is as wide as the meta­
physis and there is distinct medial and or
lateral border of the epiphysis forming a line
of demarcation at right angles to the distal
border. This stage is attained 1 year before or
at PHV.
MP3-G: The sides of the epiphysis have
thickened and also cap its metaphysic forming
a sharp edge distally at one or both sides. This
stage is attained at or 1 year after PHV.

Figure 5.43: Hagg and Taranger method
MP3-H: Fusion of the epiphysis and metaphysic
has begun and is attained after PHV but before
end of growth spurt by practically all boys and
about 90 percent of the girls.
MP3-I: Is attained before or at end of growth
spurt in all subjects except a few girls.
Third Finger Distal Phalanx
DP3-I: Fusion of the epiphysis and metaphysis
is completed. This stage signifies the fusion of
Orthodontic Diagnosis 227
the epiphysis and metaphysis and is attained
during the deceleration period of the pubertal
growth spurt by all subjects.
Radius
R-I: Fusion of the epiphysis and metaphysis
has begun. This stage is attained 1 year
before or at the end of growth spurt by about
80 percent of the girls and about 90 percent
of the boys.
228 Essentials of Orthodontics
R-IJ: Fusion is almost completed but there is
still a small gap at one or both margins.
R-J: Is characterized by fusion of the epiphysis
and metaphysis.
These stages were not attained before end
by any subject.
Skeletal Maturation Evaluation
Using Cervical Vertebrae
Hassel and Farman developed a system of
skeletal maturation determination using the
cervical vertebrae. The shapes of the cervical
vertebra were seen to differ at each level of
skeletal development. This provided a means
to determine the skeletal maturity of a person
and theraby determine whether the possibility
of potential growth existed.
The shapes of the vertebral bodies of C3
and C4 changes from somewhat wedge­shaped
to rectangular, followed by square shape.
In addition, they became taller as skeletal
maturity progressed. The inferior vertebral
borders were flat when immature, and they
were concave when mature. The curvatures
of the inferior borders were seen to appear
sequentially from C2 to C3 to C4 as the skeleton
matured. The concavities become more
distinct as the person matured.
Hassel and Farman have put forward the
following six stages in vertebral development
(Fig. 5.44):
Figure 5.44: Cervical vertebrae
Stage I: Initiation
This stage is called initiation, corresponds to
beginning of adolescent growth with 80 to
100 percent of adolescent growth expected.
Inferior borders of C2, C3 and C4 were flat at
this stage. The vertebrae were wedge­shaped,
and the superior vertebral borders were
tapered from posterior to anterior.
Stage II: Acceleration
The second stage is called acceleration. Growth
acceleration begins at this stage, with 65 to
85 percent of adolescent growth expected.
Concavities were developing in the inferior
borders of C2 and C3. The inferior border of C4
was flat. The bodies of C3 and C4 were nearly
rectangular in shape.
Stage III: Transition
The third stage called transition corresponds
to acceleration of growth towards peak height
velocity with 25 to 65 percent of adolescent
growth expected. Distinct concavities were
seen in the inferior borders of C2 and C3. A
concavity was beginning to develop in the
inferior border of C4. The bodies of C3 and C4
were rectangular in shape.
Stage IV: Deceleration
This stage called deceleration corresponds to
deceleration of adolescent growth spurt with
10 to 25 percent of adolescent growth expected.
Distinct concavities were seen in the inferior
border of C2, C3 and C4. The vertebral bodies
of C3 and C4 were becoming squarer in shape.
Stage V: Maturation
The fifth stage is called maturation. Final
maturation of the vertebrae took place during
this stage, with 5 to 10 percent of adolescent
growth expected. More accentuated conca­

vities were seen in the inferior borders of C2,
C3 and C4. The bodies of C3 and C4 were nearly
square­to­square in shape.
Stage VI: Completion
This stage called completion corresponds to
completion of growth. Little or no adolescent
growth could be expected. Deep concavities
were seen in the inferior borders of C2, C3
and C4. The bodies of C3 and C4 were square
or were greater in vertical dimension than in
horizontal dimension.
Tooth Mineralization as an Indicator
of Skeletal Maturity
The calcification patterns and stage of minerali­
zation of the teeth is believed to have a close
relationship with the skeletal maturation of an
individual. Seymour Chertkow has described
a method of determining the skeletal maturity
based on the mineralization of the lower
canine. Demirjan, Goldstein and Tannner have
described a similar method (Fig. 5.45).
Dual Energy X­ray Absorptiometry
Skeletal age was assessed with the use of dual
energy X­ray absorptiometry (DEXA) as well
as with an X­ray of the left hand, in a study
by Sartoris in 2000 which is a recent accurate
Figure 5.45: Tooth mineralization stages
Orthodontic Diagnosis 229
method in determining growth trends in
children.
Diagnostic Setup (Fig. 5.46)
Diagnostic setup was first proposed by
HD Kesling. The diagnostic setup is made
from an extra set of trimmed and polished
study models. The individual teeth and their
associated alveolar processes are sectioned off
and replaced on the model base on the desired
positions. The diagnostic setup thus helps in
simulating the various tooth movements that
are planned for patients.
Uses of Diagnostic Setup
1. It is useful in visualizing and testing the
effect of complex tooth movements and
extractions on the occlusion.
2. The patient can be motivated by simulating
the various corrective procedures on the
cast.
3. Tooth size arch length discrepancies can
be visualized by means of a setup.
Procedure
The cast is cut using a fretsaw blade to separate
the individual teeth. A horizontal cut is made
3 mm apical to the gingival margin. Vertical
cuts are made to separate the individual teeth.
230 Essentials of Orthodontics
Figure 5.46: Diagnostic setup
The individual teeth are set in desired position
using red wax.
Electromyography
Electromyography is a procedure used for
recording the electrical activity of the muscles.
The resting potential of a muscle fiber is 85
to 90 mV. Voluntary muscle consists of many
contracting fibers supplied by peripheral
nerve terminals. The membrane of each
fiber is electrically charged with positive
charge outside and negativity of 85 to 90 mV
inside. Upon receiving a stimulus, there is a
reversal of this potentiality resulting in muscle
contraction. This is called action potential
and denotes the mechanical activity of the
muscle. The electromyography is a machine
which is used to receive, amplify and record
the action potential during muscle activity.
Electromyogram is a record obtained by such
a procedure. The action potential is picked up
by electrodes which are of two types.
Surface electrodes: These electrodes are used
when the muscle is superficially placed just
below the skin.
Needle electrodes: They are used when the
muscle is placed deep inside, e.g. Pterygoid
muscles:
Having picked up the action potential with
surface or needle electrodes, it is recorded
either with the help of a moving pen in the form
of a graph or recorded in the form of sound
with the help of a magnetic tape recorder.
EMG is used to detect abnormal muscle
activity associated with certain forms of
malocclusion.
i. In severe Class II division 1 malocclusion
the upper lip is hypofunctional. Thus
during swallowing, the lower lip extends
upwards and forwards to force the
maxilla labially and a strong mentalis
muscle activity is seen. EMG can be used
to study such a condition.
ii. Abnormal buccinator activity in Class II
division 2.
iii. Overclosure of jaws is associated with
accentuated temporalis muscle activity.
iv. Children with cerebral palsy.
v. EMG can be carried out after orthodontic
therapy to see if muscle balance is
achieved.
Basal Metabolic Rate (BMR)
Endocrine upsets may produce or be partly
responsible for dental malocclusion, e.g. one of
the characterisitic sequelae of hypothyroidism
is the delayed eruption pattern which can
cause malocclusion.
A secondary oral manifestation helps
the dentist to diagnose the general medical
problems. It is the duty of the dentist to
recognize such medical problems so that the
patient receives medical care.
Physioprint (Fig. 5.47)
Physioprints were developed by Sassouni.
These are analogus to Fingerprints. They
reproduce the contour of the face at each level
of depth. It provides a contour map of the face
and at the same time gives dimensions. In a
synthetic way it translates on to a flat surface
the three dimensional architecture of the face.
This helps in distinguishing one face from
the other as the contoural and dimensional
patterns of no two faces are alike.

Figure 5.47: Physioprints
Recent Advance in Diagnostic Aids
Orthodontics is a rapidly growing fields with
developments occurring almost everyday. The
improvements basically occur in two areas. The
first is an improvement in the materials and
techniques used while the other is advances
in the diagnostic aids. Recent innovations
in medical imaging have been adapted to
dentistry and find some applications in
orthodontics as well.
Xeroradiography
Xeroradiography is a completely dry, non­
chemical process which makes use of the
electrostatic process as in Xerox machines.
It was invented by Chester F Carlson in 1937.
Xeroradiography makes use of an alumi­
num plate that is coated with a layer of vitreous
selenium.The selenium particles are given
a uniform electrostatic charge. The charged
plate is palced in a light­tight, air­tight cassette.
When the film is exposed it causes a selective
discharge of the selenium depending upon the
Orthodontic Diagnosis 231
amount of radiation used and relative density
of the 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 to the quantity of charge
present. This image is now transferred on to
a 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 paper the
selenium plate can be discharged, cleaned and
used again. It can be reused as many as 1000
times.
Xeroradiographic image differs from con­
ventional radiographs in the following ways:
1. It exhibits high edge contrast due to a
phenomenon called edge enhancement.
This facilitates perception of anatomic
details.
2. The xeroradiographic image is on paper
and is viewed in reflected light. Thus no
special illumination is needed for viewing.
3. Choice of positive or negative image is
possible.
The advantages of Xeroradiography are:
1. Reduction in exposure time.
2. Ease in manipulation. No need of darkro­
oms for developing.
3. Ease of viewing: No special light source is
required.
4. Edge enhancement effect. Boundaries
between structures are clear.
5. Cephalometric landmarks are easily iden­
tified.
Reconstruction of the cephalometric planes
and points can be made directly on paper.
232 Essentials of Orthodontics
Digi-graph
The Digi-graph is a synthesis of video imaging,
computer technology and sonic digitizing. The
Digi-graph work station equipment measures
5’ x 3’ x 7’. The main cabinet contains the
electronic circuitry. The Digi-graph enables
the clinician to perform noninvasive and
nonradiographic cephalometric analysis.
Cephalometric landmarks are digitized by
lightly touching the sonic digitizing probe to a
point on the patient’s skin corresponding to it.
This emits a sound, which is then recorded by
the microphone and monitored as X, Y, and Z
coordinates. The system allows cephalometric
evaluation and treatment progress as often
as necessary without radiation exposure.
Features of Digi-graph include:
1. Landmark can be identified as a point in
three dimensions.
2. A cephalometric analysis can be made
independently of head position.
3. Parallelism of X-ray in midsagittal plane
and symmetry of anatomic morphology
between left and right sides is not necessary.
The Digi-graph work station’s hardware
and software enable the performance of
cephalometric analysis, tracing, superi­
mposition and visual treatment objectives.
The programs are capable of 14 analyses.
Measurements for any selected analysis can
be displayed on the monitor and the observed
values are shown along with the patient norm
adjusted for age, sex, and race and head
size including standard deviations. Optional
components include:
1. A consultation unit: It transports infor­
mation into the operatory, doctor’s office
or consul­tation ares, thus allowing viewing
and com­p arison of information and
the development of visual treatment
objectives.
2. A high resolution video camera with a
telephoto lens for taking intraoral views by
Freeze framing the video image.
3. A light box for X-ray and a study model
holder for video imaging that will be
included in the floppy disk.
4. Camera and video printer for producing
copies of video monitor information.
The Digi-graph allows all patients models,
radi­o­­g raphs, photographs, cephalograms
and tracings to be stored on one small disk,
thereby reducing storage requirements.
Further­more it is a valuable tool for improving
communication among clinician, patient and
staff.
Magnetic Resonance Imaging
The magnetic resonance imaging (MRI) makes
use of two fundamental properties of protons,
i.e. spin and small magnetic movements.
The proton of hydrogen ion which is in water
(water being the major component of body)
is utilized in MRI. The protons behave like
small spinning magnets and when placed in a
magnetic field they tend to move parallel to the
field. Because of the spin the protons respond
differently within their axis progressing abnout
the direction of the magnetic field. If a coil is
now wound around a volume of protons, they
now progress at 90° around the magnetic field
at the same frequency and induce a minute
current in the coil which when amplified can
be displayed over an oscilloscope. This energy
is utilized in scanning procedure (Fig. 4.48).
The advantages of magnetic resonance
imaging are:
1. MRI does not have hazards as it uses non-
ionizing electromagnetic radiation.
2. Anatomical details are as good as in CT
scan.
3. Greater tissue characterization is possible.

Figure 5.48: Magnetic resonance imaging of TMJ
4. Imaging of blood vessels, blood flow and
visualization of thrombus is possible.
The disadvantages of MRI include:
1. Time taken is more.
2. It is not used in patients with cardiac pace­
makers.
3. Nonvisualization of bone makes it useless
in bony lesions.
Tomography
Conventional radiographs are images in
which all objects between the X­ray source
and film are superimposed. Thus the clarity
of specific radiographic findings depends
on both its location and the degree to which
its density differs from that of surrounding
objects. In some situations superimposition of
objects interferes with an observer’s ability to
clearly discover the object of interest. In these
instances tomography can be used to visualize
a section or slice or the object and thereby
eliminate undesirable overlap.
Tomographic can be conventional or
computed tomography.
Conventional Tomography
This is a process by which a layer of an image
within the body is produced while the images
of structures above and below that layer are
made invisible by blurring. Blurring of image
Orthodontic Diagnosis 233
outside the plane of interest is accomplished
by simultaneous movement of the X­ray
tube and film during the exposure. The tube
and film are connected so that movement
occurs around a point or fulcrum. As the
distance from the point of rotation increases,
the amount of image blurring also increases.
Thus objects close to the point of rotation are
sharper and objects farther are blurred. As
the angle between the source and film and
tissue increases the thickness of the image is
reduced. Thus, the greatest blurring is seen in
the periphery while the sharpest image is seen
at the central area near the fulcrum of rotation
(Fig. 5.49).
The principles of tomography can be
mechanically implemented in two ways:
1. The X­ray tube and film can move synchron­
ously in opposite directions in parallel
planes.
2. The X­ray tube and film can move synchr­
onously and in opposite directions in
parallel planes but with motions other than
straight line, i.e. circular, spiral, etc.
Computed Tomography
It is also called CT or CAT (Computed axial
tomography). CT systems are mainly complex
imaging systems which use thin beams of X­ray
Figure 5.49: Temporomandibular joint (TMJ)
tomography
234 Essentials of Orthodontics

that move in a synchronous manner with an array

of detectors which calculate and attenuate the
X­ray beams 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 axial
planes.
The advantages of CT scan are:
1. Accurate visualization of an area of interest
is possible.
2. The computer programming makes it poss­
ible to view the images in different shades
and densities. This helps differentiate fat
and blood.

Occlusograms (Fig. 5.50)

It is a tracing of a photograph or a photocopy
of a dental arch. Occlusograms are used for the
following purposes:
1. To estimate occlusal relationships.
2. To estimate arch length and width.
3. To estimate the tooth movements required
in all three planes of space.
4. To estimate spacing and crowding.
5. To estimate anchorage requirements.
Occlusograms can be obtained on two ways:
1. The occlusal surfaces of the upper and
Figure 5.50: Occlusograms
lower dental casts are photographed in a
1:1 ratio and a tracing is made using the
photographs. Visual Treatment Objective (VTO). It can be
2. The casts are photocopied on a Xerox constructed from tracings of photographic
machine and the occlusal photocopy is or photostatic copies of the occlusal aspects
used to obtain a tracing. of the maxillary and mandibular study casts.
Occlusogram is a graphic representation The tracings of the teeth of both arches are
of the arches from the occlusal view. Occluso­ superimposed on each other to reproduce
grams are mainly used as treatment planning the existing occlusal relationship, using index
aids to assist in defining the specific tooth points that are marked on the models and
movements required within and between subsequently transferred to the tracings.
arches (in the sagittal and transverse planes) Anticipated movements of individual teeth as
to achieve treatment goals. An occlusogram well as the need for extractions then can be
is essentially a two­dimensional diagnostic determined, to simulate the desired treatment
setup and is directly correlated with the goal.

Digital Subtraction Radiography
In conventional radiographs the background
structures such as alveolar bone and adjacent
teeth may draw the examiners vision away from
the diagnostic information thereby making
detection of pathologic changes difficult. The
advancement of caries from incipient lesion
through the dentino-enamel junction is often
difficult to detect. Likewise the assessment of
a healing or expanding lesion after root canal
therapy is a challenge because of the subtle
changes in the dentistry of the lesion that may
not be detectable with the unaided eye.
The detection of initial saucering of
formation of angular defects around implants
is very difficult to visualize on radiographs.
Moreover, the spread of bone loss along
the thread of the root form implant is often
obscured by the sharp contrast between
the bone and implant surface. Subtraction
radiography addresses many of the limitations
in the detection of these radiographic changes
by decreasing the amount of distracting
background information and by allowing the
eye to focus on the actual that has occurred
between two images. By subtracting all
anatomic structures that have not changed
between radiographic examinations, changes
in diagnostic information are easier for the
reader to see.
Technically this is an image enhancement
method that removes the structured noise from
the images. The result is the area of change
clearly displayed either against a neutral gray
background or is superimposed on the original
radiograph itself. The subtraction of original
two radiographs is termed an image rather
than a radiograph because it dies not directly
result from exposure of a radiographic film.
The digital subtraction technique selectively
enhances the differences between two images.
Image registration however is found to be
Orthodontic Diagnosis 235
a technical problem. It is impossible to
achieve perfect registration of images during
digitization because of imperfections in the
radiographic 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 three dimensional aspect of an
object can be obtained. The recorded image is
called a hologram. Laser is light amplification
by simulated emission of radiation.
Holography is a wave front reconstruction
process in which two coherent beams converge
to produce a constructive and destructive
inter­ference pattern which is recorded in film.
Orthodontic applications of holography:
1. Storage of study models images.
2. Measurement of incisor intrusions.
3. Study the effects of high pull headgear
traction in children’s skulls.
4. Tooth position measurements on dental
casts.
5. To study the effect of maxillary expansion
on facial skeletons.
6. To study the effect of Class II elastics on
bone displacement.
7. To study the effects of cervical pull
headgear on maxilla.
8. To determine the centers of rotation
produced by orthodontic forces.
9. Lower incisor space analysis.
10. To assess the facial and dental arch sym­
metry.
Photocephalometry
Although the standard and anteroposterior
cephalograms reveal some aspects of soft
tissue, they nevertheless do not give adequate
236 Essentials of Orthodontics
soft tissue details. In a lateral cephalogram only
the profile is seen while in an anteroposterior
cephalogram the lateral soft tissue margins
are seen.
Thomas in 1978 developed photocephalo-
metry to better visualize the soft tissues of the
patient.
Three radiopaque metallic markers
with holes are placed on the patient’s skin
with adhesives and standard lateral and
anteroposterior cephalograms are taken.
Using the same position lateral and frontal
photographs are taken. The photographs are
printed to the same size as the radiographs
and are superimposed over the radiographic
tracing taking the metallic markers as the
guide.
Cine Radiography
This is basically a radiographic motion picture.
The subject is oriented properly and stabilized
in a modified cephalostat. 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
of the patient. The X-ray motion picture is
studied using a movie projector.
Ultrasonography
The phenomenon perceived as sound is the
result of periodic changes in the pressure of
air against the eardrum. Periodicity of these
changes lies anywhere between 1500 and
20,000 cycles per second.
Principle
Electrical impulses generated by the scanner
causes the dipoles in the crystal to realign
themselves and to the electrical field and thus
suddenly change the crystal’s thickness. This
abrupt change begins a series of vibrations that
produce the sound waves that are transmitted
into the tissues being examined.
Advantages are that it does not require
special facilities, can be used to view the joint
in a continuum without invasion, discomfort.
Disadvantages include noise signal, size of
the transducer and meniscus not seen.
COMPUTERS IN
ORTHODONTICS
A computer can be described as an automatic
ele­c ­t ronic device capable of accepting
information (data), perform operations and
calculations according to the instructions
given and supply the results of the operation.
Computers commonly are employed to
enhance the diagnosis, record keeping, pra­
ctice management patient education and
motivation.
Humans live in the realm of information.
Machines operate in the realm of data. Data
are raw facts while information can be said
to be data that is placed into a meaningful
context for use by humans. Humans narrate
information better than data, while computers
handle data better than information.
Virtually everything that we do in dentistry
that involves research, teaching, administration
or patient care is based on generation,
storage and manipulation of information.
Computers are capable of handling large
amount of data. They accomplish mundane,
repetitive tasks consistently well where as
humans performance is likely to decline
overtime. Computers can perform routine
communications with greater speed and
accuracy than is humanly possible. They
are capable of massive computation and
calculations more rapidly than humans. They
have a greater capability for accuracy and
rapidity. Their processing forte is management
of large amounts of disconnected pieces
of data, with retrieval, rearrangement and
relocation in storage areas.

CHARACTERISTICS OF A
COMPUTER
Speed
Computers are capable of making calculations
at a very fast rate that is not possible by the
average human brain. The presently available
medium sized computers can execute over a
million instructions per second. To exemplify
this it would not be an exaggeration to say
that a computer can perform calculations in
one minute than an average individual would
require his entire lifetime.
Accuracy and Reliability
Computers are designed in such a way
that they exhibit a high level of endurance
capacity so that they can work without tiring.
Computers work on the principle of electric
impulse transmission which makes it very
reliable and mistake proof. They are capable
of repeating the same job over and over again
without any decline in their efficiency.
Memory
Computers are capable of storing large amount
of data and information in their inbuilt and
auxiliary memory systems. Information that
is stored in the computer memory can be
retrieved at an astonishing speed whenever
required. Modern day computers can retrieve
data from its memory in a few nano seconds.
Integrity
It is the ability to take in and store a sequence
of instructions to be obeyed. Such a sequence
of instructions given to the computer is
called a program and it must be written in a
language that the computer can understand.
The computer performs calculations or
manipulates the date that has been fed to it
using the instructions that has been given to
it and furnishes the desired results.
Orthodontic Diagnosis 237
Versatility
Computers possess the ability to communicate
with other systems and adopt several modes of
presentation such as audio, visual, animation,
etc.
Components of a Computer System
A computer system comprises of two basic
components. They are Hardware component
and Software component.
The hardware component includes all
the mechanical devices in the system, the
machinery and the electronic components
that perform physical functions. The software
is an organized set of ready made or specially
written instructions that make the equipment
work. In simple words whatever we can see
and touch in a computer can be said to be the
hardware while, the unseen instructions that
make the machine run is the software.
The typical computer system consists of a
central processing unit (CPU), input devices,
storage devices and output devices.
The central processing unit can be said to
be the brain of the computer. The functions
of the CPU include storage of data and
instructions, carrying out the data processing
as per the instructions given, controlling the
sequence of operations as per the stored
instructions, issuing commands to all parts of
the computer system and sending the results
to the output device. The CPU consists of an
arithmetic logic unit, registers, control section,
and internal bus. The arithmetic logic unit
carries out arithmetic and logical operations.
The registers store data and keep track of
operations. The control unit regulates and
controls various operations. The internal bus
connects the units of the CPU with each other
and with external components of the system.
The input devices are components of
a computer that are meant to present the
information to the computer. A computer
238 Essentials of Orthodontics
system can have one or more types of input
devices. For most computers, the principal
input devices are a key-board or mouse.
The storage devices comprise of the
internal memory and the external memory.
The internal memories of a computer are the
RAM (Random access memory) and the ROM
(Read only memory). The external memory
comprise of the floppy disk drive, CD Rom,
DVD, hard disk drive and magnetic tapes.
Output devices display the results of the
computations. The output devices include the
visual display unit or the monitor and various
types of printers.
USES OF COMPUTER IN
ORTHODONTICS
An orthodontic office can use computers for
a number of purposes. These can be broadly
classified as:
1. Administrative applications: Administrative
applications of a computer are aimed at
smooth running of the dental clinic. They
include:
i. Patient appointment and recalls
ii. Billing
iii. Accounting
iv. Correspondence
v. Inventory controls and supply orders
vi. Dental insurance claims
vii. Document preparation and word
processing
viii. Referral information
ix. Missed appointments follow-up.
2. Clinical applications: Clinical applications
of computers are those that help the dentist
in his or her professional practice. They
include:
i. Patient records storage and retrieval
ii. Patient evaluation, examination and
treatment planning
iii. Patient motivation
iv. Appliance designing using CAD,
CAM
v. Computerized imaging
vi. Computerized cephalometrics
vii. Computerized growth prediction
viii. Clinical diagnosis and treatment
planning.
3. Other applications: Computers have a
num­ber of other applications besides the
clinical and administrative uses mentioned
above. They include:
i. Creating a data base of survey infor­
mation
ii. Continuing medical education
iii. Reviewing of literature
iv. Research
v. Case presentations and other con­
ference presentation
vi. Entertainment and family use.
Computerized Scheduling
Several of the companies producing dental
office management softwares today offer
computerized scheduling modules. With these
programs, it is no longer necessary to maintain
a paper appointment book. The scheduler
allows the receptionist to find available times
for patient appointments and log them on the
computer.
Computerized Dental Patient Record
One of the applications of computers in dental
practice is the electronic storage of diagnostic
information. Electronic dental patient record
is slowly and steadily replacing bulky paper
records. Electronic dental patient records help
in storing patient information in a digital formal
which can be retrieved, duplicated, cataloged,
transmitted and achieved as needed.
Record storage problem increases as the
practice ages. Study models are bulky and
heavy, presenting considerable problem for

organizing and storage as they continue to
accumulative.
Current technology is available for in
office use of computers combined with video
cameras to copy radiographs, study models,
photographs, and handwritten records for
storage in compact digital form.
Practice Management
Dentistry, after all is a profession like any
other and today, living in a consumerist
society practitioners have to professionally
manage their hospitals and clinics in such
a way that, there is patient satisfaction and
job satisfaction. To cater to this need of
professional management, some of the dental
administrative softwares go one step beyond
patient administration and work on the date
that is fed in, creating reports that analyze the
nature of the work being done over a period
of time, the cost effectiveness of time spent on
the various procedures the productivity of the
dentist over a period of time and so on, thus
providing valuable management information
reports which analyze the practice within the
shortest time.
Practice Education
There has always been a need in all branches
of medicine to educate patients about diseases,
prevention and cure. Most dentists regard this
aspect very highly and spent a lot of their time
informing the patients about the various dental
problems, health guidelines, etc. However,
computers can save this valuable time of
the dentist by using the latest multimedia
technology. Multimedia simply means using
multiple media like text, pictures, graphics,
movies and sound to make a presentation.
Internationally, various multimedia tools for
patient education are available. This can be
purchased and played on the computer system
Orthodontic Diagnosis 239
for the benefit of the patients, just like a video
cassette is played.
Case Presentations
Most of us dentist consider ourselves as
life-long students and researchers and our
profession is not limited to practice alone.
Maintaining research data and creating
presentations is one of the greatest boons of
computerization. Most advertising agencies
use internationally marketed presentation
softwares like Microsoft’s Office, Power point
to push their products. This same tool can be
used by dentists to make slide presentations,
wherein one can use text, color, pictures
and actual photographs. These tools are
extremely user-friendly and they not only make
presentation classy and informative, but also
save valuable time, money and effort that were
formerly spent on the same.
Dental Imaging
This is a tool that is a god sent gift for most
dentists. Since dentistry, now deals with
changing the look of persons face, record
keeping naturally involves a lot of photographs
that document the treatment. But manual
photography is time consuming, laborious and
expensive over a period of time and it has its
limitations with intraoral pictures. Moreover,
it creates more paperwork. Dental imaging is
a solution wherein, a small intraoral camera
is interfaced to the computer, so that the user
has to just focus the camera to capture the
image on the monitor, click and the image can
be saved as a part of a picture album for each
patient in the computer itself. These images
can be viewed, edited, transformed into slides,
and printed, not only is it the most effective
marketing tool. There is hardly any patient
who is unimpressed by the photo recording of
their treatment and it also creates awareness
240 Essentials of Orthodontics
among patients about the need of dentistry
and its effects.
Continuing Medical Education
and Research References
Continuing medical education is essential
for the professional expertise and growth of
every doctor. With limitations of time long
distances and traffic difficulties it becomes
increasingly difficult for the dental surgeon
to attend workshops or other continuing
education programs. Access to medical and
dental journals and access to large volume of
medical reference material is easily available
on the Internet and also on CD-ROMs.
Communication and consultation with
colleagues in all parts of the world is possible
using E-mail and Internet.
Multimedia medical and dental public­
ations are now widely marketed. Multimedia
publications not only include text and pictures,
but also video clips and sound recordings.
Virtual reality presentations and animated
simulations also form an important part
of multimedia. Currently several hundred
medical and dental books are available as CD-
ROM’s.
Anybody who is involved in research knows
that a very large part of research work is tedious
tabulations, data analysis and painstaking
stati­s tical analysis. All this can be greatly
facilitated using a computer leaving valuable
time for the researcher to spend on actual
scientific findings.
Communications and Entertainment
Besides all these uses, computers have revoluti­­
onized our concepts of communications too.
A com­puter in our clinics can function as an
ans­wering machine and a fax. It can link you to
the Internet and can be used for international
comm­unications via the E-mail. It can also be
used as a tool for entertainment, not only for
playing fascinating games, but can be used to
watch televisions programs, as a CD player and
CD or DVD movie player.
Computerized Cephalometric
Systems
Prior to the introduction of computerized ceph­
al­o­­metry, all angular and linear measurements
were calculated manually. Besides being time
consu­ming, it involves the possibility of human
error.
Computerized cephalometry provides, in
addition to reliability, the advantage of speed.
It can be performed in 10 percent of the time of
a normal manual registration and calculation.
The advantages of this system include:
i. Easy storage and retrieval of cephalo­
metric images, tracings and values.
ii. Integration of cephalometric registr­
ations within an office management
computerized system.
iii. Combination of the cephalometric data
with other patient records.
The following are some of the popularly
used computerized systems:
RMO’s Jiffy Orthodontic Evaluation
RMO (Rocky Mountain Orthodontics) was the
first to provide the dental professional with
a computer aided cephalometric diagnosis
in the 1960’s. A recently designed software
package the JOE, generated tracings of lateral
or frontal cephalograms using Ricketts,
Jaraback, Steiners, Sassouni and Grummons
analysis. It can also provide a visual represen­
tation of normal for comparison to the
patient’s tracings, generate a collection of
ceph­a lo­m etric values tested in a logical
order along with the norms and amount of
deviation from normal and put together a list
of orthodontic problem analysis.

PorDios (Purpose on Request
Digitizer Input Output System)
A product of the Institute of Orthodontic com­
puter sciences, Denmark it is a cephalometric
system aimed at providing dentists with a
user-friendly program. This program can be
easily changed to satisfy individual needs and
preferences.
PorDios works with digitizer in the standard
way and also enables the use of a video/
scanner as means of digitization of X-rays.
It uses popular analyses including Bjork,
Burstone, Coben, Downs, McNamara, Ricketts
and Steiner. PorDios has built in functions to
calculate discrepancies between the actual
and its deviations from the norms. The norms
for each variable can be changed for different
ethnic groups. It is multi-lingual and the user
can choose from English, French, German,
Italian, Dutch, Spanish, Danish and Greek.
The system facilitates double digitization
minimizing error and ensuring the validity of
the whole registration procedure. The drawings
can be printed either on a matrix printer, laser
printer or a color plotter. An import export
facility makes it possible to make calculations
on all stored patients. It can produce a database
file containing the results of the digitization.
Digi-graph
This is a product of Dolphin Imaging system,
USA. The Digi-graph is a synthesis of video
imaging, computer technology and sonic
digitizing. The Digi-graph work station
equipment measures 5’× 3’×7’. It enables
the clinician to perform non-invasive and
nonradiographic cephalometric analysis.
Cephalometric landmarks are digitized by
lightly touching the sonic digitizing probe to a
point on the patients’ skin corresponding to it.
This emits a sound, which is then recorded by
the microphone and monitored as X, Y and Z
coordinates.
Orthodontic Diagnosis 241
The system allows cephalometric evalu­
ation and treatment progress as often as
necessary without radiation exposure. The
Digi-graph work station hardware and software
enable the performance of cephalometric
analyses, tracings, and superimposition and
visual treatment objectives. The program is
capable of 14 analyses. Measurement for any
selected analysis can be displayed on the
monitor and the observed values are shown
along with the patient norm adjusted for age,
sex, race and head size including standard
deviations. The Digi-graph allows all patients
radiographs tracings, cephalograms, photos
and models to be stored on the computer hard
disk, thereby reducing storage requirements.
Furthermore it is a valuable tool for improving
communication among clinician, patient and
staff. Optional components include:
i. A consultation unit: It transports infor­
mation into the operatory, doctor’s
office or consultation area, thus allowing
viewing and comparison of information
and the development of visual treatment
objectives.
ii. A high resolution video camera with a
telephoto lens for taking intraoral views
by freeze framing the video image.
iii. A light box for X-rays and a study model
holder for video imaging that will be
included in the floppy disk.
iv. Camera and video printer for producing
copies of video monitor information.
Computer Aided Diagnosis
Research is currently in progress attempting
to create a computer system that would, in
effect, simulate the diagnostic abilities of the
practicing physician. Several programs have
been designed to aid the physicians to make
multiple and complex diagnoses. Experience
with these programs, however confirms the
belief that medical diagnosis is a complex
242 Essentials of Orthodontics
process. The computer is able to construct a
differential diagnosis after being presented the
necessary historical items, symptoms, physical
signs and laboratory abnormalities associated
with a specific medical disorder. However the
program cannot recognize subcomponents of
illness, such as specific organ system involve­
ment or the degree of severity of the pathologic
processes. The computer is still limited in its
ability to reason and is unable to simulate
the thought processes and problem solving
methods employed by the human mind.
Thus, the practice of medicine remains an ‘art’
rather than an exact science, and the computer
currently remains only a tool to aid, rather than
replace, the physician.
Medical Imaging
The advent of computers has allowed rapid
technologic advances in the field of diagnostic
imaging, including X-rays, ultrasound, and
nuclear imaging systems. Clinical applications
of ultrasound diagnosis have broadened
considerably. Such technology is now used
to detect disorders involving the liver and
biliary systems, kidney and in obstetrics and
gynecology. They are also used to diagnose
craniofacial pathologies by the dental surgeon.
The medical profession is very familiar with
the use of the CAT scanner as an instrument to
provide a noninvasive information regarding
the size, shape and health of major body
organs. However, a new, more versatile and
safer method of providing three dimensional
views of the inner body has merged in recent
years. This technique called NMR (Nuclear
magnetic resonance), has several advantages
over CAT. Of greatest significance is its safety.
It is entirely noninvasive and dies not require
the use of dye injected or the exposure of the
patient to ionizing radiation. The NMR scanner
is also superior to the CAT scanner in that
it can image through bone, thus disclosing
previously hidden parts of the body, such as
the spinal cord. NMR can also differentiate
among blood, liver and muscle and in the
future the sensitivity may help distinguish
between benign and malignant tissues.
NMR works by exposing the patient
to a large magnetic fields and low level
radiofrequency pulses. Electrical charges
generated by the nuclei of atoms composing
the molecules of the body producing a
submicroscopic magnetic field, allowing
them to be attracted to an external magnetic
fields provided by the NMR scanner. After the
nuclei have been aligned by NMR, they are
bombarded withradio waves. The radiowaves
are then turned off, and the nuclei are allowed
to relax, re-emitting the radio signals that are
converted by the NMR scanners computer into
images of the body. These images are superior
to those obtained with all previous technology.
Conclusion
Thus, in conclusion the computer will provide
the doctor and his staff with immediate
access to more information than ever before.
Communi­cations is improved dramatically as
are other forms of marketing. With detailed
patient histories, diagnostic information
and treatment plans stored in the computer,
research and practice analysis can be done with
ease. These advantages are more important to a
good clinician than any initial inconveniences
that he may face while computerizing his
clinic.
All this is possible today in our country at a
reasonable cost which recovers itself in a short
period of time.
Competitive forces have further driven the
prices of computer hardware and software
lower and lower, each year, thus bringing down
the patients and doctors cost to benefit ratio.

The computer can truly be called a “Dream
Machine”.
STERILIZATION IN
ORTHODONTICS
Sterilization is the total destruction of all life.
Disinfection is the destruction of most
microorganisms but not highly resistant spores.
Milton Schaefer has outlined an approach that
identifies three possible pathways of cross-
contamination and how each should be
handled:
1. Critical: Instruments that penetrate the
mucosa must be sterilized.
2. Semicritical: Instruments that touch the
mucosa should be sterilized.
3. Least critical: Surfaces touched during
treatment should be disinfected.
Using this as a guide, scalers, scalpels,
and other tissue-cutting instruments must be
sterilized. Other hand instruments and pliers
should be sterilized. Work surfaces, triplex
syringe handles, operating light handles,
and other environmental surfaces should be
disinfected.
STERILIZATION
Sterilization can be accomplished in one of
several ways. We will examine some of the most
common ways as they relate to an orthodontic
practice:
1. Steam sterilization (autoclave) uses
saturated water vapor at 240°F, with 15
pounds of pressure for 15 to 40 minutes. It
is a time-tested method that has little value
for orthodontists because it severely rusts
pliers and damages cutting edges.
2. Dry heat provides a relatively low-cost
sterilization procedure. It has two major
Orthodontic Diagnosis 243
drawbacks. It requires from 1 to 2 hours at
320°F for a complete cycle—far too long to
be practical for inventory considerations.
A lesser problem is the tendency for the air
to stratify and cause uneven temperatures
that result in a lack of sterility.
3. Unsaturated chemical vapor sterilization
(Chemi-clave) is a suitable method for
orthodontic instruments. It operates at
240° F, with 20 to 40 pounds of pressure
for 20 minutes. Because an unsaturated
vapor is used, rusting is not a problem. It
has a cycling time that is practical for an
orthodontic office. Its chief drawback is a
chemical odor that, although not harmful,
requires adequate ventilation.
4. Glutaraldehydes—alkaline, acidic, and
heat-potentiated—are effective sterilants
for instruments other than pliers, but only
when used for 6 to 10 hours. Again, this is
an impractical cycle time. Their best use is
for plastics and other heat-sensitive items.
Disinfection
A number of methods have been used in
orthodontic offices to disinfect instruments
and environmental surfaces. A 70 percent
alcohol solution has been the most widely
used even though the least effective. A 1
percent solution of sodium hypochlorite
(bleach) is very effective, but hard on the skin
and has an unpleasant odor. The iodophors
are the best choice. They are inexpensive,
have residual effectiveness, and are easy to
use and store. Their single drawback is the
light brown residue left on surfaces, which
disappears as the compound oxidizes. It does
not stain as iodine does. These solutions can
be made by diluting 1 oz povidone-iodine
preparation in 16 oz of 70 percent isopropyl
alcohol. They are also available in dry form to
be diluted with water. It should also be noted
244 Essentials of Orthodontics
that quaternary ammonium compounds are
no longer acceptable as disinfectants.
Clinical Procedures
Contaminated instruments are removed
from the operatory to the lab, rinsed under
running water, drained, and placed in an
ultrasonic cleaner for 5 minutes. A good
quality liquid detergent (1 capful per quart
water) is used as the cleaning solution. A
500 ml beaker with acidic solution is placed
inside the main container to clean instruments
contaminated with cement. The ultrasonic
tray and instruments are removed and rinsed
under running water to remove any detergent.
All instruments must be hand dried or placed
in an alcohol solution to remove any residual
water. This is a very important step. If the
instruments are moist when placed in the
chemiclave unit, the process changes to a
saturated vapor that causes rusting, particularly
in the box joints of pliers. After drying, the
instruments are loaded into the chemiclave
tray and the sterilizing cycle begun. Depending
on the size of the load, it will take from 5 to 15
minutes to reach the required heat, followed
by a 20-minute time cycle. The unit can be left
on all day to minimize start-up time between
runs. It is important that the instruments
not be left to heat in the chemiclave unit
between cycles. The vapor injected at the
beginning of the cycle will not condense on
the warm instruments, defeating the sterilizing
process. When the timed cycle is complete,
the chemiclave shuts off and an alarm sounds.
The unit can be depressurized and the door
opened immediately. The chemiclave’s
effectiveness should be monitored at least
monthly by placing a “spore test” strip in a load
of instruments to be sterilized. After the run,
the contents of the strip and a control can be
sent to a medical lab or returned to the supplier
for incubation and a report. Simple color
change strips can be used on a more frequent
basis to determine if sterilizing conditions have
been met, but they do not indicate that sterility
has been accomplished.
The instruments are emptied onto a clean
(not sterile) towel or paper surface. They can
now be handled with instrument tongs and
placed in bags or on trays and returned to the
operatory.
All environmental surfaces touched
during treatment are wiped with povidone-
iodine between patients. This includes light
handles, bracket tables and triplex syringes.
The povidone-iodine is dispensed with a spray
bottle. Four-by-four sponges are used as wipes.
All trays are cleaned in the same manner before
placing a new paper liner.
Handwashing is a vital link in the cross-
conta­mi­na­tion control program. Many antiba­
cterial soaps are marketed; the soap that
causes the least irritation to the hands should
be used. Repeated washing roughens the
hands, causing greater retention of bacteria.
Lather the hands for 10 seconds, then rinse
while rubbing briskly under running water for
10 seconds. Dry with paper towels that can be
dispensed without contaminating the supply.
Inventory
Inventory is sterilized as follows:
First, divide your operations into various
procedures—banding-bonding, appliance
removal, arch wire change, and routine
adjustment. Make a list of instruments used
for each procedure. Then, using a week of day
sheets, count how many times each procedure
was performed. Determine the average for
each instrument per day. Allow 30 minutes to
cycle a load and you can determine how many
of each instrument you need, depending on
how often you cycle them. Disposable vacuum

tips of different styles also cut down the load.
Plastic items such as cheek retractors are
sterilized overnight in glutaraldehyde. Prophy
heads are sterilized in the chemiclave unit.
Storage
There are two practical methods for storing
sterilized instruments. Use tray setups or place
the instruments in paper bags. Trays color-
coded by procedure can be stored in racks
or in an operatory cupboard. One pint liquor
bottle bags can be stamped with procedure,
the appropriate instruments sealed inside,
and the bags placed in drawers to be taken
out as needed.
Orthodontic Diagnosis 245
General Comments
Do not touch instruments in drawers. Have
them placed on the operating tray by an
assistant. Do not touch other surfaces until
hands have been washed. Bands and brackets
should be removed from boxes with cotton
forceps. Those that have been tried for fit and
rejected should be sterilized in glutaraldehyde.
Always use gloves or a finger cot, and face
masks. Wear protective glasses to prevent
spattering saliva from entering the eyes.
Remember, the efforts you are taking in sterili­
zation and disinfection is not only the well-
being of your patients, but also your career!
246 Essentials of Orthodontics
CHAPTER
Orthodontic
6 Treatment
Planning
GENERAL FACTORS IN
ORTHODONTIC TREATMENT
PLANNING
Treatment plan in orthodontics refers to the
outline of all the measures that can be best
instituted for a patient so as to offer maximum,
long-term benefits.
Patients seek orthodontic treatment for a
variety of reasons. The orthodontist should
plan out a treatment modality based on
thorough examination and sound diagnosis
in a systematic fashion. As no simple formula
cook-book approach exists, each case should
be assessed and a customized treatment plan
formulated to suit the individual patient.
SETTING-UP GOALS
From a patient’s point of view the basic need for
orthodontic treatment is improving in esthetics
and function. The orthodontist has an added
goal in the form of treatment stability. The
orthodontist should aim at providing quality
treatment that will remain relatively intact for
many years to come after the therapy is com­
pleted.
Most patients are satisfied once the an­ter­ior
teeth are straightened. But it is the responsibility
of the orthodontist to educate the patient on
the importance of moving teeth to positions
that stand for stability. The orthodontist should
not succumb to the temptation of terminating
the treatment as soon as the anterior teeth are
straightened as such treatment invariably results
in unstable dental positions that tend to relapse.
In many cases achieving all the three goals,
esthetics, function and stability may be quite
difficult. The orthodontist should strike a
balance in fulfilling the major esthetic desires
of the patient within the bounds of keys that
stand for stability.
ENLISTING THE TREATMENT
OBJECTIVES
The orthodontist should enlist the problems
that have to be attended to in a decreasing
order or priority. The problem list helps in
setting up objectives and possible solutions
to the problem.
While setting up the objectives, the patient’s
chief complaint and parental desires should be

given adequate weightage. Most patients seek
treatment to improve esthetics or function.
If the orthodontist considers certain other
objectives more important, for an overall
solution to the problem or to achieve long-
term stability, then adequate explanation
should be given to the patient.
The orthodontist must be realistic in setting
up objectives. They should reflect the patient’s
needs, the doctor’s own level of competence,
patient cooperation, etc.
Assessment of Growth Potential
The growth status of an individual is an
important factor that should be considered
while planning treatment.
A patient who is still growing presents
the orthodontist with numerous options
that exploits the individual growth potential.
The orthodontist can modulate growth
of the dentofacial structures, can guide
teeth into more favorable positions and can
undertake therapeutic procedures to prevent
and intercept malocclusions. In an adult, the
treatment options are limited to moving teeth
and surgical correction.
The growth status of the individual should
thus be determined prior to treatment planning
so as to carry out appropriate treatment
procedures.
Assessment of Etiologic Factors
The etiologic factors responsible for the
malocclusion should be determined and
adequate steps should be planned for their
elimination. The continued presence of
the etiologic factors can constitute a severe
limitation to the corrective procedures to be
undertaken and may also predispose to relapse
of a treated malocclusion. Comprehensive
orthodontic therapy should thus involve
removal of the cause. While this is possible in
Orthodontic Treatment Planning 247
cases where the etiology is obvious, it may not
be possible if the cause is elusive or unknown.
Planning Space Requirements
Most malocclusions require space to move
teeth to more ideal positions. The following
are some of the conditions that require space
for correction:
Correction of crowding : Correction of crowded
teeth requires space. The rule of thumb is that
for every mm of crowding, an mm of arch
length (space) is required.
Rotations: Rotated anterior teeth occupy
lesser arch length. Hence, space is required
for derotating these teeth which is calculated
by subtracting the distance between the
proximal surfaces of adjacent teeth from the
total mesiodistal width of the rotated teeth.
Leveling the curve of Spee: One of the common
features associated with skeletal malocclusion
is an increased curve of Spee. A flat arch
occupies more space than one with an excessive
curve of Spee. Some provision should thus be
made in the treatment plan to provide space for
leveling. Failure to do so result in proclination
that is unstable.
Correction of proclination: Retraction of pro­
cli­ned teeth requires space. In the case of a
spaced dentition, the existing spaces can be
made use of to correct the proclination. If the
dentition is not spaced, then alternate ways of
gaining space should be planned. For every 1
mm of reduction in proclination 2 mm of space
is required.
Molar correction: Presence of an unstable
molar relation at the end of treatment is a cause
of instability. The molars should be moved to
achieve good intercuspation.
Space for Anchor Loss
Most tooth movements are accomplished by
appliances that anchor on to certain other
248 Essentials of Orthodontics
teeth in the dental arch. Some amount of
move­­ment of the anchor teeth should be
expected. While trying to retract the anterior
teeth, the molars also invariably move forward
to a certain extent. This loss of space is called
anchorage loss. Studies have shown that in
extraction cases, almost 40 percent of the space
is lost by mesial movement of the posterior
anchor teeth.
The orthodontist should sum up the space
required to correct the malocclusion. Once the
total space requirement is known, the different
avenues to acquire the needed space should
then be explored. Some of the methods of
gaining space include:
i. Use of existing spacing
ii. Proximal stripping
iii. Expansion
iv. Extraction
v. Distalization
vi. Uprighting of molars
vii. Derotation of posterior teeth
viii. Proclination of anteriors.
Planning Anchorage
Anchorage consideration forms an important
part of the treatment planning exercise. All
efforts should be taken to minimize unwanted
tooth movements. Failure to plan anchorage
invariably results in failure of treatment
mechanics.
The anchorage demand for an individual
patient depends on the following factors:
Number of teeth being moved: The greater the
number of teeth being moved, the greater
would be the demand on anchorage.
Type of teeth: Tooth movement involving
multirooted posterior teeth offer greater strain
on anchorage then tooth movement involving
smaller teeth.
Type of tooth movement: Tipping tooth move­
ments are less demanding on the anchorage
than bodily tooth movements.
Duration of treatment: Complicated ortho­
dontic treatment of prolonged duration strain
the anchor teeth, resulting in greater anchor
loss.
Once the anchorage demand is known it
is possible to classify the case as maximum,
moderate or minimum anchorage demand
case. In case of maximum anchorage demand,
adequate reinforcement of the anchorage
should be planned.
Selection of Appliance
The next step in treatment planning is the
selection of appliance, which is based on a
number of factors.
Growth potential: Growing patients who
exhibit skeletal malocclusion should be treated
with appliances that modulate the growth so
that the existing skeletal problems solved or at
least not worsened.
Type of tooth movement: Removable appliances
can be used in patients requiring simple
tipping movements. Whenever bodily tooth
movements are required, fixed orthodontic
appliances should be used. Patients requiring
complicated tooth movements including
rotation, root movements, axial movements
are best treated with fixed appliances.
Oral hygiene: Maintenance of good oral
hygiene is an essential part of orthodontic
treatment. However, fixed appliances place an
additional demand as they pose greater risk of
caries, decalcification, plaque accumulation,
etc.
Cost: Removable appliance are by far less
expensive than fixed appliances as they take
less chair side time and use limited material
to fabricate.
Skill of the operator: Clinician should select
proper appliance for that patient rather than
fitting an appliance into the patient. Clinician
should not use an appliance which he is not
fully confident of handling. Clinician has to

regularly update the techniques which are
introduced.
Patients Expectations
In planning the treatment the patients
expectation out of orthodontic treatment is
most important. Patients expectations are
mainly concerned with esthetics. Sometimes
patients may be unrealistic, in those situations
realistic compromise should be arrived.
Planning Retention
It is now accepted that teeth once moved
tend to go back to their original position.
The potential for relapse is increased by the
presence of certain factors which are listed
as follows:
Stretched periodontal ligament: The stretched
gingival fibers are a frequent cause of relapse
in case of rotated teeth, since these fibers
take a long time to reorganize around their
now positions. Thus, adequate retention for
an appropriate period should be planned
depending on the type of malocclusion.
Unstable occlusion: Teeth placed in unstable
position at the end of orthodontic therapy
tend to relapse.
Continuation of growth pattern: Continuation
of the growth pattern that has caused a skeletal
malocclusion after orthodontic therapy results
in resurfacing of the malocclusion after
treatment.
Thus retention should be planned keeping
in mind all the factors that may predispose to
relapse. In addition to the use of retainers some
adjunctive procedures might have to be carried
out so as to aid in retention.
Re-evaluation
The treatment plan should be re-evaluated
at regular intervals during the active phase
of treatment so as to confirm whether the
Orthodontic Treatment Planning 249
objectives that were set up are being fulfilled.
Changes might have to be made in the
treatment plan if the desired changes are not
taking place or if unforeseen problems arise.
AGE FACTOR IN ORTHODONTICS
An important consideration in orthodontic
diagnosis and treatment planning is the age of
the patient. In addition age factors influence
the treatment mechanics and prognosis.
Diagnosis and Age
Diagnosis forms a vital part of successful
orthodontic therapy. In order to diagnose
abnormalities of the dentofacial complex, the
orthodontist should know what constitutes
normalcy. Normalcy in the dentofacial region
differs from age-to-age. There are certain
features of the developing dentofacial complex
which are normal in a child, however, if present
in an adult would constitute malocclusion.
These are referred to as self correcting
malocclusion or transient malocclusions.
Some of the transient malocclusions are:
i. Openbite seen in the gum pads
ii. Spacing in deciduous dentition
iii. First deep bite
iv. Flush terminal plane
v. Ugly duckling stage
vi. Second deep bite.
These malocclusions are considered
normal for that age and need no treatment
as they get corrected automatically as the age
advances.
The chronological age of the patient
may 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 sometimes
250 Essentials of Orthodontics
called is determined by studying a hand-wrist
radiograph. The hand-wrist region has a
number of carpal bones. The ossification and
union of these skeletal centers follow a definite
timetable and pattern. Thus by ascertaining
the status of these ossification centers and
comparing them with standards for different
skeletal ages, one can determine the exact
skeletal maturity status of an individual. The
dental age of an individual is determined by
assessing the stage of calcification and root
developing.
Considering the fact that orthodontic and
dentofacial orthopedic appliances are most
effective during growth, the assessment of
skeletal maturation in young patients is of
utmost importance for the success of therapy.
TREATMENT AND AGE
Early Treatment
Most orthodontist believe in the concept of
‘catch them young.’ Treating a patient at an
early age when dentofacial growth is active has
numerous benefits.
Scope for growth modification: Skeletal malo­
cclusion that occurs as a result of altered growth
direction and amount can be intercepted by
modulating further growth. These procedures
that modify growth should be initiated at an
early age before craniofacial growth ceases.
Scope for prevention and interception: One of
the advantages that early treatment offers is
the possibility of preventing or intercepting
a malocclusion. Even if the malocclusion
cannot be totally eliminated, its severity can
be reduced so that complex orthodontic
treatment involving extraction and surgery
can be minimized.
Harnessing natural growth forces: The human
dentition has a natural tendency to move in a
mesial and occlusal direction. These natural
tendencies can be used to guide the erupting
teeth to more favorable positions.
Minimizing psychological distress: Treatment
carried out at an early age avoids psychological
disturbances as a result of coping with a full
fledged malocclusion.
Late Treatment
Role of growth: Orthodontic treatment carried
out during adolescent or still later in adults
cannot make use of the growth potential.
Although working with growth potential has
numerous advantages as enlisted earlier, certain
maloc­clusions are best treated after growth
completion. Most skeletal malocclusions
indicated for orthognathic surgery are to be
treated after growth completion so as to avoid
recurrent growth changes associated with
continuation of abnormal growth pattern.
Limited treatment options: In a growing
patient, the orthodontist has a number of
patient, the orthodontist has a number of
options in his armamentarium that include
growth modulation, guidance of eruption,
use of natural forces, etc. However, in an adult
patient the treatment options are limited to
moving teeth and surgery.
Compromise on treatment objectives: In an
adult patient in whom growth has ceased,
it may not be possible to achieve all the
objectives of function, esthetics and stability
that represent ideal dentition and occlusion.
In many adult patients compromises might
have to be made in the treatment. While setting
treatment objectives for adult patients the
orthodontist should set goals that are realistic,
attainable and which strike the best possible

balance in function, esthetics and treatment
stability.
TOOTH MOVEMENT AND AGE
Vitality of Tissue
Ortho­dontic tooth movement is most effecti­vely
carried out in young patients. Young patients
exhibit increased vascularity and cellularity of
periodontal membrane and bone as compared
to older patients. Patients of younger age are
hence more responsive to orthodontic forces
which make it possible to move teeth faster.
Role of Growth
Most orthodontic and orthopedic corrections
are effectively carried out during the growth
period. This is due to the fact that younger
growing patients react more favorably to
orthodontic and orthopedic forces.
Although it is desirable to carry out orth­o­d­
ontic treatment at a younger age, it is nevertheless
possible to move teeth in older patients by
altering the force magnitude and duration.
Role of Apical Foramen
In an adult patient the apical foramen is
narrow. Force application during treatment
may pose a greater chance of nonvitality, root
resorption and ankylosis of teeth occurring. In
a young patient, the apical foramen is wider
thus there is lesser chance of pulpal damage.
Density of Bone
As adults exhibit greater density of bone,
orthodontic tooth movement is much slower.
YOUNG VERSUS ADULT PATIENTS
In recent times there has been an increase
in the number of adult patients who desire
Orthodontic Treatment Planning 251
orthodontic correction of their malocclusion.
Numerous differences exist between adult
orthodontics and orthodontics for the young
child. The following are some of the important
areas where the difference is seen:
Growth to Work With
One of the important differences in treating
a child and an adult is the fact that in a child
the orthod­ontist has growth to work with.
Most orthodontic and orthopedic treatment
is efficiently carried out using the growth
potential of the patient. In comparison, an
adult lacks growth. Thus the orthodontist
merely relies on tooth movement or surgery.
Diagnosis
Most of the routine diagnostic aids can be
used in both young as well as adult patients.
An adult patient shows greater possibility of
dormant pathosis, impaction, periodontal
problems, wear of dentition, faulty restoration,
bone loss, loss of tooth due to decay, etc. The
diagnostic exercise in an adult should hence
consider these factors as some of them may
hamper the success of the orthodontic therapy.
Appliance Selection
Younger patients who are growing can
benefit from orthopedic and myofunctional
appliances that help modulate growth in case
of abnormal growth amount and direction.
In an adult patient the options are restricted
to orthodontic tooth movement and surgery.
It is a fact that younger patients tolerate
most appliances and are not bothered by the
appe­arance of the appliance. In case of adults,
the appliance tolerance is much lesser than a
child. Adults are often bothered by the looks
of the appliance. In such patients, removable
appliances and fixed appliances that are more
esthetic or inconspicuous are advocated
whenever feasible.
252 Essentials of Orthodontics
Periodontal Problems
Presence of periodontal involvement and
bone loss is more common in an adult patient.
Periodontally involved teeth move more
readily and offer poor anchorage.
Patient motivation and cooperation: Most
adult patients seeking orthodontic therapy are
well-motivated as compared to children. Thus,
the orthodontist can expect more cooperations
in an adult patient.
Tissue vitality: The tissue vitality and respon­
siveness to force is much greater in a child than
in an adult patient. This is because of reduced
vascularity and cellularity in an adult patient.
Treatment objectives: In an adult patient,
many compromises might have to be made.
The three 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
objectives.
Treatment appreciation: Adult patients are
more appreciative of the treatment results than
a child patient.
PHASES OF ORTHODONTIC
TREATMENT
Broadly orthodontic treatment can be divided
into four phases:
1. Primary dentition: Preventive orthodontics.
2. Mixed dentition: Interceptive orthodontics.
3. Permanent dentition: Corrective orthodo­
ntics.
4. Postpermanent dentition: Surgical ortho-
dontics.
Treatment Planning in
Primary Dentition
The objectives in treatment during primary
dentition period:
i. To remove obstacles to normal growth
of the face and the jaws.
ii. To restore or maintain normal function.
Conditions to be treated
1. Anterior crossbite
2. Posterior crossbite
3. Space maintenance—space maintainers
4. Retained deciduous BA/AB which interfere
with eruption of permanent teeth
5. Habits that cause abnormal function
6. Occlusal equilibration
7. Openbite due to abnormal habits—habit
breaking appliances.
Contraindications
1. When there is no awareness that the results
will be sustained.
2. When better results can be achieved with
less effort at another time.
Treatment Planning in Mixed
Dentition
Reasons for treatment, any case may be
treated:
i. Provided treatment does not impede
normal growth.
ii. Provided that malocclusion cannot be
treated more efficiently in this permanent
dentition.
Conditions Treated
1. Loss of primary teeth—giving space
main­tainers.
2. Loss of space—giving space regainers.
3. Malocclusion that interferes with
normal development. Cause faulty
patterns of mandibular closure.
4. Extraction of supernumerary teeth.
5. Crossbites.
6. Correction of habits—habit breaking
appliances.
7. Oligodontia.

8. Spacing between incisors—if space
closure is indicated.
9. Class I with severe dental proclination.
10. Class II functional.
11. Class II dental.
Conditions that may be treated are:
1. Class II skeletal—maxillary prognathism,
mandibular retrognathism or combination.
2. Serial extractions.
3. Gross inadequacies of the apical base.
4. Class III skeletal due to maxillary retro­
gnathism, mandibular prognathism or
combinations.
Treatment Planning in
Permanent Dentition
All malocclusions possible to correct may be
taken up in permanent dentition.
Treatment planning in
postpermanent dentition
Cases requiring surgical treatment are treated
during this period.
LIMITATIONS IN ORTHODONTICS
Factors Related to the Patients
1. Limiting skeletal factors: Wherein there is
gross osseous dysplasias, e.g. when there is
severe maxillary prognathism it is beyond
the scope of orthodontic therapy.
2. Limiting dental factors: Where there is dis­
harmony between arch size and tooth size
variation, it is difficult to manage only by
orthodontic means.
3. Limiting neuromuscular factors: Where
there is an abnormal neuromuscular
factor as it is seen in retained infantile
tongue thrust pattern, it is difficult to treat
orthodontically.
Orthodontic Treatment Planning 253
Factors Related to the Dentist
1. Aptitude: To have a clear concept of right
or wrong, the identification of the one
best way to treat every case is a must to
encounter difficulties in orthodontics.
2. Undergraduate and postgraduate training
in orthodontics.
3. Experience: Adequate experience.
4. Attitude: Objective criticism of his own
clinical efforts.
5. Avoid adherence to poor methods. The
above few qualities are necessary for a good
orthodontist. Lacks of them are limitations.
Factors Related to the Nature
of Orthodontics
1. The nature of developmental oral biology.
2. Mechanical limitations related to orofacial
region.
3. Role of the patient in orthodontic therapy.
4. Paucity of adequate compromising
alternative treatments.
METHODS OF GAINING SPACE
The correction of malocclusions requires
space in order to move teeth into move ideal
locations. Space is required for correction
of crowding, retraction of proclined teeth,
leveling of steep curve of Spee, derotation of
anterior teeth and for correction of unstable
molar relation. The orthodontist is often faced
with the dilemma of how to obtain space
required for these corrections.
Some of the methods of gaining space
include:
1. Proximal stripping
2. Expansion
3. Extraction
4. Distalization
5. Uprighting of molars
254 Essentials of Orthodontics
6. Derotation of posterior teeth
7. Proclination of anterior teeth.
PROXIMAL STRIPPING (REPROX­
I­MI­­ZATION, SLENDERIZATION,
DISKING AND PROXIMAL
SLICING) (FIGS 6.1A AND B)
Proximal stripping is a method by which the
proximal surfaces of the teeth are sliced in
order to reduce the mesiodistal width of the
teeth. Although this procedure is routinely
carried out in the lower anteriors it can also
be done on the upper anteriors and buccal
segments of the upper and lower arches.
Indications for Proximal Stripping
1. Proximal stripping is usually indicated
when the space required is minimal, i.e.
0 to 2.5 mm. In these cases, it is possible
to avoid extraction of teeth by performing
reproximation.
2. If the Bolton’s analysis shows mild tooth
material excess in either of the arches, it
is possible to reduce the tooth material by
proximal stripping.
3. It can be undertaken in the lower anterior
region as an aid to retention.
Contraindications
1. Proximal stripping is not carried out in
young patients as they possess large pulp
A B
Figures 6.1A and B: Proximal stripping
chamber which increases the risk of pulpal
exposure.
2. Patients who are susceptible to caries or
those who have a high caries index.
Advantages of Proximal Stripping
1. It is possible to avoid extraction in border­
line cases where space requirement is
minimal.
2. A more favorable overbite and overjet
relation can be established by eliminating
tooth material excess in either of the
arches.
3. More stable results can be established
by broadening the contact area thereby
eliminating small contact points which can
clip and cause rotation of teeth.
Disadvantages of Proximal Stripping
The procedure of proximal stripping has a
number of drawbacks which include:
1. The stripping procedure creates roughened
proximal surface that attracts plaque.
2. Caries susceptibility is increased as part
of the enamel is removed, leaving behind
a roughened area.
3. Patients may experience sensitivity of teeth.
4. Improper procedure at the hands of inex­
perienced operators can result in alteration
of morphology of the teeth, creating an
unnatural appearance of the teeth.
5. Loss of contact between adjacent teeth may
result in food impaction.
Diagnostic Aids for Proximal Stripping
Arch perimeter analysis: Arch perimeter or
Carey’s analysis showing a tooth material
excess of 0 to 2.5 mm over the arch length is
a diagnostic criteria favoring reproximation.
Bolton’s analysis: Bolton’s analysis revealing
an excess of tooth material in either of the
arches is an indication to reduce tooth mat­

erial in that arch. Minimal interarch tooth
material discrepancies can also be corrected
by proximal stripping.
Intraoral periapical radiographs: It is advisable
to carefully analyze an accurately taken
intraoral periapical radiograph of the region.
This would give an idea of the enamel thickness
and a rough estimate of the amount of enamel
that can be removed from the proximal surface,
without exposure of the pulp.
Amount of proximal stripping: Not more than
50 percent of the enamel thickness should be
reduced by proximal stripping. Whenever,
reproximation is undertaken in a segment of an
arch, it is advisable to equally distribute them
over all the teeth.
Procedure of Proximal Reduction
Proximal stripping is carried out in one of the
following ways:
1. Use of metallic abrasive strips.
2. Safe sided carborundum disks.
3. Long thin tapered fissure burs.
Fluoride Application
The increased caries susceptibility after slend­
eri­­zation is managed by a thin comprehensive
fluoride program following the procedure.
EXPANSION
Expansion is one of the noninvasive methods
of gaining space. It is usually undertaken in
patients having constricted maxillary arch or
in patients with unilateral or bilateral crossbite.
Expansion can be skeletal or dentoalveolar.
Skeletal expansion involves splitting of the
midpalatal suture while dentoalveolar expan­
sion produces a dental expansion with no
skeletal change. Expansion is brought about
Orthodontic Treatment Planning 255
by various appliances that incorporate jack
screws or by use of springs.
An apparently complex yet relatively
sim­ple procedure in orthodontics is palatal
expansion. Its versatility is unique for despite
the many controversies surrounding it,
desirable results are achieved when used in
the appropriate situation by a skilled clini­
cian.
Expansion of the palate was first achieved
by Emerson C Angell in 1860. Palatal expansion
can be carried out in different ways which are
classified as rapid and slow.
Rapid Maxillary Expansion
Rapid maxillary expansion (RME) is also
known as rapid palatal expansion or split
palate. It is a skeletal type of expansion that
involves the separation of the midpalatal
suture and movement of the maxillary shelves
away from each other.
Emerson C Angell is considered Father of
rapid maxillary expansion. Angell, for the first
time in 1860, used a jack screw type of device
between the maxillary premolars in a 14-year-
old girl and achieved an increase in arch width
by 1/4 inch in 14 days. Walter Coffin in 1877
introduced a spring called Coffin spring for the
purpose of expanding the arch. These efforts
however, were not accepted by the orthodontic
community at that time.
It was the oral surgeons and ENT surgeons
who popularized this technique during the
early part of this century. ENT surgeons
used this technique in treatment of nasal
insufficiency and constricted nasomaxillary
complex with great success.
Korkhaus and Andrew Hass during
the 1950s, reintroduced rapid maxillary
expansion to the orthodontic community.
They popularized the concept with excellent
256 Essentials of Orthodontics
research publications on animals and humans
using a variety of techniques and methods.
Applied Anatomy
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 a 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 at its posterior and
superior aspects leaving the anterior and
inferior aspects free, which makes it vulnerable
for lateral displacements.
The intermaxillary and the interpalatine
sutures are collectively called the midpalatal
suture. Rapid maxillary expansion should
be initiated prior to the ossification of the
midpalatal suture. Various studies have
been done to ascertain the age at which the
midpalatal suture ossifies. Melsen reports that
the transverse growth of the midpalatal suture
continued up to 16 years in girls and 18 years
in boys. Most studies report a broad range of
ossification timetable, i.e. between 15 and 27
years. The sphenoid and the zygomatic bones
have a buttressing effect resisting midpalatal
suture opening.
Indications
Rapid maxillary expansion has been carried
out for dental as well as medical purposes. The
following are some of the indications for rapid
maxillary expansion:
1. Posterior crossbite associated with real
or relative maxillary deficiencies. A real
maxillary deficiency is associated with an
undersized or narrow maxilla. Relative
maxillary deficiency is characterized by
normal maxilla but oversized mandible.
2. Class III malocclusion of dental or skeletal
cause. Improvement is seen in both
anterior as well as posterior crossbites.
3. Cleft palate patients with collapsed maxill­
ary arch.
4. In cases requiring face mask therapy, RME
is used along with face mask to loosen the
maxillary sutural attachments so as to
facilitate protractions.
5. The medical indications for rapid palatal
expansion include nasal stenosis, poor
nasal airway, septal deformities, recurrent
ear and nasal infections, allergic rhinitis,
deviated nasal septum, etc.
Diagnostic Aids
The routine diagnostic aids such as case history,
clinical examination and study models are
useful in diagnosis. The midpalatal suture
can be visualized in a maxillary occlusal view
radiograph. These radiographs are also useful
during treatment to check for midpalatal split
and also to estimate the amount of maxillary
expansion achieved. PA cephalogram is another
valuable diagnostic aid in rapid maxillary
expansion procedures to estimate the amount
of expansion that has taken place.
Effects of RME
Though RME is essentially a dentofacial
orthopedic appliance used by orthodontists,
it finds application in other fields such as oral
surgery, ENT and plastic surgery.
Maxillary skeletal effect: The maxillary poster­
ior teeth are used as handles to apply a
transverse reciprocal force so as to open the
midpalatal suture. Since, the force employed
for the procedure is very high, not much
of orthodontic changes can be observed.
The appliance on activation compresses
the periodontal ligament and bends, the
alveolar process bucally and slowly opens

the midpalatal suture. The opening of the
midpalatal suture is fan-shaped or triangular
with maximum opening at the incisor region
and gradually diminishing towards the
posterior part of palate. This can be appreciated
in a post RME occlusal radiograph. Similar
fan-shaped or nonparallels opening is also
seen in the superior-inferior direction. The
maximum opening is towards the oral cavity
with progressively less opening towards the
nasal aspect.
According to Krebs, the two halves of
the maxilla rotate in the sagittal and coronal
planes. In the coronal plane the two halves
of the maxilla rotate away from each other.
The point at which the rotation takes place
is around the frontomaxillary suture. In the
sagittal plane, the maxilla is found to rotate in
a downward and forward direction.
Amount of expansion achieved: An increase
in maxillary width of up to 10 mm can be
achieved by rapid maxillary expansion. The
rate of expansion is about 0.2 to 0.5 mm per
day.
Effect on alveolar bone: The alveolar bone in
the area adjacent to the anchor teeth bends
slightly. This is due to the resilient nature of
the alveolar bone.
Effect on maxillary anterior teeth : The
appearance of midline spacing between the
two maxillary central incisors is the most
reliable clinical evidence of the maxillary
separation. The incisor separation is about half
of the distance the screw is opened. By three to
five months, the midline diastema closes as a
result of the transseptal fiber traction.
Effect on maxillary posterior teeth: The
maxillary posterior teeth are used as anchors
during rapid maxillary expansion. These teeth
show buccal tipping and are also believed to
extrude to a limited extent.
Effect on mandible: Most authors have
observed a downward and backward rotation
Orthodontic Treatment Planning 257
of the mandible following rapid expansion.
This is accompanied by a slight increase in the
mandibular plane angle. The reason attributed
for the mandibular rotation is the extrusion
and buccal tipping of the maxillary molars.
Effect on adjacent cranial bones and sutures:
Rapid maxillary expansion not only results
in opening of the midpalatal suture but also
has for reaching effects on adjacent cranial
structures. In addition to the effects on those
bones directly articulating with the maxilla,
bones of the cranium such as parietal and
occipital were also found to be displaced.
Effects of RME on nasal cavity: Following rapid
maxillary expansion an increase in intranasal
space occurs due to the outer walls of nasal
cavity moving apart. This increase in nasal
cavity width is maximum in the inferior region
of the nasal cavity and gradually decreases
towards the superior aspect. Similar gradient
is also found in an anteroposterior direction
with the greatest increase being in the anterior
region.
Airflow resistance is believed to reduce by
45 to 60 percent thereby improving nasal
breathing.
TYPES OF APPLIANCES USED
Numerous appliances have been used for
rapid maxillary expansion. Broadly they can
be classified as:
1. Removable applianced
2. Fixed appliances
a. Tooth borne
b. Tooth and tissue borne.
Removable Appliances
The reliability of these in producing skeletal
expansion is highly questionable. Although it
is possible to split the sutures using removable
plate, it nevertheless is unpredictable.
258 Essentials of Orthodontics

Treatment during the deciduous or early

mixed dentition is consi­dered more favorable
in producing appreciable skeletal effects.
A removable type of rapid maxillary
expansion device consists of a split acrylic
plate with a midline screw. The appliance is
retained using clasps on the posterior teeth.
The dis­a dvantages of a removable rapid
expansion appliance are the need for patient
cooperation and the difficulty in retaining the
plate inside the mouth.

Fixed Appliances
Appliances that are fixed onto the teeth are
more reliable and found to produce consistent
skeletal effects. These fixed rapid expanders
can be classified into tooth and tissue borne
appliances and tooth borne appliances. Two
of the commonly used tooth and tissue borne
appliances are:
1. Derichsweiler type
2. Hass type.
Examples of tooth borne appliances include:
1. Issacson type
2. HYRAX type.
Derichsweiler Type
The first premolars and the first molars are
banded. Wire tags are soldered onto the
palatal aspect of the bands. These wire tags
get inserted into a split palatal acrylic plate
incorporating a screw at its center.
Hass Type (Fig. 6.2)
The first premolar and molar of either side are
banded. A thick stainless steel wire of 1.2 mm
diameter is soldered on the buccal and lingual
aspects connecting the premolar and molar
bands. The lingual wire is kept longer so as
to extend past the bands both anteriorly and
posteriorly. These extensions are bent palatally
to get embedded in the palatal acrylic. The split
Figure 6.2: Hass appliance
palatal acrylic has a midline screw. The plate
does not extend over the rugae area.
Issacson Type
This is a tooth borne appliance without any acrylic
palatal covering. This design makes use of a
spring loaded screw called a MINNE expander
(Developed at the University of Minnesota,
Dental School).
The first premolars and molars are banded.
Metal flanges are soldered onto the bands on
the buccal and lingual sides. The expander
consists of a 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.
Hyrax Type (Fig. 6.3)
This type of appliance make use of a special
type of screws called HYRAX (Hygienic Rapid
Palatal Expander). The screws have heavy
gauge wire extensions that are adapted to
follow the palatal contour and are soldered to
bands on premolars and molars.

Figure 6.3: HYRAX appliance
Bonded RME
Most of the rapid maxillary expansion appli­
ances described earlier are banded appliances.
They incorporate bands on the first premolars
and 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 cap splints are made of silver
copper alloy. The acrylic splints are made of
polymethyl-methacrylate. A wire framework
may be adapted around the teeth to reinforce
the acrylic. These splints are bonded to teeth
using either glass ionomer or other bonding
adhesives, after adequate etching.
Description of a Typical Expansion
Screw
A typical expansion screw consists of an oblong
body divided into two halves. Each half has
a threaded inner side that receives one end
of a double ended screws. The screws has a
central bossing with four holes. These holes
receive a key which is used to turn the screws.
The turning of the screws by 90o brings about
a linear movement of 0.18 mm. The pattern
Orthodontic Treatment Planning 259
of threading on either side is of opposite
direction. Thus turning the screw withdraws
it from both sides simultaneously.
Activation Schedule
Various authors have advocated different
activation schedules to achieve the desired
results.
Schedule by Timms
For patients of up to 15 years of age 90o rotation
in the morning and evening. In patients over
15 years, Timms recommends 45o activation
4 times a day.
Schedule by Zimring and Issacson
In young growing patients, they recommend
two turns each day for 4 to 5 days and later
one turn per day till the desired expansion is
achieved. In case of nongrowing adult patients,
they recommend two turns each day for first two
days, one turn per day for the next 5 to 7 days
and one turn every alternate day till desired
expansion is achieved.
Treatment Evaluation during RME
Clinically, the most noticeable feature during
rapid maxillary expansion is the appearance of
a midline diastema. Studies by various authors
show that the amount of incisor separation
is roughly half the amount of jack screw
separation. But the amount of diastema should
not be taken as a reliable factor in estimating
the amount of expansion. Maxillary occlusal
radiograph and palatocephalogram are more
reliable in estimating the amount of maxillary
expansion.
Contraindications of RME
Some cases where RME is contraindicated are:
1. Single tooth crossbites.
2. In patients who are uncooperative, RME is
contraindicated as the appliance requires
260 Essentials of Orthodontics
frequent activation and maintenance of
good oral hygiene.
3. Rapid maxillary expansion is not carried out
after ossification of the midpalatal suture
unless it is accompanied by adjunctive
surgical procedures.
4. Skeletal asymmetry of maxilla and man­­
di­ble and adult cases with severe antero­
posterior skeletal discrepancies.
5. Vertical growers with steep mandibular
plane angle are usually a contraindication.
6. As the posterior teeth are used as anchors
to move the bones apart, the procedure
is not indicated in a periodontally weak
dentition.
Retention following RME
Failure to retain the expansion results in
relapse. Most authors recommend a retention
period of not less than 3 to 6 months. Issacson
recommends the use of the RME appliance
itself for the purpose of retention. The screw
should be immobilized using cold dure acrylic.
Alternatively, either a removable or fixed
retainer can be used.
Surgery as an Adjunct
Patients who exhibit unusual resistance to
separation of the palatine bones may require
surgical intervention. This usually occurs
in female patients over 16 years of age and
male patients over 18 years of age in whom
the midpalatal suture has ossified. Surgical
separation may also be required in patients
exhibiting increased circummaxillary rigidity
as a result of aging.
Maxillary expansion can be brought about
by surgery alone or by surgery along with
a rapid expansion appliance. The surgical
procedures usually carried out are:
i. Palatal osteotomy
ii. Lateral maxillary osteotomy
iii. Anterior maxillary osteotomy.
Clinical Tips for RME
1. Oral hygiene instructions should be given
to the patient and reinforced during the
procedure.
2. Orthodontic movement of the anchor
teeth should be avoided prior to rapid
maxillary expansion, as mobile teeth do
not offer adequate anchorage for palatal
split. Recently moved teeth tend to tip.
3. The patient should be trained to use the
key. The key should be tied to a sting and
the free end should be secured around
the patient’s wrist to avoid accidental
swallowing.
4. Maxillary occlusal radiographs should be
taken at regular intervals to monitor the
expansion.
5. The possible immediate effects of prem­
ature appliance removal include dizziness,
pressure at the bridge of nose, pressure
under eyes, blanching of soft tissues under
the eyes, etc. These symptoms may occur
on removal of the appliance for repair
or recementation. The patients should
therefore be kept seated and asked not to
stand immediately after appliance removal.
SLOW EXPANSION
According to the proponents of the slow
expansion, the results are more stable when
the maxillary arch is expanded slowly at a rate
of 0.5 to 1 mm per week. The forces generated
by such procedures are much lower, i.e. 2 to 4
pounds as against 10 to 20 pounds generated
during rapid maxillary expansion. Unlike in
rapid maxillary expansion where the treatment
is completed in 1 to 2 weeks, slow expansion
may take as much as 2 to 5 months.
Slow expansion has traditionally been
termed dentoalveolar expansion, although
some skeletal changes can be observed.
 Orthodontic Treatment Planning 261

Appliances Used for Slow Expansion

Jack Screws (Figs 6.4A to D)

The various jack screws incorporated in the

appliances described for rapid expansion can
be used for slow expansion, but with a more
spread out activation schedule. The screws
used for slow expansion have a smaller pitch
than those used in RME.

Coffin Spring (Fig. 6.5)

This appliance was designed by Walter Coffin
around the beginning of this century. It is remo­
vable appliance capable of slow dentoalveolar
expansion. The appliance consists of an
omegashaped wire of 1.25 mm thickness,
placed in the midpalatal region. The free ends
of the omega wire are embedded in acrylic
covering the slopes of the palate. The spring
is activated by pulling the two sides apart
manually. It can also be activated by using
A
B
Figure 6.5: Coffin springs
three prong pliers. Coffin spring is believed to
bring about dentoalveolar expansion. However,
use of this appliance in younger patients
is believed to bring about some amount of
skeletal expansion.
Quadhelix (Fig. 6.6)
One of the appliances used to expand a
narrow maxilla is the Quadhelix. It is said to
have evolved from the original Coffin loop.
The quadhelix incorporates four helices
that increase the wire length. Therefore, the
flexibility and range of action of this appliance
is more. The appliance is constructed using

Figures 6.4A to D: Jack screw expanders Figure 6.6: Quadhelix appliance

262 Essentials of Orthodontics
0.038 inch wire and is soldered to bands on
the first molars.
The quadhelix consists of a pair of anterior
helices and a pair of posterior helices. The
portion of wire between the two anterior
helices is called the anterior bridge. The wire
between the anterior posterior helices is called
the palatal bridge. The free wire ends adjacent
to the posterior helices are called outer arms.
They rest against the lingual surface of the
buccal teeth and are soldered onto the lingual
aspect of the molar bands.
The quadhelix can be used to expand a
narrow arch as well as to bring about rotation of
molars. It can be preactivated by stretching the
two molar bands apart prior to cementation or
by using three prong pliers after cementation.
The quadhelix beings about slow
dentoalveolar expansion. But when it is used
in children during the deciduous and early
mixed dentition periods, a skeletal midpalatal
splitting can be achieved.
Wilson’s ‘W’ Arch Appliance (Fig. 6.7)
Wilson devised a fixed type of expansion
appliance similar to quadhelix which looks like
“W”, and commonly used in mixed dentition.
Figure 6.7: Wilson’s ‘W’ arch appliance
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 as the quadhelix or the transpalatal arch
can be used along with fixed mechanotherapy.
EXTRACTIONS IN ORTHODONTICS
One of the frequently resorted methods of
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 orthodontic treatment.
Extraction of one premolar from each quadrant
of the jaw provides sufficient space to correct
the confronting problem (crowding and procli­
nation) without unduly hampering function
and esthetics. In addition, the location of
premolars in the arch is such that the space
gained by their extraction can be utilized for
correction in both the anterior as well as the
posterior segments of the arch.
It is not uncommon to extract molars or
lower anteriors during orthodontic therapy.
However, extraction of canines and upper
incisors is usually avoided.
The philosophy of extraction in conjunction
with orthodontic treatment is not new.
Establishment of normal functional occlusion
in balance with supporting structures occasi­
onally requires the reduction of one or more
teeth.
Most extractions are performed as part
of a general plan of treatment which also
involves the use of an appliance. The nature
of malocclusion and the age of the patient
may be important factors in deciding whether

or not to resort to extraction. Extractions
in ortho­d ontics include serial extraction
carried out as an interceptive procedure
and therapeutic extractions carried out as a
treatment procedure for gaining space.
Historical Background
To extract or not to extract has always been
and will always remain a controversy in
orthodontics. The great extraction controversy
of 1920s was based on two schools of thought
backing the philosophy of two pioneers in
orthodontics namely, Edward Angle and his
student Calvin Case. The former advocating
nonextraction while the latter recommend
extraction.
Edward Angle believed that an individual
was capable 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 thus necessitating
extractions.
By the late 1940s extraction was reintro­
duced into orthodontics by Charles Tweed who
observed that the post-treatment occlusion
was more stable in patients treated with
extraction of four first premolars. By the
early 1960s more than half of the orthodontic
patients had extractions of some teeth, usually
but not always first premolars.
need for Extraction
There are a number of circumstances that
necessitate extraction of teeth as a part of
orthodontic treatment they are listed as
follows:
Orthodontic Treatment Planning 263
Arch Length tooth Material Discrepancy
Ideally the arch length and tooth material
should be in harmony with each other. The
size of the dentition and arch 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.
In many cases the tooth material arch
length disproportion cannot be treated by
increasing the arch 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
discrepancy.
Correction of Sagittal interarch
Relationship
Abnormal sagittal malrelationship such as
Class II or Class III malocclusion may require
extraction of teeth to achieve normal sagittal
interarch relation. The extraction of teeth in
such cases helps in establishing normal incisor
and molar relationship.
It is a known fact that extraction of teeth
impairs the forward development of the
dental arches and the alveolar process. Thus,
extraction of certain teeth in Angle’s Class
II and Class III malocclusions improves
the sagittal relationship not only by tooth
movement but also by selective forward growth
impairment.
Angle’s Class I: These patients are characterized
by a normal sagittal interarch relation. Thus, it
is not advisable to discourage the development
of on edental arch more than the other. Hence
in Angle’s Class I cases, it is preferable to extract
in both the upper and lower arches.
Angle’s Class II: In most Class II cases the
upper dental arch is forwardly placed or the
264 Essentials of Orthodontics
lower arch placed back. Thus, by extracting
only in the upper arch it is possible to reduce
the abnormal upper proclination and also to
discourage the forward development of the
upper arch.
Angle’s Class III: There is lower arch crowding
or the molars are not in full Class III occlusion,
it may be necessary to avoid extraction in
upper arch and preferably only lower arch
extraction is required.
Abnormal Size and form of Teeth
Teeth that are abnormal in size or form may
necessitate their extraction in order to achieve
satisfactory occlusion. Examples of such
anomalies include macrodontia, severely
hypoplastic teeth, calcification and abnormal
crown morphology.
Skeletal Jaw Malrelations
Severe skeletal malrelationship of the jaws may
not be satisfactory treated using orthodontic
appliances alone. Surgical resective procedures
along with extraction may be required in such
cases.
Choice of Teeth for Extraction
The decision to extract teeth during
orthodontic therapy should be based on a
sound diagnostic exercise. The premolars are
the most commonly extracted teeth as part of
orthodontic treatment.
Extraction of Upper Incisors
The maxillary incisors are rarely extracted as
a part of orthodontic therapy. However, there
are certain condition when one or more of the
upper incisors may have to be sacrificed. The
following are some of them:
1. An unfavorably impacted upper incisor that
cannot be brought to normal alignment
within the arch.
2. A buccally or lingually blocked out lateral
incisor with good contact between the
central incisor and canine can be extracted.
3. If one of the lateral incisors is congenitally
missing, the opposite lateral may have to
be extracted in order to maintain the arch
symmetry.
4. A grossly carious incisor that cannot be
restored may have to be sacrificed.
5. Malformations of incisor crowns that
cannot be restored by prosthesis may
necessitate their extraction.
6. Trauma or irreparable damage to incisors
by fracture may indicate their removal.
7. An incisor with dilacerated root cannot be
efficiently moved by orthodontic therapy.
It is hence preferable to extract them.
Extraction of Lower Incisors
Extraction of lower incisors should as far as
possible avoided. The extraction of a lower
incisor to relieve lower anterior crowding is often
followed by the narrowing of lower intercanine
width, retroclination of lower incisors, deep bite
and reappearance of crowding. This leads to a
collapse of the lower arch.
The reduction in lower intercanine width
often leads to a secondary reduction in upper
intercanine width resulting in upper anterior
crowding. The extraction of a lower anterior
may thus have far reaching consequences that
are best avoided.
There are however some conditions when
a lower incisor may have to be extracted:
1. If one of the incisors is completely out of
the arch with good interdental contact
between the rest of the teeth.
2. A lower incisor that was traumatized, or
exhibiting severe caries, gingival recession
or bone loss may have a poor prognosis.
3. Presence of severe arch length deficiency
is often characterized by the presence

of fan-shaped flaring out of the lower
incisor crowns. In these cases it may not
be possible to flatten the lower anterior
segment by extraction teeth further distally
in the arch. Thus one of the incisors may
have to be extracted so as to improve the
crowding and axial inclination of rest of the
incisors.
4. In mild Class III cases with lower crowding,
one of the lower incisors may be extracted
to achieve normal overjet, overbite and to
relieve crowding.
Extraction of Canines
Canines are not frequently extracted as a part
of orthodontic treatment. The extraction of
canines is said to cause flattening of face,
altered facial balance and change in facial
expression. In addition, the contact produced
between the premolar and lateral incisor is
rarely satisfactory.
Some of the conditions under which
canines may have to be extracted are as
follows:
1. The canines develop far away from their
final location. In addition they have a
long path of eruption from their site of
development to their final position in
the oral cavity. Thus, the canines are
highly susceptible to ectopic eruption and
impaction. Such unfavorably impacted
canines or canines that have erupted in
unusual locations may have to be removed.
2. A canine that is completely out of the arch
with reasonably good contact between
the lateral incisor and first premolar is an
indication for its extraction.
3. Premature shedding of a deciduous canine
usually indicates the extraction of its fellow
on the opposite side of the arch to restore
symmetry.
4. In Class II cases if the lower deciduous
canines are shed early, the upper deciduous
Orthodontic Treatment Planning 265
canines should also be removed so as to
avoid worsening of the postnormally (Class
II tendency).
5. In Class III cases if the upper deciduous
canines are shed early, it may necessitate the
extraction of the lower deciduous canines to
avoid worsening of the prenormally (Class
III tendency).
6. Deciduous canines may be extracted as a
part of serial extraction procedure.
Extraction of First Premolars
The first premolars are the most commonly
extracted teeth extracted as part of orthodontic
treatment. The reasons for their extraction are
as follows:
1. Their location in the arch is such that the
space gained by their extraction can be
utilized for correction both in the anterior
as well as the posterior regions.
2. The contact that results between the canine
and second premolar is satisfactory.
3. The extraction of the first premolar leaves
behind a posterior segment that offers
adequate anchorage for the retraction of
the six anterior teeth.
The following are some of the indications
for first premolar extractions:
1. They are the teeth of choice for extraction
to relieve moderate to severe anterior
crowding of the upper or lower arch.
2. The first premolars are extracted for correction
of moderate to severe anterior proclination
as in a Class II division 1 malocclusion or a
Class I bimaxillary proclination.
Extraction of Second Premolars
The indication for extraction of second pre­
molars are:
1. The extraction of second premolars
instead of the first premolars results in the
anchorage of the anterior segment being
strengthened. Thus, an environment is
266 Essentials of Orthodontics
created that favors mesial movement of
the posterior teeth. The second premolars
are usually extracted to treat mild anterior
crowding. The remaining space can be
closed by controlled mesial movement of
the molars.
2. The second premolars are usually extracted
when 4 to 5 mm of anchorage loss is
deliberately desired.
3. Whenever the second premolars are
unfavorably impacted, it is preferred to
extract them rather than the first premolars.
4. If extractions are to be undertaken in
openbite cases, it is preferable to extract
the second premolars as their extraction
encourages deepening of the bite.
5. In case of grossly carious or deeply filled
second premolars, it is wise to extract them
and preserve the first premolars.
6. Early loss of a decidous molar may cause
forward movement of the first permanent
molar leaving inadequate space for the
second premolar to erupt. In such cases, the
second bicuspid erupts completely out of
the arch. Such a tooth may be indicated
for extraction.
Extraction of First Molars
The first molars are not commonly extracted
in conjunction with orthodontic therapy.
Extraction of the first permanent molars is
avoided for the following reasons:
1. The extraction of the first molar does not
give adequate space in the incisor region.
2. The extraction of the first molar results in
deepening of the bite.
3. The second premolar and second molar
may tip into the extraction space.
4. Mastication may be affected.
The indications for first molar extraction
are as follows:
1. Minimal space requirement for correction of
mild anterior crowding or mild proclination.
2. Grossly decayed molar or heavily filled
teeth.
3. Openbite cases can benefit from extraction
of first molar as there is a tendency for
the bite to deepen after extraction of first
molars.
Wilkinson Extraction
Wilkinson advocated extraction of all the four
first permanent molars between the ages of
8½ to 9½ years. The basis for such extractions
is the fact that the first permanent molars are
highly susceptible to caries. The other benefits
of extracting the first molars at an early age are:
1. Their extraction provides additional space
for eruption of the third molars. Thus,
impaction of third molars can be avoided.
2. In general, crowding of the arch is mini­
mized. Thus the other teeth are at a lower
risk of caries.
Wilkinson’s extraction has a number of
drawbacks. The following are some of them:
1. The extraction of first molars offers limited
space to relieve crowding.
2. The second bicuspids and second molars
rotate and may tip into the extraction
space.
3. The removal of the first molars deprives the
orthodontist of adequate anchorage for any
orthodontic appliance.
Extraction of Second Permanent
Molars
The extraction of second permanent molars
although not common is advocated for a
number of reasons as follows:
1. To prevent third molar impaction: The
removal of second molars has been
advocated for the prevention of lower third
molar impaction. The cases that benefit
from such extractions are those where
the third molars are upright or not tipped
mesially more than 30o. Upper second

molar extraction if carried out prior to
the eruption of the third molars, results in
satisfactory third molar position.
2. To relieve impaction of second bicuspids:
The premature loss of second deciduous
molars is usually followed by forward
drift of the first permanent molars leaving
inadequate space for the second bicuspids
to erupt. The extraction of second molar in
such cases may allow the distal movement
of the first permanent molars thereby
offering sufficient space for the second
premolars to erupt.
3. Lower incisor crowding: Very mild crowding
in the anterior part of the arch can be
relieved by extraction of the second molars.
Some authors suggest that extraction
of second molars minimizes anterior
imbrication and crowding.
4. 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.
5. Openbite cases: The extraction of the
second molars deepens the bite. Thus, they
can be considered in openbite cases.
Extraction of Third Molars
Extraction of third molars during orthodontic
treatment dies not yield space that can be used
for decrowding or reduction of proclination.
Third molars are extracted for other reasons
as follows:
1. Grossly impacted third molars that are
unable to erupt into ideal position are
usually extracted.
2. The erupting third molars have been
implicated to be the cause for late lower
anterior crowding. Although this theory
has not been confirmed it nevertheless may
have some role in lower anterior crowding.
Orthodontic Treatment Planning 267
3. Malformed third molars that interfere with
normal occlusion.
Balancing Extractions
Removal of a tooth from one side of a dental
arch results in a tendency for the rest of the
teeth to move towards the extraction space.
The teeth distal to the extraction space move
into the space while the teeth mesial to the
extraction space can also move distally into
the space. Thus, the midlines of the arch may
shift to the side of the extraction space. To
avoid such unesthetic shifts of the dental arch,
balancing extractions are advocated. Balancing
extractions refers to removal of another tooth
on the opposite side of the same arch.
Compensating Extractions
Compensating extractions refers to extraction
of teeth in opposite jaws. Compensating
extractions are carried out to preserve the
buccal occlusal relationships.
Enforced Extractions
These extractions are carried out because of
compulsion as in the case of:
i. Grossly decayed tooth
ii. Poor periodontal status
iii. Fractured tooth
iv. Unfavorably impacted tooth
v. Tooth in the line of fracture of jaws
vi. Any pathologies like cyst tumors, etc.
DISTALIZATION
One of the techniques that have gained
popularity in recent times is distalization of
molars. Distalization procedures are aimed at
moving the molars in a distal direction so as to
gain space. This approach is becoming popular
268 Essentials of Orthodontics
due to the fact that extraction can be avoided.
Distalization is usually indicated in patients
in whom the second permanent molars have
not erupted.
Distalization can be brought about by the
following methods:
Extraoral Methods
Headgears derive anchorage from the cervical
or cranial region be used to distalize molars.
The headgear assembly consists of a facebow
which is made of an inner and an outerbow.
The innerbow is fixed to buccal tubes present
on the molars. The outerbow is attached to
the extraoral head cap or neck strap. The use
of extraoral forces for distalization has the
following disadvantages:
i. Patient cooperation is essential for
timely wear of the appliance.
ii. The appliance is usually not worn conti­
nuously. Thus, they are intermittent in
their action resulting in prolonged treat­
ment time.
Intraoral Methods
In order to overcome the drawbacks of extraoral
methods, various intraoral appliances to
distalize molars were introduced. These
appliances are fixed on to the teeth and
therefore produce a continuous effect. The
following are some of the intraoral devices used:
Sagittal appliance: Molar distalization can
be brought about by removable appliances
incorporating jack screws. The appliance
consists of a split acrylic plate joined together
by a jack screw. The acrylic plate is sectioned in
such a say that the tooth that is to be distalized
is isolated, while the rest of the arch is used for
the purpose of anchorage.
These appliances are retained using Adam’s
clasp on the molars and premolars. The jack
screws are positioned in such a way that their
long axis is parallels to the occlusal plane as
well as the buccal surface of the molars. This
type of appliance can be used for distalization
of only one tooth at a time to avoid undue
strain on the anchorage.
Distalization using intraoral magnets: Intraoral
repelling magnets can be used to distalize
molars. These devices consist of repelling
magnets placed on the molar to be distalized
and the tooth anterior to it. The anterior
anchorage can be reinforced using a Nance
holding arch.
Use of open coil springs: Molar distalization can
be brought about using open coil nickel titan­
ium spring compressed between the molar and
the anterior segment. The anterior anchorage
is reinforced by use of a Nance button that rests
against the anterior part of the palate.
Pendulum appliance: It is an intraoral appliance
to distalize the molars that incorporates a
modi­fied Nance button for purpose of ancho­
rage. In addition, it consists of a stainless
wire with helix, the distal end of which is
inser­ted into a sleeve on the palatal aspect
of the molars to be distalized. Distalization is
pro­duced by opening the helix and forcefully
engag­ing the distal ends into the sleeves
(Fig. 6.8).
Figure 6.8: Pendulum appliance

UPRIGHTING OF MOLARS
Premature loss of second deciduous molar
or extraction of a second premolar can cause
mesial tipping of the first permanent molar. A
mesially tipped molar occupies more space
than an upright molar. Thus, by uprighting
these tipped molars, certain amount of space
can be recovered. Molars can be uprighted
using molar uprighting springs or some form
of space regainers.
DEROTATION OF POSTERIOR
TEETH (FIG. 6.9)
Rotated posterior teeth occupy more space than
normally placed posterior teeth. Derotation of
these teeth hence provides some amount of
these teeth hence, provides some amount of
arch length. Derotation is best achieved with
fixed appliances incorporating springs or
elastics using a force couple.
PROCLINATION OF ANTERIOR
TEETH
Proclination of a retruded anterior teeth results
in gain of arch length. This is usually indicated
Figure 6.9: Derotation of posterior teeth
Orthodontic Treatment Planning 269
in cases where the teeth are retroclined or in
those cases where protracting the anteriors will
not affect the soft tissue profile of the patient.
TREATMENT PLANNING IN
CLASS I MALOCCLUSION
Angle’s Class I malocclusion is characterized by
normal interarch relationship. These patients
exhibit a normal Class I molar relationship
where the mesiobuccal cusp of the maxillary first
permanent molar occludes with the mesiobuccal
groove of the lower first permanent molar. Class
I malocclusion can include irregularities of
individual teeth conditions of crowding, spacing,
as well as malocclusions in the vertical and
transverse planes such as openbite, deep bite,
and crossbite. Class I malocclusion accounts for
the majority of the cases encountered in ortho­
dontic practice.
CLINICAL FEATURES OF
CLASS I MALOCCLUSION
A patient with Angle’s Class I malocclusion
has normal buccal segment relationship. The
patient may have one or more of the following
features:
1. Crowding
2. Spacing
3. Long axial rotations
4. Anterior or posterior crossbites
5. Anterior openbite
6. Deep bite
7. Proclination
8. Retroclination
9. Bimaxillary protrusion.
Crowding (Fig. 6.10)
Crowding is another common manifestation
of a Class I malocclusion. Crowding usually
occurs as a result of disproportion between
270 Essentials of Orthodontics
Figure 6.10: Crowding
tooth size and arch length. A relative decrease
in arch length or an increase in tooth material
can result in crowding.
Etiology
The following are some of the causes of
crowding:
i. Arch length—tooth material discre­
pancies due to decreased arch langth
or an increase in tooth material.
ii. Presence of supernumerary or extra
tooth can result in a crowded arrange­
ment of teeth.
iii. Prolonged retention of deciduous teeth
can result in eruption of their successors
in an abnormal location. The presence
of an over retained deciduous tooth
along with its permanent counterpart
can cause crowding.
iv. Abnormalities in size and shape of teeth
can lead to a crowded arch. Teeth that
are abnormally large can predispose to
crowding.
v. Premature loss of a deciduous tooth
invariably results in drifting of adjacent
teeth into the extraction space. An
example of such a condition is the early
loss of second deciduous molars. In
these cases the first permanent molar
drifts into the extraction space. Thus,
the second pre­m olars do not have
adequate space to erupt and may do so
in an abnormal position predisposing
to crowding.
Diagnosis
Clinical examination should be carried out to
determine the extent and location of crowding.
Model analysis can be of use in determining
the amount of arch length tooth material
discrepancy. The possible cause for the
crowding should also be determined.
Treatment
Gaining space: Crowded teeth require space from
their normal alignment. On an average for every
1 mm of crowding, an equal amount of space
is required for correction. Thus, the amount of
crowding should be calculated and the means
of obtaining this space should be determined.
The various methods of gaining space include
proximal stripping, expansion, extraction,
molar distalization derotation and uprighting
of posterior teeth and proclination of anteriors.
Use of removable appliance: Once the provision
for space is made, teeth can be moved to
normal non-crowded positions by using
removable appliances that incorporate coil
springs, canine retractors, labial bows, etc.
Use of fixed appliances: Fixed appliances can
be used to treat crowding. Fixed appliances
that make use of multilooped archwires or
resilient nickel titanium wires are very effective
in correction of crowding.
Spacing (Fig. 6.11)
The presence of spacing between teeth is one of
the commonly seen manifestations of a Class
I malocclusion. The presence of spacing is a
normal feature in deciduous dentition and is
considered as a positive prognostic sign. In
the permanent dentition presence of spacing

Figure 6.11: Spacing
between the teeth is abnormal. The space can
be in a localized area or the entire arch can
exhibit spacing.
Etiology
The following are some of the causes of
spacing:
i. Generalized spacing usually occurs as
a result of disproportion between arch
length and tooth material. Presence of
increased arch length or a reduction
in tooth material can result in space
between the teeth. Conditions such as
oligodontia and microdontia therefore
lead to spacing.
ii. Spacing can occur as a result of alteration
in tooth morphology. Abnormal tooth
form such as peg-shaped laterals can
predispose to spacing.
iii. Deleterious oral habits such as thumb
sucking and tongue thrusting can cause
spacing in the anterior region.
iv. The presence of an abnormally large
tongue, a condition termed macroglossia
can predispose to spacing.
v. Presence of unerupted supernumerary
teeth or other pathology and cystic
lesions between the teeth can cause
spacing.
Orthodontic Treatment Planning 271
vi. Premature loss of permanent teeth can
cause spacing.
Diagnosis
The routing orthodontic diagnostic aids
should be employed for diagnostic purposes.
Model analysis can yield valuable information
about arch length tooth material discrepancy.
Radiographic examination should be carried
out to diagnose bony pathology or unerupted
teeth that may cause spacing.
Treatment
Removal of the etiology: The cause for the
spacing should be diagnosed and adequate
steps taken to eliminate the same. In case of
spacing as a result of abnormal pressure habits,
habit breakers may be employed to intercept
the habit. In case of presence of bony pathology
or cystic lesions, they should be eliminated.
Use of removable and fixed appliances:
Active removable appliances incorporating
labial bows can be used to close spaces that
occur in conjunction with proclination.
Fixed appliances along with elastic chains or
elastic thread are most effective in closure of
generalized spacing.
Use of crowns and prosthesis: Spacing occurs
as a result of microdontia can be treated using
suitable crowns. A condition that is quite
frequently encountered involving the maxillary
lateral incisors are peg-shaped or small teeth
with resultant spacing between the rest of the
teeth due to drifting. In such cases, the space
for the lateral incisor can be regained using
a removable appliance incorporating finger
springs or fixed appliances incorporating
an open coil spring. The space regained can
be used for a prosthetic crown on the lateral
incisor.
A similar condition is the absence of teeth
such as maxillary lateral incisors. In such
cases the rest of the teeth can be consolidated
272 Essentials of Orthodontics
together and a space left in the lateral incisor
region which can be replaced by a fixed or
removable partial prosthesis.
MIDLINE DIASTEMA
Midline diastema refers to anterior midline
spacing between the two maxillary central
incisors. It is one of the most frequently seen
malocclusions.
Causes of Midline Diastema
Transient Malocclusion
Midline diastema can occur due to a variety
of causes. It is very often seen as an incipient
malocclusion that is self correcting. Midline
spacing can occur as a part of the generalized
spacing seen in the deciduous dentition.
Midline spacing can occur during the mixed
dentition period associated with the eruption of
the permanent canines, i.e. ugly duckling stage.
Tooth Material Arch Length Discrepancy
A discrepancy in which the arch length exceeds
the tooth material can result in midline dia­
s­t ema. This includes conditions such as
missing teeth, microdontia, macrognathia and
extractions with resultant drifting of adjacent
teeth.
Abnormal Frenal Attachments
The presence of a thick and fleshy labial
frenum can give rise to a midline diastema.
This kind of frenal attachment prevents the two
central incisors from approximating each other
due to the fibrous connective tissue interposed
between them.
Pressure Habits
Habits such as thumb sucking, tongue
thr­u ­s ting, etc. also predispose to midline
diastema. These patients generally present
with proclination and generalized anterior
spacing.
Midline Pathology
Presence of an unerupted mesiodens and
midline pathologies such as cysts, odontomas
and tumors often cause spacing between the
maxillary central incisors.
Iatrogenic
Midline diastemas can occur when certain
therapeutic procedures are undertaken. The
appearance of midline spacing is an important
prognostic sign during rapid maxillary expan­
sion.
Racial Predisposition
The presence of midline spacing also has a
racial and familial background. The Negroid
race shows the greatest incidence of midline
diastema.
Diagnosis
A proper history and clinical examination is
necessary as in any other malocclusion. A
blanch test is performed to diagnose a fleshy
labial frenum. It is done by pulling the upper
lip outwards. Presence of a thick and fleshy
frenum is confirmed by the blanching of the
tissue in the incisive papilla region palatal to
the two central incisors. Presence of a notching
in the interdental alveolar bone as seen on a
radiograph is also diagnostic of a thick and
fleshy frenum. Midline radiographs are a
valuable aid in diagnosing midline pathology
that causes spacing. Tooth material arch length
discrepancies can be determined using model
analysis.
Treatment
The treatment of midline diastema is done in
three phases:

1. Removal of cause
2. Active treatment
3. Retention.
The first phase involves removal of the
etiology. Habits should be eliminated using
fixed or removable habit breakers. Unerupted
mesiodens should be extracted. Frenectomy
should be performed to excise a thick fleshy
frenum. Any midline pathology should be
treated as indicated.
The second phase consists of active
treat­ment. It can be done using removable
appliances or fixed appliances.
Removable Appliances to Treat
Midline Diastema
Simple removable appliances incorporating
finger springs or a split labial bow can be used
to close midline spacing. Finger springs can
be given distal to the two central incisors. An
alternative would be to use a split labial bow
made of a 0.7 mm hard stainless wire. The
labial bows are made to extend upto the distal
aspect of the opposite central incisor.
Fixed Appliances to Treat Midline
Diastema
Fixed appliances incorporating elastics or
springs bring about the most rapid correction
of midline diastema. Elastics can be stretched
between the two central incisors in order
to close the space. Elastic thread or elastic
chain can be used between the two central
incisors for the same purpose. An alternative
is to stretch a closed coil spring between
the two central incisors. ‘M’ shaped springs
incorporating three helices can be inserted
into the two central incisor brackets. This
spring is activated by closing the helices.
The third phase of treatment involves
retaining the treated malocclusion. Midline
diastema is often considered easy to treat but
difficult to retain. The key to its successful mana­
Orthodontic Treatment Planning 273
gement is the elimination of the etiologic factors
involved. Most orthodontists recommend
long-term retention using suitable retainers.
Since prolonged retention is indicated, it is
advisable to use lingual bonded retainers. The
other retainers that can be used include banded
retainers, Hawley’s retainers, etc.
Role of Cosmetic Restorations
Esthetic composite resins are generally used
to close midline diastema especially in adult
patients. It requires gradual composite build-
up on the mesial surface and stripping of the
distal surface of centrals and laterals in order
to achieve a natural shape and size of the teeth.
Prosthesis or Crown
Presence of peg-shaped laterals or teeth with
other anomalies of shape and size require
prosthetic rehabilitation. Missing teeth should
be replaced with fixed or removable prosthesis.
Rotations
Rotations are tooth movements that occur
around their long axis. Two types of rotations
are possible:
1. Mesiolingual or distobuccal rotation
2. Distolingual or mesiobuccal rotation.
Anterior teeth that are rotated occupy less
space and therefore, require additional space
for their derotation. Posterior teeth occupy
more space when they are rotated. Thus, space
is gained when posterior teeth are derotated.
Treatment
Space management: Treatment of anterior
tooth rotation requires space. Provision should
hence be made in the treatment plan for
obtaining the required space.
Use of removable appliances: Mild rotation
can be treated using a removable appliance
that incorporates a double cantilever spring
(z-spring) along with a labial bow.
274 Essentials of Orthodontics
Use of fixed appliances: Whenever, multiple
rotations of teeth are present, the appliance
should be a fixed appliance.
Derotation can be brought about by use of
derotation springs or elastics.
Retention of rotations: It is usually said that
dero­tations are easy to correct, but difficult to
retain. They have a very high-risk of relapse
due to the stretching of the supralveolar and
transeptal gingival fibers which readapt very
slowly to the new position. Thus, long-term
retention is req­u ired to achieve stability
of treatment. Pericision or circumferential
supracrestal fiberotomy is an adjunctive
surgical procedure where the gingival fibers
are incised to prevent relapse.
Anterior Openbite (Fig. 6.12)
Anterior openbite is a condition where there
is no vertical overlap between the upper
and lower anteriors. Anterior openbites are
esthetically unattractive particularly during
speech when the tongue is pressed between
the teeth and lips.
Classification
Anterior openbite can be classified as:
1. Skeletal anterior openbite
2. Dental anterior openbite.
Etiology
Anterior openbites can occur due to a variety
of hereditary and nonhereditary factors. The
A B
Figures 6.12A and B: Anterior and posterior openbite
following are some of the etiologic factors for
anterior openbites:
i. Abnormal habits such as thumb sucking,
tongue thrusting and mouth breathing.
ii. Inherited factors such as increased
tongue size, and abnormal skeletal
growth pattern of the maxilla and
mandible can also be responsible for
openbite malocclusion.
Clinical Features of Skeletal Anterior
Openbite
A patient having a skeletal anterior openbite
may reveal the following features:
i. Increased lower facial height.
ii. A steep mandibular plane angle.
iii. The patient may have a short upper lip
with excessive maxillary incisor expo­
sure.
iv. The patient often has a long and narrow
face.
v. Cephalometric examination may reveal
a downward and forward rotation of the
mandible. In some patients, an upward
tipping of the maxillary skeletal base can
be observed. Another common feature
is a vertical maxillary increase.
Clinical Features of Dental Anterior
Openbite
Dental anterior openbite do not present
with the skeletal complications mentioned
above. The following are the features of dental
openbite:
i. Proclined upper anterior teeth.
ii. The upper and lower anteriors fail to
overlap each other resulting in a space
between the maxillary and mandibular
anteriors.
iii. The patient may have a narrow maxillary
arch due to lowered tongue posture
associated with a habit.

Treatment of Anterior Openbite
Removal of the cause: Openbites that have been
diagnosed due to habits such as thumb sucking
or tongue thrusting, require their interception
using passive habit breaking appliances. The
habit breaker can be either a removable or
a fixed type of crib. Persistence of the cause
will offer a severe limitation in the corrective
procedures.
Myofunctional therapy: Skeletal anterior
openbites can be treated during growth
using functional appliances such as Frankel
IV or a modified activator. These appliances
incorporate bite blocks interposed between
the posterior teeth, that have an intrusive
action on the upper and lower posterior teeth.
Patients exhibiting a downward and backward
rotation of the mandible with increased
vertical growth, benefit from therapy using a
vertical pull headgear with chin cup if treated
during the mixed dentition period.
Orthodontic therapy: Mild to moderate open­
bites can be successfully managed using fixed
mechanotherapy in conjunction with box
elastics. This form of elastic application consists
of elastic that is stretched to extend between the
upper and lower anteriors. This brings about
extrusion of the upper and lower anteriors. It
may not be advisable to resort to this form of
therapy in severe skeletal openbites.
Surgical correction: Skeletal openbites in
adults are best treated by surgical procedures
involving the maxilla and the mandible.
Posterior Openbite (Figs 6.12A and B)
Posterior openbite is a condition characterized
by lack of contact between the posteriors when
the teeth are in centric occlusion. It mostly
occurs in a segment of the posterior teeth.
Causes of Posterior Openbite
Posterior openbites are usually a result of infra-
occlusion of a segment of the posterior teeth.
Orthodontic Treatment Planning 275
Factors that inhibit eruption of the posterior
teeth can result in posterior openbite. The
following are some of the causes of posterior
openbite:
i. Lateral tongue thrust or lateral tongue
posture.
ii. Ankylosed or impacted posterior teeth
that fail to erupt to normal occlusal level.
iii. Chronic cheek biting.
Treatment
The primary aim of treatment should be to
remove the cause. Lateral tongue spikes are a
valuable aid in control of lateral tongue thrust.
Cheek bumpers can be used in case of chronic
cheek biting. Once the habit is intercepted, a
spon­tan­eous improvement often follows. The
posteriors can be forcefully extruded. In cases
of posterior openbite due to infraocclusion of
ankylosed teeth; it is best treated by crowns
on posteriors to restore normal occlusal level.
CROSSBITE
Crossbite is a term used to describe abnormal
occlusion in the transverse plane. The term is
also used to describe reverse overjet of one or
more anterior teeth.
Graber has defined crossbite as a condition
where one or more teeth may be abnormally
malposed buccally or lingually or labially with
reference to the opposing tooth or teeth.
Classification of Crossbite
Crossbite can be classified based on location
as:
1. Anterior crossbite
i. Single tooth
ii. Segmental.
2. Posterior crossbite
i. Unilateral
ii. Bilateral.
276 Essentials of Orthodontics
Based on the nature of the crossbite as:
1. Skeletal crossbite
2. Dental crossbite
3. Functional crossbite.
Anterior Crossbite
This is a condition where a reverse overjet is
seen. The mandibular anterior teeth overlap
the maxillary anteriors. An anterior crossbite
can involve a single tooth or an entire segment
of the arch.
Posterior Crossbite
This refers to an abnormal transverse relation­
ship between the upper and lower posterior
teeth. In this condition, instead of the mandi­
bular buccal cusps occluding in the central
fossa of the maxillary posterior teeth, they
occlude buccal to the maxillary buccal cusps.
Thus, posterior crossbite occurs as a result of
lack of coordination in the lateral dimension
between the upper and the lower arches.
Posterior crossbites can be unilateral
involving one side of the arch or bilateral which
involves both the sides.
Buccal Nonocclusion
This is a form of posterior crossbite where the
maxillary posteriors occlude entirely or the
buccal aspect of the mandibular posteriors.
This condition is also called as scissors bite.
Lingual Nonocclusion
This is a form of posterior crossbite where the
maxillary posteriors occlude entirely on the
lingual aspect of the mandibular posteriors.
Skeletal Crossbite
Crossbites can occur as a result of malposition
or malformation of the jaws. This kind of
crossbite is usually inherited or may result
from defective embryological development.
They may present either in the anterior or the
posterior region. Skeletal anterior crossbites
are usually as a result of retarded maxillary
growth or a maxilla that is backwardly positi­
oned. It can also occur as a result of excessive
mandibular growth. Skeletal posterior
crossbites are usually characterized by a
narrow upper arch.
Dental Crossbite
Dental crossbites are a result of localized
disturbances such as extopic eruption of
permanent teeth or an over retained deciduous
tooth. Tooth material arch length discrepancies
can result in crowding and lingual positioning
of upper teeth leading to a dental crossbite.
Functional Crossbite
Presence of occlusal interferences can result in
deviation of the mandible during jaw closure.
This can present as an unilateral posterior
crossbite. Habitual forward positioning of the
mandible (pseudo Class III) may lead to an
anterior crossbite.
Etiology
Crossbites of the anterior or posterior region
can occur as a result of a number of causes
such as:
1. Persistence of a deciduous tooth often
results in palatal deflection of its erupting
successor causing single tooth anterior
crossbite.
2. Crossing and abnormal displacement of
one or more teeth as a result of arch length
tooth material discrepancies may cause
dental crossbites.
3. Presence of habits such as thumb sucking
and mouth breathing can cause lowered
tongue position. Thus the tongue no
longer balances the forces exerted on the
teeth by the buccal group of musculature.

This disharmony between the external
and internal muscle forces can result in
narrowing of the upper arch leading to
posterior crossbite.
4. Retarded development of maxilla in sagittal
as well as transverse direction can cause
crossbites in the anterior or posterior
region.
5. Narrow upper arch resulting from decre­
ased growth stimulation in the midpalatal
suture.
6. Collapse of maxillary arch as seen in
congenital defects such as clefts of the
palate.
7. Sagittal discrepancies of the jaws such as
a forwardly positioned mandible results
in the wider part of the mandibular arch
occluding with a narrower part of the
maxillary arch.
8. Unilateral hypo-or hyperplastic growth of
any of the jaws can cause crossbite.
Treatment of Anterior Crossbite
Use of tongue blade: Developing single tooth
anterior crossbites can be successfully treated
using a tongue blade. It can be used in case
there is sufficient space for the tooth to be
brought out. The tongue blade is a flat wooden
stick resembling an ice cream stick. It is placed
inside the mouth contacting the palatal aspect
of the tooth in crossbite. The blade is made to
rest on the mandibular tooth in crossbite which
acts as a fulcrum and the patient is asked to
rotate the oral part of the blade upwards and
forwards.
This is continued for 1 to 2 hours for about
2 weeks. Most developing crossbites that are
recognized by the dentist at an early stage can
be successfully treated by this form of therapy.
Catalan’s appliance or lower inclined plane:
Inclined plane constructed on the lower
anterior teeth can be used to treat maxillary
teeth in crossbite. The inclined plane can
Orthodontic Treatment Planning 277
be made of acrylic or cast metal and can be
designed to treat a single tooth in crossbite
or a segment of the upper arch in crossbite.
The inclined plane is designed to have a 45o
angulation which forces the maxillary teeth in
crossbite to a more labial position.
It is indicated when adequate space exists
in the arch for the alignment of the maxillary
teeth in crossbite. They are to be used only
in those cases where the crossbite is due to a
palatally displaced maxillary incisor.
The lower anterior inclined plane has a
number of disadvantages which include:
i. The patient encounters problems in
speech during the therapy.
ii. The patient has to put up with dietary
restrictions.
iii. If the appliance is used for more than 6
weeks it can result in anterior openbite
due to supra eruption of the posteriors.
iv. The appliance may need frequent
recementation.
Double Cantilever Spring (Z-spring)
Anterior crossbites involving one or two
maxillary teeth can be treated using a double
cantilever spring. In case of a deep overbite the
spring should be given along with a posterior
bite plane to help in jumping the bite. The use
of Z-spring is indicated only when there is
adequate space for labialization of the teeth
in crossbite is present.
Treatment of skeletal anterior crossbites during
growth period: Skeletal anterior crossbite
that occurs as a result of retropositioned
maxilla should be treated before termination
of growth by using a protraction face mask
(reverse headgear). These face masks helps in
protraction of the maxilla thereby normalizing
the skeletal crossbite.
Excessive mandibular growth leading
to skeletal anterior crossbites should be
intercepted by use of chin cup.
278 Essentials of Orthodontics
Fixed appliances for treatment of anterior
crossbite: Dental anterior crossbite involving
one or two teeth can be treated with fixed
appliances using multilooped archwires.
Treatment of Posterior Crossbites
Crossbite Elastics
Single tooth crossbite involving the molars
can be treated using elastics that are stretched
between the maxillary palatal surface and
mandibular buccal surface. These elastics
extend through the bite and are indicated if
sufficient space exists for moving the tooth
into the arch. These elastics are to be worn
day and night. The treatment should not be
continued for more than 6 weeks as the elastics
can extrude the teeth.
Coffin Spring
The coffin spring was designed by Walter
Coffin. It is a removable appliance that consists
of an omega-shaped wire of 1.25 mm diameter
placed in the midpalatal region. The free ends
of the omega are embedded in an acrylic
plate that covers the slopes of the palate. The
spring brings about dentoalveolar expansion.
However, it is capable of skeletal changes when
used in young patients.
Quadhelix Appliance
The quadhelix is a spring that consists of
four helices. The quadhelix is capable of
dentoalveolar expansion of the molar as well
as premolar region. It can bring about skeletal
expansion when used in younger patients.
Rapid Maxillary Expansion
Bilateral skeletal crossbite characterized by
a deep palate, nasal obstruction and narrow
maxilla can be treated by rapid maxillary
expansion where in the midpalatal suture is
split. This is done by using appliances that
incorporate screws that are to be activated at
regular intervals.
Removable Plates
Unilateral crossbites can be treated using
removable appliances incorporating jack
screws. The appliance consists of a split acrylic
plate, a jack screw and Adam’s clasps on the
posterior teeth to retain the plate. A labial bow
can also be incorporated into the appliance for
minor space closure and retraction.
The desired effect is achieved by sectioning
the plate in such a way that a small segment
and larger segment are formed. The two
segments are connected by one or more jack
screws. The smaller segment of the plate
adjoins the area in crossbite whereas the larger
segment is used for anchorage.
Fixed Appliances
Unilateral crossbites can also be treated
by using fixed appliances. Asymmetrically
expanded archwires can bring about correction
of crossbite.
Deep Bite
The maxillary dental arch being larger than the
mandibular arch allows the maxillary anteriors
to overlap the mandibular anteriors. This
overlapping of the mandibular teeth occurs in
both the horizontal as well as vertical direction.
The horizontal overlap is called overjet while
the vertical overlap is termed overbite. Thus
some degree of vertical overlapping or overbite
is a normal feature of dentition. However,
some patients present with excessive vertical
overlapping of the mandibular anteriors by
maxillary anteriors is called deep bite.
Deep bite is one of the frequently seen
malocclusions that can occur along with other
associated malocclusions. It is said to be one

of the most damaging malocclusions when
considering from the view point of the future
health of the masticatory apparatus and the
dental units.
Graber has defined deep bite as a condition
of excessive overbite, where the vertical
measurement between the maxillary and
mandibular incisal margins is excessive when
the mandible is brought into habitual or centric
occlusion. Deep overbite can be of two types:
Incomplete Overbite
It is an incisor relationship in which the lower
incisors fail to occlude with either the upper
incisors or the mucosa of the palate when the
teeth are occluded.
Complete Overbite
This is a relationship in which the lower
incisors contact the palatal surface of the upper
incisor or the palatal tissue when the teeth are
in centric occlusion.
Classification: Deep bite can be broadly
classified into two types:
Skeletal deep bite: Skeletal deep bites are
usually of genetic origin. This kind of deep
bite is caused by upward and forward rotation
of the mandible. The deep bite can be further
worsened by a downward and forward
inclination of the maxilla. These skeletal deep
bites are characterized by the presence of the
following features:
i. Patients exhibit a horizontal growth
pattern.
ii. The anterior facial height is reduced.
iii. A reduced interocclusal clearance (free
way space).
iv. A cephalometric examination reveals
that most of the horizontal cephalometric
planes such as mandibular plane, FH
plane, SN plane, etc. are parallel to each
other.
Orthodontic Treatment Planning 279
Dental Deep Bite
This kind of deep bite is characterized by the
absence of any skeletal complicating features
which are seen in skeletal deep bites. Dental
deep bites occur due to overeruption of
anteriors of infraocclusion of molar.
Deep bite due to overeruption of anteriors:
Dental deep bite associated with overeruption
of lower incisors is usually seen in Class II
malocclusion. The presence of an increased
overjet allows the lower incisors to overerupt
until they meet the palatal mucosa. These
patients hence exhibit an excessive curve of
Spee. The interocclusal clearance is usually
normal as the molars are fully erupted.
Deep bite due to infraocclusion of molars:
Deep bites can occur due to infraocclusion
of the molars. The presence of a lateral
tongue posture or lateral tongue thrust may
prevent the molars from erupting to their
normal occlusal level. It can also occur due
to premature loss of posterior teeth. Deep
bites caused by infraocclusion of molars are
characterized by the presence of partially
erupted molars (reduced crown height) and
large interocclusal clearance.
Diagnosis
The routine diagnostic aids such as clinical
examination, study models and lateral
cephalogram are used for the diagnostic
exercise. The orthodontist should be able to
differentiate skeletal deep bite from dental
deep bite. Lateral cephalometric analysis of the
skeletal pattern helps in diagnosing a skeletal
deep bite. These patients show a reduced
mandibular plane angle as well as a reduced
anterior facial height.
Factors to be considered in treatment of deep
bite: Deep bites are usually corrected by
intrusion of the anterior teeth or by extrusion
of the posterior teeth. The orthodontist should
280 Essentials of Orthodontics
decide which of the two modalities is indicated
for a given patient. There are certain factors
that help in deciding whether to intrude the
anteriors of extrude the molars.
Lip relationship: Patients with deep bite who
exhibit a short upper lip or a gummy smile
should be treated by intrusion of the anteriors.
In patients exhibiting normal upper lip with
only 2 to 3 mm of maxillary incisal edge
exposed, it is ideal to extrude the molars.
Consideration of vertical facial relationship:
Extrusions of one or more posterior teeth
usually result in downward and backward
rotation of the mandible. Thus an increase
in anterior facial height occurs. This can be
a benefit in treating skeletal deep bites with
excessive horizontal growth and upward
rotation of mandible.
Consideration of interocclusal space: The
average interocclusal space is 2 to 4 mm.
Presence of an increased interocclusal space
is an indication that the molars are not fully
erupted. In such cases, they can be extruded.
The orthodontist should not reduce a
normal interocclusal clearance by extrusion
of molars as it can result in fatigue of the
muscles of mastication which gets stretched
and predispose to relapse. The presence of a
normal interocclusal clearance is therefore an
indication for intrusion of the incisors rather
than extrusion of molars.
Treatment of deep bite: Deep bites can be treated
using removable, fixed or myofunctional
appliances.
Removable Appliances
Anterior bite plane (Figs 6.13A and B) is the
most commonly used removable appliance for
treatment of deep bite. The anterior bite plane is
a modified Hawley’s appliance with a flat ledge
of acrylic behind the upper anteriors. When the
patient bites, the mandibular incisors contact
A B
Figures 6.13A and B: Anterior bite plane
the bite plane thus disoccluding the posteriors
which are free to erupt.
The anterior bite plane consists of Adam’s
clasp on the molars which help in retaining the
appliance. A labial bow is also incorporated to
counter any forward component of force on the
upper anteriors. The height of the anterior bite
plane should be just enough to separate the
posteriors by 1.5 to 2 mm. As the posterior teeth
erupt, the height of the bite plane is gradually
increased.
Myofunctional Appliances
Deep bite cases diagnosed to be due to
infraocclusion of molars can be treated by
an activator designed and trimmed to allow
the extrusion of these teeth. The interocclusal
acrylic is trimmed gradually to encourage the
eruption of the posterior teeth. Bionator can
also be used for a similar purpose.
Fixed appliance therapy: Fixed orthodontic
appliances can be used to intrude the anteriors.
The following are some of the methods used in
fixed appliances to treat deep bite:
Use of anchorage bends: Anchorage bends are
given in the arch wire mesial to the molar tubes
so that the anterior part of the arch wire lies
gingival to the bracket slot. Thus when these
arch wires are pulled occlusally and engaged
 Orthodontic Treatment Planning 281

into the brackets, gingivally directed intrusive Incidence

forces is exerted on the incisors which reduced According to Moyers, any teeth can get
the deep bite. impa­cted but the most common teeth to get
Use of arch wires with reverse curve of Spee: involved are mandibular third molar, maxillary
Resilient arch wires that have been curved in a canines, mandibular and maxillary second
direction opposite to that of the curve of Spee premolars, mandibular canines, and maxillary
can be used to intrude anteriors. When these incisors.
arch wires are inserted into the molar tubes,
the anterior segment curves gingivally. This Etiology
anterior segment is forced occlusally into the Bishara summarized Moyer’s theory that
bracket slot resulting in an intrusive force on impaction is caused by:
the incisors.
Primary Causes
1. Rate of root resorption of deciduous teeth.
IMPACTED TEETH 2. Trauma to deciduous tooth bud.
(FIGS 6.14A AND B) 3. Disturbance in tooth eruption sequence.
4. Availability of space in the arch.
The ectopic eruption and impaction of teeth 5. Premature root closure.
are frequently encountered clinical problems. 6. Rotation of tooth buds.
Once the teeth is impacted it may lead to mild- 7. Canine eruption into cleft area in patient
to- moderate arch length discrepancy, and with cleft palate.
treating such cases puts the clinician into great
dilemma whether to extract or not to extract. Secondary Causes
The diagnosis and treatment of impaction 1. Abnormal muscle pressure
requires the expertise and cooperation of the 2. Febrile diseases
general dentist, the pediatric dentist, the oral 3. Endocrine disturbances
surgeon, the periodontist, and orthodontist. 4. Vitamin D deficiency.
As per orthodontic perspective, the The common causes for impactions are
common treatment approach is to make space usually localized and are results of any one, or
in the arch, expose the tooth surgically, fix an combin­ation of the following factors:
attachment to it, and exert an extrusive force i. Tooth size arch length discrepancies.
to bring the tooth into line of occlusion. ii. Prolonged retention or early loss of
The prognosis of orthodontic intervention deciduous teeth.
depends mainly on the position and inclination iii. Abnormal position of tooth bud.
of the impacted tooth. iv. Ankylosis.
v. Cystic or neoplastic formations.
vi. Dilacerations of the root.
vii. Fibrous gingival tissue.
viii. Sclerotic bone.
ix. Iatrogenic origin.
x. Idiopathic condition with no apparent
A B
cause.
Figures 6.14A and B: Impaction
282 Essentials of Orthodontics

Sequelae Periapical Films

Shafer has suggested the following sequelae
for impaction:
1. Labial or lingual malpositioning of impa­
cted tooth.
2. Migration of adjacent teeth and loss of arch
length.
3. Internal and external resorption of impa­
cted as well as adjacent teeth.
4. Dentigerous cystal formation.
5. Infection with partially erupted teeth lead­
ing to referred pain.
6. Functional problems.
7. Esthetic problems.
The presence of impacted teeth may cause
untoward complications and these potential
complications emphasize the need for close
observation of the development and eruption
of the teeth during routine periodic dental
examination of the growing child.
Diagnosis
Successful treatment of the impacted tooth
is dependent on careful evaluation of case,
localization of its position and angulations in
relation to jaw bases.
The diagnosis of impaction is based on both
clinical and radiographic examinations.
A single periapical film provides the clinician
with a two-dimensional representation of
the dentition. It would relate the tooth to the
neighboring teeth both mesiodistally and
superainferiorly. To locate the position of the
tooth buccolingually, a second periapical film
should be obtained by one of the following
methods:
Tube Shift Technique or Clark’s Rule
(Fig. 6.15)
Two periapical films of the same area are
taken with the horizontal angulation of the
cone changed when the second film is taken.
If the object in question moves in the same
direction as the cone, it is lingually positioned.
If the object moves in opposite direction, it is
buccally positioned.
Buccal Object Rule
If the vertical angulation of the cone is changed
by approximately 20° in two successive peri­

Clinical Evaluation
It has been suggested that the following clinical
signs might be indicative of impaction:
i. Delayed eruption of permanent teeth.
ii. Prolonged retention of deciduous te­
eth.
iii. In case of canine, absence of labial bulge
and presence of palatal bulge.
iv. Mesial and distal tipping or migration
of adjacent teeth.

Radiographic Evaluation
Various radiographic techniques can help in
evaluating the position of impacted teeth. Figure 6.15: Tube shift technique

apical films, the buccal object will move in the
direction opposite the source of radiation. On
the other hand the lingual object will move in
the same direction as the source of radiation.
Occlusal Films
An occlusal film also helps in determining the
buccolingual position of the impacted tooth in
conjunction with periapical films.
Panoramic Radiographs
Panoramic radiograph helps in visualizing
the entire structures in one film and also
help in determining the position of the tooth
mesiodistally.
Computed Tomography
Computed tomography is suggested in cases
where conventional radiograph does not give
in depth analysis, and actual relationship
between the impacted tooth and roots
of adjacent teeth and also in cases when
anatomic situation is complexes, for instances
in cases of multiple impactions combined
with supernumerary teeth or congenital
abnormalities.
The proper localization of impacted
tooth plays a crucial role in determining the
feasibility of, as well as the proper access to, the
surgical approach, and for the proper direction
of application of orthodontic forces.
Management
Each patient with an impacted tooth must
undergo a comprehensive evaluation of
malocclusion. The clinician should consider
various treatment options available for the
patient such as:
i. Extraction of the impacted tooth and
movement of adjacent teeth in its
position.
ii. Autotransplantation of the impacted
tooth.
Orthodontic Treatment Planning 283
iii. Prosthetic replacement of the impacted
tooth, either with crown and bridge or
with an implant.
iv. Surgical exposure of the impacted tooth
and orthodontic treatment to bring
the tooth into the line of occlusion
(guidance of eruption).
As in preference to orthodontic context, it
is advisable for the conservative management
or impacted tooth and ideal line of treatment
is surgical exposure of impacted tooth and
guiding its eruption. Once we decide for
guidance of eruption, the important aspect is
how to achieve sufficient space in the arch for
proper alignment of the impacted tooth. It can
be achieved by:
1. Extraction of succedaneous tooth or some
other tooth and alignment of the impacted
tooth.
2. Molar distalization or expansion (non-
extraction approach) and alignment of
impacted tooth.
Creating space in the arch prior to disim­
pacting the tooth is recommended for two
basic reasons, first nonavailability of space
in the arch leads to failure of eruption. And
secondly, the edentulous space in the arch
provides an adequate zone of attached gingival
to act as a donor site for a partial thickness
apically or laterally positioned flap.
Once we achieve sufficient space in
the arch, the next important step is how to
surgically expose the tooth and what should
be the mode of attachment and traction.
Surgical Exposure
The impacted tooth should be surgically
exposed after careful evaluation of its position,
angulation, amount of attached gingival
available and feasibility of access.
Gaulis and Joho have mentioned two basic
types of surgical procedure used for exposing
impacted tooth.
284 Essentials of Orthodontics
1. Closed eruption: In which a full thickness
mucoperiosteal flap is raised and crown of
the tooth is exposed, an attachment is fixed
to it, and the flap is sutured back over the
crown leaving only twisted wire passing
through the mucosa to apply orthodontic
traction.
2. Open eruption: Here a punch incision is
made on the crown of a tooth to make a
window and a cemented pack is placed
on it. Other method is to raise a partial
thickness flap associated with apically
repositioned or lateral repositioned flap,
pedicle graft, or when necessary, a free
gingival graft.
According to Johnston, Gaulis and Joho, in
all cases of palatally impacted tooth a closed
eruption philosophy should be undertaken;
while in case of labially impacted tooth an
open eruption approach with repositioned
mucoperiosteal flap should be performed to
avoid any future mucogingival problem.
Methods of Orthodontic Attachment
Different methods of orthodontic attachment
to impacted tooth have been suggested, such
as:
1. Lasso technique.
2. Polycarbonate crown.
3. Thread posts.
4. Bonded brackets.
5. Magnets.
Bonding of a brackets using self cure, light
cure or acid etch primer is an universally
accepted approach for disimpacting the tooth
and aligning it into the arch. The mode of
traction or the force can be applied by using
either of the following:
1. Ligature wire
2. Elastic threads
3. Elastomeric chain
4. Coil springs
5. Niti arch wires
6. Ballista springs
7. Kilroy springs
8. Cantilever spring.
Regardless of material used, the direction
of the applied force should initially move the
impacted tooth away from the roots of the
neighboring teeth.
In addition, following considerations
should be taken into account:
i. The use of light force to move the
impacted tooth, no more than 50 to 70
gm.
ii. Availability of sufficient space in the arch
for the impacted tooth.
iii. Maintenance of space created.
iv. Use of rigid base arch wire to resist
deformation by force applied to it as the
canine is extruded.
Retention
After alignment of the impacted tooth, a
fiberotomy or a bonded fixed retainer should be
considered to minimize or to prevent rotational
relapse, before the appliances are removed.
Clark suggested that, after alignment of palatally
impacted tooth, lingual drift can be prevented by
removal or a halfmoon shaped wedge of tissue
from the lingual aspect of the tooth.
TREATMENT PLANNING IN
CLASS II MALOCCLUSION
According to Angle’s classification as Class II
malocclusion indication that the mandibular
arch is in a distal relation to that of the maxilla.
Class II malocclusion is characterized by a
Class II molar relation where the distobuccal
cusp of the upper first permanent molar
occludes in the buccal groove of the lower first
permanent molar. It can occur in two main
forms—Class II division 1 and division 2. The

only similarity that both these forms exhibit is
the Class II molar relation.
CLASS II DIVISION 1
MALOCCLUSION
Class II division is a condition exhibiting Class
II molar relationship with proclined maxillary
anterior teeth.
Clinical Features
i. The patient exhibits a Class II molar
relation. The molar relation can vary
from an end-to-end molar to one that
is full fledged Class II.
ii. The classical feature of a Class II
division malocclusion is the presence
of proclined maxillary anteriors with
resultant increased overjet.
iii. The patient exhibits a convex profile.
iv. Due to proclined upper anteriors, the
lower anterior teeth fail to make contact
with the palatal surface of the upper
anteriors. Thus they are free to erupt
leading to an increased overbite and
excessive curve of Spee.
v. The patient may have a short hypotonic
upper lip. In addition the patient may
place the lower lip against the palatal
surface of the upper incisors. This is
called lip trap. The presence of a short
upper lip along with lip trap increases
the tendency for the upper anteriors to
procline.
vi. Patients often lack an anterior lip seal
due to the short upper lip. Restoration
of normal lip seal is essential to maintain
the teeth in their corrected position.
vii. Most Class II division 1 cases exhibit
abnormal muscle activity. They exhibit
abnormal buccinator activity leading to
Orthodontic Treatment Planning 285
a constricted, narrow upper arch which
predisposes to posterior crossbite. A
hyperactive mentalis activity is another
common finding in Class II division 1
malocclusion.
viii. Class II division 1 malocclusion can
sometimes be associated with proclined
lower anteriors. This is a natural
compensation that has taken place to
reduce the overjet.
Skeletal Features
A class II malocclusion may be complicated by
the presence of abnormal skeletal relationship
of maxilla and the mandible. The abnormal
skeletal features most often found are:
1. Maxillary prognathism
2. Mandibular retrognathism
3. Combination of maxillary prognathism and
mandibular retrognathism.
Etiology
Class II malocclusion can occur due to a variety
of causes. Broadly the etiologic factors can be
classified as:
Prenatal Factors
Hereditary: The size, position and relationship
of the jaws are to a large extent determined
by the genes. Thus Class II malocclusion
exhibiting skeletal anomalies such as a
prognathic maxilla or a retrognathic mandible
can be due to hereditary cause.
Teratogenesis: Administration of certain drugs
during pregnancy can result in perverted or
abnormal development. The drugs that are
capable of such an effect are called teratogens.
Irradiation: Radiation exposure of a pregnant
mother is another cause of altered development
of the dentofacial complex.
Intrauterine fetal posture: One of the factors
that seem to play a role in molding the
286 Essentials of Orthodontics
craniofacial region is the intrauterine fetal
posture. Abnormal posture such as hands
across the face is found to affect mandibular
growth.
Natal Factors
Trauma can sometimes be induced by
improper forceps application during delivery.
This results in trauma to the condylar region.
The temporo­man­­dibular joint is such cases
can get ankylosed or fibrosed leading to under
development of the mandible.
Postnatal Factors
There are a number of conditions that can
influence the normal development of the
dentofacial complex. The following are some
of them.
i. Traumatic injury to the mandible and
temporomandibular joint.
ii. Long-term irradiation therapy of the
skeletal craniofacial region.
iii. Infectious conditions such as rheu­
matoid arthritis can influence mandi­
bular growth.
iv. Abnormal function such as oral
respiration, abnormal swallowing and
habits such as thumb sucking prevent
normal muscle activity. These patients
have a low tongue position leading to
unrestrained activity of the buccinator
group of muscles.
Treatment Objectives
In Class II division 1 malocclusion, the major
treatment objectives are to relieve crowding
and irregularity of the teeth and to establish
stable incisor and molar relationship. The
following are the treatment objectives:
i. Reduction of overjet.
ii. Reduction of overbite.
iii. Correction of crowing and local irregul­
arities.
iv. Correction of unstable molar relation­
ship.
v. Correction of posterior crossbites if any.
vi. Normalizing of musculature.
Treatment of Skeletal Class II
Malocclusion
There are three basic approaches to the
treatment of Class II division 1 malocclusion
they are:
Growth Modification
Class II division 1 malocclusion are often
complicated by the presence of underlying
skeletal abnormalities. Most often maxillary
prognathism or mandibular deficiency occur.
These abnormal skeletal patterns can be
intercepted by means of functional and
orthopedic appliances to reduce the severity
of the skeletal relationships. These treatment
procedures are usually carried out during the
mixed or early permanent dentition period
prior to the cessation of growth.
An important prerequisite for these growth
modification procedures is to accurately
diagnose the underlying skeletal discrepancy.
Analysis of lateral cephalograms can help
establish the skeletal malrelationship.
Correction of mandibular deficiency: Class
II malocclusion complicated by mandibular
deficiency or retrognathism is treated during
myofunctional appliances such as activator or
functional regulator. In case the patient is at
the end of the growth period, fixed functional
appliances like Herbst appliance, or Jasper
Jumper is indicated.
Correction of maxillary prognathism: Class
II malocclusion exhibiting maxillary progn­
athism can be intercepted by the use of
facebow with headgear to restrict further
maxillary growth.
In some patients, Class II malocclusion is
complicated by the presence of both maxillary

prognathism as well as mandibular deficiency.
In such patients an appliance such as activator
with headgear is used to restrict maxillary
growth and promote mandibular growth.
Camouflage
In patients who are beyond growth, it is not
possible to undertake growth modification
procedures. Thus the underlying skeletal
discrepancy can be camouflaged by ortho­
dontic tooth movement. This is often done by
extraction of certain teeth and moving the rest
of the teeth into the space created.
Surgical Correction
In patients exhibiting severe skeletal mal­
relationship, surgery may be the ideal treatment
modality. Based on the underlying skeletal
pattern a maxillary set back or a mandibular
advancement is undertaken after the completion
of growth.
Role of Extraction
Based on the severity of the malocclusion,
the patient can be treated by a nonextraction
approach or by extraction of some teeth. In mild
Class II division 1 malocclusion exhibiting upper
anterior spacing it may be possible to reduce
the overjet without extraction of teeth. But most
cases may require the extraction of certain teeth
in both the upper and lower arches.
Space requirement in the upper arch is
essentially to reduce the overjet, over bite,
and to correct minor local irregularities of
teeth. Extraction in the lower arch may be
necessitated to correct unstable molar relation,
correction of crowding, deep bite and minor
local irregularities.
The teeth that are most frequently extracted
are the first premolars. In case of a well-aligned
lower arch with a Class II molar relation with
excellent intercuspation, it is possible to
reduce the overjet and obtain stable results
Orthodontic Treatment Planning 287
by extracting first premolars only in the upper
arch. In case space is required in the lower arch
to correct unstable end on molar relation or
lower crowding, rotations or excessive proclin­
ation, both upper and lower first premolars are
to be extracted.
In minimum anchorage cases, where the
space requirement is not much, the second
premolars can be extracted to encourage
mesial movement of the buccal segment.
Correction of Deep Bite and Crossbite
Class II malocclusion can be associated with
anterior deep bite. This can be treated in the
following ways:
i. Use of removable anterior bite planes to
encourage vertical development of the
posterior dentoalveolar segments.
ii. By using fixed appliances to intrude the
lower and upper anteriors.
Crossbites are a common feature of Class II
division 1 malocclusion. They occur as a result
of the following factors:
i. Abnormal buccinator muscle activity
due to lowered jaw and tongue posture
can cause constriction of the maxillary
arches.
ii. If the mandible is brought forward by
use of functional appliances the broader
segment of the mandible is made to
occlude with the narrower segment of
the maxillary arch leading to a posterior
crossbite.
Crossbites are treated using appliances
incorporating screws or springs that expand
the maxillary arch.
CLASS II DIVISION 2
MALOCCLUSION
The Class II division 2 malocclusion is a
condition characterized by a Class II molar
288 Essentials of Orthodontics
relationship with retroclined upper centrals that
are overlapped by the lateral incisors. Variations
of the classical type include retroclined centrals
as well as lateral incisors and very rarely include
retroclined canines as well.
Retroclination of upper incisors in a Class
II division 2 malocclusion is usually a natural
dentoalveolar compensation for a Class
II skeletal pattern in order to decrease the
overjet.
Clinical Features
Mild forms of Class II division 2 malocclusion
may be perfectly acceptable with regard to
function as well as facial appearance. In severe
cases, the bite is often very deep and poses the
risk of periodontal trauma in the upper palatal
and lower labial aspects. The following are the
features of Class II division 2 malocclusion:
i. Molars in distoocclusion.
ii. Retroclined central incisors and rarely
of other anteriors as well.
iii. Deep overbite.
iv. Pleasing straight profile.
v. Broad square face.
vi. Backward path of closure.
vii. Deep mentolabial sulcus.
viii. Absence of abnormal muscle activity.
Treatment Objectives
The treatment objectives include:
i. Relief of gingival trauma.
ii. Correction of incisor relationship.
iii. Relief of crowding and local irregularities.
iv. Correction of buccal segment relation­
ship.
The role of extraction in the treatment and
correction of the buccal segment relationship
is essentially the same as was described for
Class II division 1 malocclusion. The deep
anterior over bite and retroclination that is
characteristic of division 2 malocclusion is
treated by:
i. Reduction in incisal over bite.
ii. Alteration of incisal inclination.
The deep overbite is reduced by use
of anterior bite plane or fixed appliances
incorporating anchor bends or reverse curve of
Spee. The incisor inclination often necessitates
the use of torquing spring to move the upper
incisor roots lingually and the crowns buccally.
Role of Functional Appliances
During the mixed dentition period, it is
possible to procline the maxillary incisors,
thereby converting a Class II division 2 into a
malocclusion that resembles Class II division
1. This can be followed by the use of functional
appliances as described for Class II division 1
malocclusion.
TREATMENT PLANNING IN
CLASS III MALOCCLUSION
A malocclusion that is very easy to identify
but often difficult to treat is the Class III
malocclusion. This condition represents
a prenormalcy where the mandible is in a
mesial relation to the upper arch. According
to Angle a Class III molar relationship refers
to a condition where the mesio-buccal cusp
of the upper first molar occludes between the
mandibular first and second molars. Although
this definition represents a typical Class III
relationship, the lower molar can be in a mesial
relationship to a varying degree. This kind of
malocclusion finds highest incidence in Japan
and Korea.
CLINICAL FEATURES OF
CLASS III MALOCCLUSION
The following are the features of a Class III
malocclusion:
i. The patient has a Class III molar rela­
tionship.

ii. The incisor may be in an edge-to-edge
relationship or an anterior crossbite
may occur. It is not uncommon to find
a normal incisal relationship.
iii. The upper arch is frequently narrow
and short while the lower arch is broad.
Thus posterior crossbites are a common
feature of Class III malocclusion. This
tendency is exaggerated due to the
mesial sagittal relationship of the lower
arch due to which the broader part of the
mandibular arch opposes the narrow
part of the upper arch.
iv. It is common for the upper teeth to
be crowded as the arch is narrow and
short while the mandibular arch is often
spaced.
v. The patient has a concave profile due to
the presence of a prominent chin.
vi. Vertical growers exhibiting an increased
intermaxillary height may have an
anterior openbite. In some patients a
deep overbite may occur.
vii. A type of Class III malocclusion referred
to as pseudo Class III malocclusion
is characterizded by the presence of
occlusal prematurities resulting in a
habitual forward positioning of the
mandible. These patients may exhibit a
forward path of closure.
SKELETAL FEATURES OF
CLASS III MALOCCLUSION
Class III malocclusion are quite often associated
with underlying skeletal malrelationships. The
following are some of the commonly seen
skeletal features:
1. Retrognathic maxilla.
2. Prognathic mandibles.
3. Combination of retrognathic maxilla and
prognathic mandible.
Orthodontic Treatment Planning 289
Etiology
True Class III malocclusion that exhibits
underlying skeletal imbalance is usually
inherited. Class III malocclusions are said to
have a very strong genetic basis. The other
causes of a prenormalcy include habitual
forward positioning of the mandible due to
occlusal prematurities or enlarged adenoids.
Diagnosis
The diagnostic procedure should help in
determining the type of Class III malocclusion,
i.e. dental or skeletal, true or pseudo.
The clinical examination should include
observation of path of closure. In addition,
study models and radiographs should also be
taken. A lateral cephalogram offers valuable
information on the skeletal nature of the
malocclusion.
Treatment
Class III malocclusion should be recognized
and treated early due to the following reasons:
i. Recognizing the malocclusion at an
early age makes it possible to intercept
the abnormal skeletal pattern so as to
reduce the severity of the developing
malocclusion.
ii. The Class III malocclusion characterized
by anterior crossbites often results in
retarded maxillary growth due to locking
of the maxilla within the mandible.
iii. The occlusal forces on the mandibular
incisors exerted by the maxillary incisors
in crossbite encourage the continued
forward growth of mandible further
worsening the prenormalcy.
Interception during Growth
Class III malocclusion with an underlying
skeletal malrelationship require early
treatment to intercept the developing skeletal
malocclusion. The following are some of the
290 Essentials of Orthodontics
growth modulation procedures that can be
carried out:
i. Frankel III, a myofunctional appliance
can be used during growth to intercept
a Class III due to maxillary skeletal
retrusion.
ii. Reverse activator.
iii. Chin cup with high pull headgear us
used to intercept Class III malocclusion
due to mandibular prognathism.
iv. Severe Class III malocclusion that are
a result of maxillary retrusion can be
treated by reverse headgear to protract
maxilla.
Treatment of Anterior Crossbite
Mild anterior crossbites can be treated using
lower anterior inclined planes or removable
appliances incorporating screws designed for
anterior expansion.
Treatment of Posterior Crossbite
Class III malocclusions are often accompanied
by posterior crossbite. The posterior crossbite
can be treated by rapid maxillary expansion.
Role of Extractions
Class III malocclusions characterized by lower
arch length deficiencies and anterior crossbite
can be treated by extracting the lower first
premolars followed by fixed mechanotherapy.
Class III intermaxillary elastics should be used
to retract the lower anteriors. In case of arch
length deficiencies involving both the arches,
the first premolars should be extracted in both
the upper and lower arches.
Treatment of Severe Class III after Growth
Severe Class III malocclusion after growth
com­pletion is treated by surgical and corr­
ective procedures. Class III due to maxillary
deficiency is treated by maxillary advancement
procedures such as Le Fort I osteotomy.
Class III malocclusions that are a result of
mandibular prognathism are treated by
mandibular setback procedures.
Treatment of Pseudo Class III
Pseudo Class III malocclusion that occurs as
a result of occlusal prematurities improves
on removal of the cause by occlusal grinding.
DRUGS USED IN
ORTHODONTICS
In orthodontics, some drugs are used as pro­
phyl­actic or during treatment such as the
antibiotics, anticholinergics, fluoride, anti­
anxiety drugs, and drugs used for myofacial
pain.
The use of anticholinergic drugs to control
salivary flow prior to the acid-etch bonding
of orthodontic appliances has caused the
orthodontist to become interested in the
application of pharma­c ology to clinical
practice. Many orthod­o ntists have spent
years in practice without employing any
pharmacologic agents and may have forgotten
or not followed recent trends in pharmacology.
PROPHYLACTIC ANTIBIOTICS
FOR PREVENTION OF INFECTIVE
ENDOCARDITIS
Because of the increased number of orthodontic
patients, it is likely that the orthodontist will
have to prescribe antibiotics for the prevention
of infective endocarditis (formerly called
subacute bacterial endocarditis). Because
of the possibility of causing a bacteremia
from oral microorganisms, antibiotic
administration has been recommended
for such dental procedures as prophylaxis,

curettage, gingivectomy, endodontics, extr­
actions, biopsy, and oral surgery in patients
with valvular heart involvements, valvular
prosthesis, and a history of rheumatic fever.
Even in the absence of clinically detectable
heart disease, antibiotic prophylaxis is also
recommended for those patients who have had
a documented previous episode of infective
endocarditis, and additional antibiotic doses
are advocated for those patients who are taking
antibiotics to prevent recurrence of acute
rheumatic fever.
Since, there have been no controlled clinical
trials in human beings and recommendations
for antibiotic prophylaxis are based on
experiments in animal models, specific
recommendations for every dental situation
are not possible. Even less clear are those
procedures in orthodontics that warrant
antibiotic coverage. For example, the American
Heart Association has made a general
recommendation that “antibiotic prophylaxis
is recommended for all dental procedures that
are likely to cause gingival bleeding” “but no
antibiotic coverage is recommended for simple
adjustments of orthodontic appliances.”
The dental literature is very limited as to
which orthodontic procedures cause transient
bacteremia of sufficient magnitude to justify
antibiotics. Although contrary to expectation,
Degling was unable to demonstrate in twenty-
five fully banded orthodontic patients that
banding and debanding caused a transient
bacteremia. Heslop, however, was able to show
that 0.02 inch brass wire orthodontic tooth
separation caused a bacteremia equal to that
of dental extraction in twenty female rhesus
monkeys.
Because of the limited scientific information
concerning bacteremia after various ortho­
dontic procedures, the orthodontist’s judgment
must prevail as to whether to administer
Orthodontic Treatment Planning 291
antibiotics to heart-damaged orthodontic
patients. Acid-etch bonding of orthodontic
appliances could be a procedure in which
antibiotic prophylaxis is unnecessary, and
it may be the ideal method of orthodontic
appliance application for prevention of
infective endocarditis in susceptible patients.
Banding, debanding, and possibly tooth
separation by certain wires or clips would
represent orthodontic procedures that could
warrant antibiotic premedication. However,
only after consultation with the patient’s
physician or cardiologist and after evaluation
of each practitioner’s own peculiar office
methods can determination of antibiotic use
be made. Also, the orthodontist must consider
medicolegal impli­cations for each patient.
The most common organism implicated
in infective endocarditis following dental pro­
cedures is the alpha-hemolytic streptococcus
(for example, Streptococcus viridans) and
parenteral administration of antibiotics
should be favored when practical. Antibiotic
administration according to regimens A or
B may be used in patients with: (1) most
congenital heart diseases, (2) rheumatic
valvular heart disease, (3) other acquired
valvular disease, (4) idiopathic hypertrophic
subaortic stenosis, and (5) mitral valve
prolapse. For higher-risk patients (for example,
those with prosthetic heart valves), regimen B
is recommended.
Doses for children should not exceed
recommendations for adults for a single dose
or for a 24-hour period. Also, additional doses
of antibiotic may be necessary for unusual
circumstances or in the case of delayed
healing, even though the bacteremia rarely
persists longer than 15 minutes after the dental
procedure is terminated. In some patients
receiving continuous oral penicillin for
prevention of rheumatic fever, alpha-hemolytic
292 Essentials of Orthodontics
streptococci relatively resistant to penicillin are
sometimes found in the oral cavity. In these
cases it is likely that use of regimen A would
be sufficient, but the orthodontist may choose
one of the drugs suggested in regimen B or oral
erythromycin. Also, the orthodontist should
realize that the antibiotic regimens established
by the American Heart Association could
change and he must therefore keep informed
of all future recommendations.
Regimens A and B are as follows:
Regimen A—Penicillin
1. Parenteral and oral combined: Adults:
Aqueous crystalline penicillin G (1,000,000
units intramuscularly) mixed with pro­caine
penicillin G (600,000 units intramu­scularly).
Give 30 minutes to 1 hour preoperatively;
then give penicillin V (phenoxymethyl
penicillin), 500 mg orally every 6 hours for
eight doses.
Children: Aqueous crystalline penicillin G
(30,000 units per kilogram intramuscularly)
mixed with procaine penicillin G (600,000
units intramuscularly). Timing of doses
for children is the same as for adults. For
children who weigh less than 60 pounds,
the dose of penicillin V is 250 mg orally
every 6 hours for eight doses.
2. Oral
Adults: Penicillin V (2.0 gram orally 30
minutes to 1 hour preoperatively and then
500 mg orally every 6 hours for eight doses).
Children: Same as above. For children who
weigh less than 60 pounds, give 1.0 gram
orally 30 minutes to 1 hour preoperatively
and then 250 mg orally every 6 hours for
eight doses.
For patients allergic to penicillin
1. Parenteral and oral combined (see regi­-
men B)
2. Oral
Adults: Erythromycin (1.0 gram orally 1½
to 2 hours preoperatively and then 500 mg
orally every 6 hours for eight doses).
Children: Erythromycin (20 mg/kg orally
1½ to 2 hours preoperatively and then 10
mg/kg every 6 hours for eight doses).
Regimen B—Penicillin Plus
Streptomycin
Adults: Aqueous crystalline penicillin G
(1,000,000 units intramuscularly) mixed
with procaine penicillin G (600,000 units
intramuscularly) plus streptomycin (1.0 gram
intramuscularly) between 30 minutes and 1
hour preoperatively; then give penicillin V, 500
mg orally every 6 hours for eight doses.
Children: Aqueous crystalline penicillin G
(30,000 units per kilogram intramuscularly)
mixed with procaine penicillin G (600,000
units intramuscularly) plus streptomycin (20
mg/kg intramuscularly). Timing of doses for
children of less than 60 pounds: Give penicillin
V, 250 mg every 6 hours for eight doses.
For Patients Allergic to Penicillin
Adults: Vancomycin (1 gram intravenously over
30 minutes to 1 hour). Start initial vancomycin
infusion ½ to 1 hour preoperatively; then
erythromycin, 500 mg orally every 6 hours for
eight doses.
Children: Vancomycin (20 mg/kg intravenously
over 30 minutes to 1 hour). The total dose of
vancomycin should not exceed 44 mg/kg/24
hours. Timing of doses for children is the same
as for adults. Erythromycin dose is 10 mg/kg
every 6 hours for eight doses.
Anticholinergics (antimuscarinics) used
to reduce salivary flow.
Prevention of saliva contamination of
teeth is critical for the successful acid-etch
bonding of orthodontic appliances. Recently

such anticholi­nergic drugs as methantheline
(Banthine) and propantheline (Pro-Banthine)
have been used by the orthodontist to reduce
salivary flow. When the orthodontist admini­
sters a drug, he must know and understand the
nature of the drug’s action, contraindications,
side effects, and drug-to-drug interactions.
The anticholinergics exert their action by
competitively blocking acetylcholine action
on the effector cells innervated by the postgan­
glionic parasympathetic fibers. Besides
depressing salivary secretions (antisialic
action), the anticholinergics exert effects upon
other organs, and there are some variations
between different anticholinergic drugs in
their relative potencies on these organ systems.
Also, the different responses by the various
organs are dose-dependent ; small doses
depress salivary, lacrimal, bronchial, and
sweat secretions, while larger doses dilate the
pupils, increase heart rate, and cause urinary
retention and constipation. Stimulation of
the central nervous system is also noted with
low anticholinergic doses and depression of
the central nervous system with large doses.
A simplistic view of anticholinergic actions
states that the anticholinergics antagonize
the parasympathetic “SLUD” syndrome,
which means that these drugs decrease or
block salivation, lacrimation, urination, and
defecation.
Although the belladonna anticholinergics,
atropine and scopolamine, have antisialic
action, they have somewhat pronounced
cardiovascular and central effects. Therefore,
anticholinergic drugs with more selective action
have become popular today. Such synthetic
quaternary ammonium anticholinergics as
methantheline (Banthine) and propantheline
(Pro-Banthine) have recently been used as
antisialagogues because they have fewer side
effects. Methantheline and propantheline have
Orthodontic Treatment Planning 293
little or no central action, milder cardiovascular
effects, and less effect on the eye than atropine.
Methantheline and propantheline, however,
are poorly and unreliably absorbed after oral
administration and, therefore, could present
special problems for the orthodontist with
respect to dose, onset, and length of action in
individual patients. Also, the synthetic quat­
er­nary ammonium compounds have more
pronounced gastrointestinal effects than
atropine. Furthermore, methantheline and
propantheline have been approved by the
Food and Drug Administration only for use
in the treatment of peptic ulcers and other
gastrointestinal disorders.
Methantheline and propantheline are
more potent and have a more prolonged
action than atropine; the clinical effects of
atropine usually last 4 hours, while those
of methantheline and propantheline last 6
hours. Also, propantheline is more potent
than an equal dose of methantheline. Clinical
doses of methantheline and propantheline
very rarely elicit any adverse reactions;
however, caution should be used with the
administration of all drugs, since the dose
versus response differs from individual-to-
individual, and even clinical doses can be
dangerous for some drug-sensitive persons.
Only single doses of the antisialagogues are
recommended for dentistry. There are no
data to suggest that, in oral therapeutic doses,
methantheline is a better antisialagogue than
propantheline and vice versa. Manufacturers
of Banthine and Pro-Banthine, however, claim
that parenterally administered Banthine has
antisialic properties that are superior to those
of Pro-Banthine.
The recommended adult single doses of
Banthine and Pro-Banthine are 50 mg and
15 mg, respectively. Pediatric single doses for
Banthine can range from 12.5 mg to 50 mg
294 Essentials of Orthodontics
for children over 1 year of age. “Since there
is inadequate experience with the use of Pro-
Banthine in children, safety and efficacies
in children have not been established.”
Many patients, however, may need double
the recommended dose of Banthine and
Pro-Banthine because of the unreliable
oral absorption of these drugs. Banthine
and Pro-Banthine are contraindicated for
patients with glaucoma, prostate hypertrophy,
myasthenia gravis, obstructive disease of
the gastrointestinal tract, and some types of
cardiovascular disease. Also, patients should
not wear contact lenses before, during, and
at least 6 hours after administration of the
drug because of the mydriasis produced.
Adverse reactions to the drugs may include
blurred vision, tachycardia, hypotension,
skeletal muscle paralysis (including respiratory
muscles), urinary retention, and dry skin.
The anticholinergics are potentiated by
antihistamines, tricyclic antidepressants, MAO
inhibitors, and phenothiazine tranquilizers.
Drugs that antagonize or inhibit anticholinergic
action include achlorhydria agents, urinary
acidifiers, anticholinesterases, guanethidine,
and reserpine.
Fluorides and Orthodontics
Although much research documents the
inhibition of caries through the use of
fluoridated water, fluoride tablets, topical
fluorides, or fluoride mouth rinses, a cause-
and-effect relationship between fluoride
application and the prevalence of malocclusion
is not clear. Some investigations showed no
significant difference in the prevalence of
malocclusion among children in fluoridated
and nonfluoridated communities, but most
research indicates that malocclusion can
be reduced when children use fluoride.
The difference in the research on fluoride
and malocclusion is possibly because of
the influence that heredity had on the data.
Therefore, fluoride would have such a limited
effect on malocclusion, other than that
resulting from tooth or space loss caused by
dental caries, that studies to elucidate its single
effect would be difficult from cross-sectional
research. Nevertheless, no one can argue
against the benefits of fluoride, particularly
ingestible fluoride, in the prevention of caries;
therefore, the orthodontist should be in a
knowledgeable position to inform patients
concerning fluorides.
Before the orthodontist decides whether to
recommend ingestible fluoride for a patient, he
should consider the patient’s oral hygiene and
caries susceptibility. The orthodontist should
also consider the patient’s age, both dental and
skeletal, and the natural level of fluoride in the
drinking water. It apears that fluoride provides
its greatest benefits during the period of tooth
development, from infancy to 12 to 14 years of
age.
It is generally accepted that maximal
protection from dental caries can be obtained
by the daily ingestion of drinking water
containing 1 part per million of fluoride
and food containing 1 mg of fluoride, in
conjunction with other preventive measures.
Water supplies with less than 0.3 ppm of
fluoride require supplementation of 0.5 mg
per day for children under 3 and 1 mg. per
day for children over 3 years of age. Water
supplies with between 0.3 and 0.7 ppm
require supplementation of 0.25 mg per day
for children under 3 and 0.5 mg per day for
children over 13 years of age.
When the fluoride level rises to 1.5 ppm,
white spots and flecking of the enamel are
observed, and at higher concentrations
severe pitting and staining occur; this is
termed chronic endemic dental fluorosis

(mottled enamel). Fluorosis is most evident
in permanent teeth, and deciduous teeth are
affected only at high levels of fluoride intake.
In order to avoid the possibility of unesthetic
dental fluorosis, the prescribed dietary fluoride
allowance should be decreased in proportion
to the amount of fluoride in the drinking water.
Also, it should be pointed out that infant food
or formula processed with fluoridated water
contains higher levels of fluoride than identical
products processed with water containing low
levels of fluoride. It may also be necessary to
reduce fluoride in certain infant foods, such
as chicken, which presently contain high
amounts of fluoride.
Accidental ingestion of excessive fluoride
results in a salty or soapy taste in the mouth,
tremors, convulsions, shock, and, possibly,
renal failure. The toxic dose ranges from 2 to
5 grams in adults, but it is less in children and
is approximately 600 mg at age three years.
Treatment consists of inducing emesis with
syrup of ipecac or mustard water, followed by
having the patient drink large quantities of milk
and having him transported to the emergency
room of the nearest hospital, whereupon 10
cc of calcium gluconate 10 percent can be
administered; these measures are directed at
attempting to form insoluble calcium fluoride
(CaF2). All fluoride should be stored out of the
reach of children.
A professional decision on the use of dietary
fluoride or topical applications of fluoride will
depend in part upon the age of the child.
Prescribing supplements of dietary fluorides
is the method of choice for the very young
child, whereas topical fluoride applications
or fluoride mouth rinses are preferable for
the older child whose permanent teeth have
already erupted. Children under 14 years of
age who are highly susceptible to caries may
benefit from receiving both measures.
Orthodontic Treatment Planning 295
In addition to providing a benefit systemi­
cally to unerupted teeth, there is good evidence
that fluoride supplements can impart a
posteruptive topical benefit to the teeth.
Because of this benefit, it is advisable to instruct
children to dissolve or chew the fluo­r ide
before swallowing. Sodium fluoride tablets
are available in concentrations of 0.55 mg
(Luride, 0.25 mg Lozi-Tabs), 1.1 mg (Luride,
0.5 mg Lozi-Tabs), and 2.21 mg (Luride, 1.0 mg
Lozi-Tabs, Karidium, Phos-Flur). Each of these
supplies fluoride in concentrations of 0.25, 0.5
and 1.0 mg, respectively and each is chewable
except Karidium. Infant drops are available in
concentrations of 0.125 mg/drop (Karidium),
0.1 mg/drop (Luride), 0/25 mg/drop (Flouritab,
Flura-Drop) and 0.5 mg/cc (Pediaflor).
Topical fluoride, although of less value
than ingested fluoride, can be used to control
and prevent dental disease. Recent research
indicates that, in addition to controlling caries,
topical fluoride may improve periodontal
conditions by inhibiting the types of micro­
organisms and their byproducts found in
the mouth. However, infrequent fluoride
application has no major impact on the
control of dental microbial plaque diseases.
Since intensive fluoride therapy may be self-
administered at home, it may be of benefit to
the orthodontic patient. Also, topical fluoride
gels or fluoride mouth rinses may be applied
immediately before orthodontic banding.
There are three types of office fluoride
solution: (1) sodium fluoride (NaF), (2)
stannous fluoride (SnF2), and (3) acidulated
phosphate fluoride (APF). Reduction of enamel
solubility is greatest with sequential APF and
SnF2 treatments, less with combined APF and
SnF2, still less with SnF2 alone, and least with
APF alone.
The properties of sodium fluoride are
very similar to those of acidulated phosphate
296 Essentials of Orthodontics
fluoride. In comparison with sodium fluoride,
stannous fluoride is simpler to use, more
beneficial in reducing caries in fluoridated
areas, more effective in adults, and capable
of arresting existing caries. However, it has
an unpleasant taste, it is unstable in solution,
and it will stain teeth slightly. Stable, dilute
solutions of stannous fluoride (0.4%) have
been prepared and are reported to be effective
in preventing decalcification in orthodontic
patients.
Sodium fluoride rinses are marketed in
concentrations of 0.05 percent (Fluorigard
dental rinse, Fluorinse, Kari-Rinse, Sodium
Fluoride Home Rinse) and 0.2 percent
(Fluorinse, Point-Two dental rinse); the gel
is available only in a concentration of 1.1
percent (Kari-Gel). Stannous flouride rinses
and gels are available only in concentrations
of 0.4 percent (Gel-Kam, Iradicay stannous
fluoride). Acidulated phosphate fluoride rinse
is marketed as Iradicay acidulated phosphate
home fluoride 0.02 percent and the gel as
fluoride 0.5 percent. A 1.23 percent APF gel is
recommended for tray application, and tray
application is mandatory between the ages of
3 and 6, since the use of fluoride rinses requires
full control of the swallowing reflex which is
not mature prior to age 6.
Since the liquid catalyst in zinc oxyphos­
phate cements, which are used in orthodontic
cements, has a low pH, these cements may
have a tendency to decalcify the teeth in
certain patients. Some orthodontic cements
have fluoride within them, but the addition
of an equal amount of a 30 percent solution
of stannous fluoride to a dehydrated cement
liquid can impart protection to the teeth
without significantly affecting the compressive
strength or setting time of the cement.
Antianxiety Agents
Benzodiazepine antianxiety agents, such as
diazepam (Valium) and chlordiazepoxide
(Librium), may have limited application
in orthodontics as premedication for the
hysterical or apprehensive patient. However,
the benefits of the drug must outweigh the
possible risks. Although most patients are
reasonably alert and coherent with barbi­
turates in proper dosages, they are more so
with the benzodiazepines. The antianxiety
drugs would relieve anxiety and tension, as
well as controlling the patient’s pain reaction.
Diazepam is contraindicated for patients
who have glaucoma and is not the preferred
drug for psychotic patients. Driving an
automobile is not recommended while one
is under the influence of diazepam; also
tolerance to alcohol is decreased by their
concurrent use. Diazepam is available in
bottles of 100 and 500 tablets and in doses of
2 mg, 5 mg, and 10 mg tablets. The usual adult
dose is between 2 and 10 mg two to four times
daily. The usual pediatric dose of diazepam
ranges from 1 to 2.5 mg three to four times
per day. Chlordiazepoxide is marketed in the
form of 5, 10, and 25 mg capsules and the usual
dose is between 5 and 25 mg three to four
times daily as needed. Chlordiazepoxide is not
recommended for children under 6 years of
age, but for children over 6 the usual pediatric
dose is 5 mg two to four times daily. Side
effects of the antianxiety drugs are drowsiness,
fatigue, and ataxia; physical dependence can
be produced with compulsive use.
Pharmacologic Agents for
Myofascial Pain
Orthodontic patients, either before, during, or
after treatment, are susceptible to myofacial

and/or dental pain. Very rarely is the pain of
such a magnitude that aspirin will not suffice.
Such analgesics as aspirin, with or without
codeine, acetaminophen (Tylenol, Tempra,
Phenaphen, Datril, Nebs), with or without
codeine, propoxyphene (Darvon, Dolene),
and pentazocine (Talwin) can be used for
alleviation of mild pain. Pharmacologic
treatment for the “myofascial pain dysfunction
(MPD) syndrome” (TMJ syndrome) is directed
at reducing the stress and tension associated
with these patients and also relaxing the facial
muscles that may be in spasm. Such minor
tranquilizers as chlordiazepoxide (Librium),
diazepam (Valium), and meprobamate
(Miltown, Equanil) have been used to reduce
the anxiety-tension of the MPD patient. Muscle
relaxants such as chlorzoxazone with aceta­
minophen (Parafon Forte) may reduce the
spasms and pain associated with the facial
muscles. Diazepam, chlordiazepoxide, and
meprobamate have combined sedative and
muscle relaxant properties. Also, ethyl chloride
sprayed directly on the facial muscles has been
shown to be effective in relieving some of the
painful symptoms of the MPD syndrome.
Because of psychic contributions to the MPD
syndrome, the orthodontist should be cautious
when prescribing drugs for these patients;
placebo preparations have also been shown
to be effective in reducing or eliminating the
MPD symptoms in some pati­ents.
SUMMARY AND CONCLUSION
Antibiotic premedication for the heart-dam­aged
orthodontic patient would appear necessary for
Orthodontic Treatment Planning 297
such orthodontic procedures as metal tooth
separation and banding; the value of antibiotic
coverage for other orthodontic procedures
is less clear. Such anticholinergic drugs as
methan­theline (Banthine) and propantheline
(Pro-Banthine) have recently become of interest
to the orthodontist as antisialagogues prior to
the direct bonding of orthodontic appliances.
Possible compli­cations and the justification
of this procedure must be considered.
During ortho­d ontic procedures requiring
fixed appliances, fluoride mouth rinses may
have application in reducing caries and
periodontal disease. Antianxiety drugs, such
as diazepam (Valium) and chlordiazepoxide
(Librium), would have very limited usefulness
as premedication for the apprehensive
orthodontic patient or as adjunctive therapy
for the treatment of myofascial pain.
The orthodontist is cautioned about
the pre­s cribing of drugs without a proper
understanding of the drugs’ pharmacologic
action, dosage, contraindications, and other
side effects. Also, before the orthodontist
prescribes any drug he must decide whether
the benefits of the drug outweigh any potential
risks; even the most innocuous drug can be
dangerous for certain drug-sensitive persons.
Finally, since the drug literature is constantly
changing, the orthodontist should always
check the latest Physicians’ Desk Reference,
drug packet insert, and other appro­priate
references before prescribing any drug.
 CHAPTER
7 Biomechanics
MECHANICS OF TOOTH
MOVEMENT
Physics, mathematics and engineering are
three important disciplines that can 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 clear understanding
of the theories of mechanics has potential
applications in three areas:
1. Precise application of forces.
2. A better understanding of clinical and
histological response to various magni­
tudes of force.
3. Improving the design of orthodontic
appliances.
NEWTON’S LAWS OF MOTION
Everybody continues in its state of rest or of
uniform motion in a straight line, unless it
is compelled to change that state by forces
impressed upon it applies to dentition.
The response of a tooth to an applied force
can be at three levels, i.e. clinical, cellular and
stress strain 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 overemphasized as almost all the
assumptions made about the stress-strain
activity in the periodontium are based on several
mathematical formulations and conclusions.
For a better understanding of mechanics one
should be familiar with the terminology used.
Force
Force can be defined as an act upon a body that
changes or tends to change the state of rest or
of uniform motion of that body.
Being a vector, force has a definite
magnitude, a specific direction and a point
of application. In clinical practice it is either a
‘push’ or a ‘pull’. In the metric system the unit
of force is expressed in grams.
Stress and Strain
Stress is the force applied per unit area while
strain can be defined as the internal distortion
per unit ares.

Stress and strain are interrelated terms as
stress is an external force acting upon a body
while strain is the resultant of stress on that
body. Strain can be expressed in the form of
a change in either the external dimension or
internal energy of the body.
Couple
Couple is a pair of concentrated forces having
equal magnitude and opposite direction with
parallel but noncollinear line of action.
A couple when acting upon a body brings
about pure rotation.
Moment
Moment can be defined as the measure of
rotational potential of a force with respect to
a specific axis.
Moment = Magnitude of force × distance
(perpendicular distance from the center of
resistance of the body to the line of action of
the force).
Center of Resistance (Fig. 7.1)
Everybody or free object behaves as it its mass
is concentrated at a single point on which it can
be perfectly balanced. For physical calculation,
this point can be taken as the point where the
whole body weight is concentrated and can be
termed center of gravity.
However, teeth cannot move in a free
manner within the jaws. They are restricted by
the investing tissues around their roots. In such
a situation, a point analogous to the center of
gravity is made use of and is called the center
of resistance.
Center of resistance of a tooth can be
defined as that point on the tooth when a single
force is passed through it, would bring about its
translation along the line of action of the force.
Generally the center of resistance of a tooth is
constant. In a single rooted tooth it lies between
one-third and one-half of the root, apical to the
Biomechanics 299
Figure 7.1: Center of resistance
alveolar crest while in a multirooted tooth the
center of resistance lies between the roots, 1 to
2 mm apical to the furcation.
Two factors which can change the position
of the center of resistance are the root length
and alveolar bone height. Longer the root, the
center of resistance will be placed more apically.
Likewise if the alveolar crest is higher, the center
of resistance will be placed more coronally.
Center of Rotation
Center of rotation is a point, about which a
body appears to have rotated, as determined
from its initial and final positions.
The center of rotation is a variable point
and changes according to the type of tooth
movement. It can be at any position on or off
the tooth.
For example, in case of controlled crown
tipping, the center 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 center of rotation
several times.
TYPES OF TOOTH MOVEMENTS
(FIG. 7.2)
The prime motive of orthodontic treatment
is to move the teeth into more favorable
300 Essentials of Orthodontics
Figure 7.2: Types of tooth movement
and corrected positions. In the process of
achieving this goal, the teeth undergo a variety
of movements in all the three planes of space,
i.e. sagittal, coronal and transverse.
Tooth movements within the oral cavity can
be listed as follows:
1. Tipping
2. Bodily movement (Translation)
3. Intrusion
4. Extrusion
5. Torquing
6. Uprighting.
Tipping
Tipping is a simple type of tooth movement
where a single force is applied to the crown
which results in movement of the crown in
the direction of the force and the root in the
opposite direction. Tipping is considered to
be the simplest among the tooth movements.
It can be of two types:
Controlled tipping: Controlled tipping of
a tooth occurs when a tooth tips about a
center of rotation at its apex. Here there is a
lingual movement of the crown and minimal
movement of the root in labial direction.
Uncontrolled tipping: Uncontrolled tipping
of a tooth describes the movement of a tooth
that occurs about a center of rotation apical
to and very close to the center of resistance. It
is characterized by the crown moving in one
direction while the root moves in the opposite
direction.
Bodily Movement (Translation)
If the line of action of an applied force passes
through the center of resistance of a tooth,
all the points on the tooth will move more
an equal distance in the same directions
signifying a bodily displacements. This is called
translation.
Intrusion: Intrusion is the bodily displacement
of a tooth along its long axis in an apical
direction.
Extrusion: Extrusion is the bodily displacement
of a tooth along its long axis in an occlusal
direction.
Rotation: Rotations are labial or lingual
movements of a tooth around its long axis.
Torquing: Torquing can be considered as a
reverse tipping characterized by labial or
lingual movement of the root.
Uprighting: Mesiodistal root movements to
make the root parallel are called uprighting.
During orthodontic treatment, the crowns
of certain teeth will be tipped in a mesiodistal
direction with the roots tipped in the opposite
way. Tipping these roots back to 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:
Pure Translation
It occurs when all points on the 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 center of
resistance of a tooth. Pure translation can be
of three types:
1. Intrusion

Figure 7.3: Derotation
2. Extrusion
3. Bodily movement (mesiodistal, labiolin­
gual).
Pure Rotation (Fig. 7.3)
A displacement of the body, produced by a
couple, characterized by the center of rotation
coinciding with the center of resistance, i.e. the
movement of points of the tooth along the area
of a circle, with the center of resistance being
the center of the circle. Pure rotations can be
divided into two types.
Transverse rotation: Those tooth displacements
during which the long axis orientation changes,
e.g. tipping and torquing.
Long axis rotation: Here the angulation of the
long axis is not altered, e.g. rotation of a tooth
around its long axis.
Generalized Rotation
Any movement that is not pure translation or
rotation can be described as a combination
of both translation and rotation and can be
termed generalized rotation. This type of
Biomechanics 301
movement can be seen during routine clinical
practice.
TYPES OF FORCE (FIG. 7.4)
As is well-stated by the pioneers in the subject,
if malocclusion is the disease in orthodontics,
force is definitely its medicine. It is therefore,
very important for the clinician to use his
knowledge and experience in determining the
type, amount and direction of force required to
bring about efficient treatment results.
Based on the duration of application, force
can be divided into:
Continuous Force
It is an active orthodontic force that decreases
little in magnitude between appointment
periods, e.g. light wire appliances.
For an appliance to deliver continuous
force the appliance components should
be highly flexible and the activation must
be done to a relatively low force level. This
is because continuous forces are expected
to bring about direct resorption of the root
sockets. They should hence not occlude more
than a small percentage of blood vessels
within the periodontal ligament and non-
substantially interfere with their nutritional
supply. Moreover the continuous force cycle
includes no rest period and little interference
Figure 7.4: Types of forces
302 Essentials of Orthodontics
with normal biologic functioning within the
soft tissue can be tolerated.
Intermittent Force
It is an active orthodontic force that decays to
zero magnitude or nearly so prior to the next
appointment, e.g. removable active plates.
For an appliance to deliver intermittent
force the appliance components should have
high stiffness and the initial activation should
be twice the expected corresponding soft
tissue deformation. Due to a relatively high
activation, a greater force is exerted on the
teeth. This leads to undermining 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 periodontium.
Interrupted Force
It is an orthodontic or orthopedic force that
is inactive for intervals of time between
appointments. It often exhibits cyclic, long-
term magnitude time pattern, e.g. force exerted
by and extraoral appliance worn only at night.
For an interrupted force to be delivered,
the prerequisites include:
i. It should deliver heavy force.
ii. There should not be any force decay.
iii. There should be a specific magnitude-
time pattern. For example, 200 to 300
gram of force 10 to 14 hour per day.
iv. 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 the normal way, it might occur
to us that a continuous force may bring about
a continuous movement or an increased force
may lead to an increased tooth movement. But,
these assumptions are 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 understood.
BIOLOGY OF TOOTH
MOVEMENT
Orthodontic treatment is made possible by
the fact that teeth can be moved through the
alveolar bone by applying appropriate forces.
Orthodontic tooth movement is a unique
process where a solid object (tooth) is made to
move through a solid medium (bone).
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 ligament appeared between the
tooth and the alveolar socket. The appearance
of this periodontal tissue enabled independent
tooth movement.
PHYSIOLOGIC TOOTH MOVEMENT
Physiologic tooth movements are naturally
occurring tooth movements that take place
during and after tooth eruption.
Physiologic tooth movements include:
1. Tooth eruption
2. Migration or drifting of teeth
3. Changes in tooth position dur ing
mastication.
Tooth Eruption
Tooth eruption is the axial movement of the
tooth from its development position in the jaw
to its final position in the oral cavity.

Three types of tooth eruptive movements
occur:
Pre-eruptive Tooth Movement
Movement of the deciduous and permanent
tooth gems within the tissues of the jaw
before they begin to erupt. As the deciduous
tooth gems grow, the space for them in the
developing jaw becomes less, and initially
they are “crowded” in the anterior region.
This “crowding” usually is alleviated before
emergence by growth of the jaws, mainly in
the midline, which permits mesial movement
of the anterior tooth germs.
The deciduous molar germs gradually
increase in size and become displaced distally
in association with sagittal growth of the
jaws. At the same time, the tooth germs are
moving occlusally with the increase in height
of the jaws. The permanent anterior tooth
germs initially develop on the lingual aspect
of their predecessors. From this position
they shift considerably as the jaws develop
(e.g. the incisors eventually come to occupy
a position on the lingual aspect of the roots of
their predecessors, and the premolar germs
are positioned between the divergent roots
of the deciduous molars). In the maxilla, the
permanent molar germs initially develop with
their occlusal surfaces facing distally, and
swing into position only when the maxilla has
grown sufficiently to provide space for such
movement. In the mandible, the permanent
molars develop with their axes showing a
mesial inclination, which gradually becomes
more vertical.
Eruptive Tooth Movement
This includes “pre-emergent” and “post-
emergent” tooth movement. The mechanism
of eruption of deciduous and permanent teeth
is thought to be similar, bringing about the
Biomechanics 303
axial and occlusal movement of the tooth from
its developmental position within the jaw to its
final functional position within the occlusal
plane. Preemergent tooth movement seems to
be controlled by a different mechanism than
post­emergent tooth movement.
Eruptive movement begins soon after the
root begins to form. The PDL also develops only
after root formation has been initiated, and once
established, it must be remodeled to permit
eruptive tooth movement. The remodeling of
the PDL fiber bundles is achieved by fibroblasts,
which simultaneously degrade and synthesize
the collagen fibers as required across the entire
extent of the ligament. As the tooth moves
occlusally, bone is resorbed occlusal to it and
new bone is formed apical to the tooth.
At the time of emergence of the tooth into
the oral cavity, its dental follicle fuses with
the oral epithelium. Following emergence
the tooth erupts rapidly until it approaches
the occlusal level (post-emergent spurt).
Environmental factors such as muscle forces
from the tongue, cheeks and lips, as well as
forces of contact of the erupting tooth with
other erupted teeth, help determine the final
position of the tooth in the dental arch. The
effect of thumb sucking on the dentition
is an obvious example of environmental
determination of tooth position.
Posteruptive Tooth Movement
Movement of the teeth after they have reached
their functional position in the occlusal plane
is called posteruptive movement. The same
mechanisms that control postemergent tooth
movement seem to regulate posteruptive tooth
movement in the vertical plane. Posteruptive
tooth movement can be divided into three
categories:
1. Vertical movement occurring in concert
with jaw growth (“juvenile occlusal
304 Essentials of Orthodontics
equilibrium”). This movement is completed
toward the end of the second decade, when
jaw growth ceases, and it occurs earlier in
girls than in boys. It is related to the growth
of the mandibular ramus, which causes the
maxilla and mandible to grow apart from
each other, permitting further eruptive
movement of the teeth.
2. Movement to compensate for the
continuous occlusal wear of the teeth
(“adult occlusal equilibrium”). This axial
posteruptive movement occurs even after
the apices of the teeth are fully formed. It
is demonstrable by the tendency of teeth
to overerupt when their antagonist is lost,
at any age.
3. Movement to compensate for interproximal
wear. Wear also occurs at the contact points
between teeth on their proximal surfaces,
and its extent can be considerable (more
than 7 mm in the mandibular dental arch).
This interproximal wear is compensated
for by a process known as “mesial drift.”
The mechanism of this mesial drift is
multifactorial and is attributed to the
anterior component of the occlusal force,
to contraction of the trans-septal fibers
and/or pressure from the perioral and
intraoral soft tissues (cheeks and tongue).
The mechanism of tooth eruption is not
clearly understood; most investigations have
concluded that eruption is a multifactorial
process in which cause and effect are difficult
to separate. Some theories attempting to
explain the mechanisms of tooth eruption are:
1. The root elongation theory, which supports
the idea that root growth is responsible for
occlusal movement of the crown.
2. The hydrostatic pressure theory (vascular
theory), according to which local increases
in tissue fluid pressure in periapical tissues
push the tooth occlusally.
3. The alveolar bone growth theory according
to which apposition of bone to the crypt
beneath the erupting tooth, and resorption
of bone occlusal to it, is what causes the
tooth to rise into functional occlusion.
4. The pulp theory, which states that the pulp
produces a propulsive force generated by
extrusion of pulp due to growth of dentin,
by interstitial pulp growth, or by hydraulic
effects within the pulpal vasculature. This
results in an eruptive force because of
pressure gradients that are greater below
the tooth than above it.
5. The periodontal ligament theory, according
to which the mechanism for tooth eruption
lies within the periodontal ligament,
possibly related to the contractility of
collagen fibers.
6. The dental follicle theory, which states
that tooth eruption largely is a function
of bone resorption above the erupting
tooth (forming its eruption pathway), in
combination with intense osteoblastic
activity below it, both of which are
controlled by the dental follicle.
The above listed theories are not necessarily
mutually exclusive; in fact there is reasonable
evidence that tooth eruption is regulated by a
different mechanism in the preemergent and
postemergent stages. Physiological factors
such as hormonal fluctuations also seem to
play an important role.
Migration or Drift of Teeth
Migration regers to the minor changes in tooth
position observed after eruption of teeth. The
human dentition shows a natural tendency
to move in a mesial and occlusal direction.
Tooth migration is usually a result of proximal
and occlusal wear, they move in a mesial and
occlusal direction to maintain interproximal
and occlusal contact.

Tooth Movement during Mastication
During mastication, the teeth and periodontal
structures are subjected to intermittent heavy
forces which occur in cycles of one second
or less and may range from 1 to 50 kilograms
based on the type of food being masticated.
A tooth subjected to these heavy forces,
exhibits slight movement within its socket and
subsequently returns to its original position as
soon as the load is removed.
TOOTH MOBILITY
Clinical mobility of tooth can be classified as:
Physiologic (Normal) Mobility
The limited amount of tooth displacement
allowed by the resilience of an intact and healthy
periodontal ligament and by the bending
potential of the alveolar bone, when a light or
moderate force is applied to the crown of a tooth.
Increased Mobility (Hypermobility)
Increased tooth mobility is associated with
various physiologic phenomena such as tooth
eruption (due to incomplete maturation of the
periodontal ligament), pregnancy (as a result
of the hormonal influences on collagen and
the vascular structures of the PDL tissues)
and orthodontic treatment (due to remodeling
of the PDL tissues during tooth movement).
Pathologic conditions related to increased
tooth mobility are trauma from occlusion and
periodontal disease.
Reduced Mobility (Hypomobility)
Tooth mobility below the physiologic levels can
be found in cases of ankylosis. In such situations
there is no intrasocket tooth displacement and
any movement of the tooth can be attributed to
elastic deformation of the alveolar bone.
Biomechanics 305
HISTOLOGY OF TOOTH
MOVEMENT
When force is applied on a tooth to bring about
orthodontic movement, it results in formation
of areas of pressure and tension around the
tooth. Areas of pressure are formed in the
direction of the tooth movement, while areas
of tension form in the opposite direction.
Bone is a living tissue which reacts to
pressure and tension in a certain defined
manner. Bone surface subjected to pressure
reacts by bone resorption while bone subjected
to tension exhibits deposition.
When a tooth is moved due to application of
an orthodontic force, there is bone resorption
on the pressure side and new bone formation
on the side of tension.
The histologic changes seen during tooth
movement vary according to the amount
and duration of force applied. The histologic
changes seen during tooth movement can be
studied under two headings as:
1. Changes following application of mild
force.
2. Changes following application of extreme
force.
Changes following application of mild force:
When a force is applied to a tooth, areas of
pressure and tension are produced.
Changes on pressure side: The periodontal
ligament in the direction of the tooth movement
gets compressed to almost one-third of its
original thickness. A marked increase in the
vascularity of periodontal ligament on this side
is observed due to increase in capillary blood
supply helps in mobilization of cells such as
fibroblasts and osteoclasts.
Osteoclasts are bone resorbing cells that
line up along the socket wall on the pressure
side. They lie within shallow depressions in
bone called Howship’s lacunae. A change in
306 Essentials of Orthodontics
orientation of the bony trabeculae is seen
several weeks after continued orthodontic
force application. The trabeculae which
are usually paralleled to the long axis of
the teeth become horizontally oriented,
i.e. parallel to the direction of orthodontic
force. The trabecular pattern reverts back to
normal pattern during retention phase of the
treatment.
The osteoclasts that lie within Howship’s
lacunae start resorbing bone. When the
forces applied are within physiologic limits,
the resorption is seen in the alveolar plate
immediately adjacent to the ligament. This
kind of resorption is called ‘Frontal resorption’.
Changes on tension side: The areas of the tooth
opposite to the direction of force are called the
tension side. On application of orthodontic
force, the periodontal membrane on the
tension side gets stretched. Thus the distance
between the alveolar process and the tooth is
widened.
In addition to stretching of the periodontal
fibers, a raised vascularity is seen on the
tension side just as on the pressure side. The
raised vascularity causes mobilization of cells
such as fibroblasts and osteoblasts in this
area. In response to this traction, osteoid is
laid down by osteoblasts in the periodontal
ligament immediately adjacent to the lamina
dura. This lightly calcified bone in due couse
of time matures to form woven bone.
Secondary remodeling changes: Whenever
a force is applied to move teeth, the bone
immediately adjacent shows osteoclastic
and osteoblastic activity on the pressure
and tension side respectively. In addition,
bony changes also take place elsewhere to
maintain the width or thickness of the alveolar
bone. These changes are called secondary
remodeling changes. For example, if a tooth
is being moved in a labial direction there is
compensatory deposition of new bone on the
outer side of the labial alveolar bony plate
and also a compensatory resorption on the
lingual side of the lingual alveolar bone. These
compensatory structural alterations maintain
the thickness of the supporting alveolar
process even though the tooth may be moved
over a distance several times greater than the
thickness of the alveolar bony plates.
Changes following application of extreme
forces: Whenever extreme forces are applied to
teeth, it results in crushing or total compression
of the periodontal ligament. On the pressure
side, the root closely approximates the lamina
dura, compresses the periodontal ligament
and leads to occlusion of the blood vessels. The
ligament is hence deprived of its nutritional
supply leading to regressive changes called
hyalinization.
In this case, the bone cannot resorb in the
frontal portion adjacent to the teeth. Rather
bone resorption occurs in the adjacent marrow
spaces and in the alveolar plate below, behind
and above the hyalinization zones. This kind of
resorption is called undermining or rearward
resorption.
On the tension side, the periodontal
ligament gets overstretched leading to tearing
of the blood vessels and ischemia.
Thus when extreme force is applied there
is a net increase in osteoclastic activity as
compared to bone formation with the result
that the tooth becomes loosened in its socket.
In addition, pain and hyperemia of the
gingival may occur due to application of
extreme forces during orthodontic tooth
movement.
OPTIMUM ORTHODONTIC FORCE
(TABLE 7.1)
Optimum orthodontic force is one which
moves teeth most rapidly in the desired

Table 7.1: Optimum forces for orthodontic tooth move­
ment
Type Force (grams)
Tipping 50–75
Bodily movement (Translation) 100–150
Root uprighting 75–125
Rotation 50–75
Extrusion 50–75
Intrusion 15–25
direction, with the least possible damage to
tissue and with minimal patient discomfort.
Oppenheim and Schwarz following
extensive studies state that the optimum
force is equivalent to the capillary pulse
pressure which is 20 to 26 gm/sq cm of root
surface area. From a clinical point of view,
optimum orthodontic force has the following
characteristics:
i. Produces rapid tooth movement
ii. Minimal patient discomfort
iii. The lag phase of tooth movement is
minimal
iv. No marked mobility of the teeth being
moved.
From a histologic point of view the use of
optimum orthodontic force has the following
characteristics:
i. The vitality of the tooth and supporting
periodontal ligament is maintained
ii. Initiates maximum cellular response
iii. Produces direct or frontal resorption.
HYALINIZATION
Hyalinization is a form of tissue degeneration
characterized by formation of a clear,
eosinophilic homogeneous substance. This
hyalinization can occur in organs such as
kidneys, lungs, etc. Hyalinization of the
Biomechanics 307
periodontal ligament denotes a compressed
and locally degenerated periodontal ligament.
The conventional pathologic process of
hyalinization is an irreversible one; however,
hyalinization of the periodontal ligament is a
reversible process.
Experimental evidences show that
hyalinization of the periodontal ligament
on the pressure side occurs in some areas
during almost all forms of orthodontic tooth
movement. But the areas are wider when the
force applied is extreme.
The changes observed during formation of
hyalinized zones are as follows:
i. There is a gradual shrinkage of perio­
dontal ligament fibers.
ii. The cellular structures become indis­
tinct. Some nuclei become smaller
(pyknotic) while some nuclei disappear.
iii. The compressed collagenous fibers
gradually unite into a more or less cell
free mass.
iv. In addition certain changes also occur
in the ground substance.
v. There is a breakdown of the blood
vessel walls leading to spilling of their
contents.
vi. Osteoclasts are formed in marrow spaces
and adjacent areas of the inner bone
surface after a period of 20 to 30 hours.
The presence of hyalinized zone indicates
that the ligament is nonfunctional and
therefore bone resorption cannot occur.
The tooth is hence not capable of further
movement until the local damage tissue has
been removed and the adjacent alveolar bone
wall resorbs.
The elimination of hyalinized tissue occurs
by two mechanisms:
1. Resorption of the alveolar bone by osteo­
clasts differentiating in the peripheral
intact perio­d ontal membrane and in
adjacent marrow­spaces.
308 Essentials of Orthodontics
2. Invasion of cells and blood vessels from the
periphery of the compressed zone by which
the necrotic tissue is removed. The invading
cells penetrate the hyalinized tissue and
eliminate the unwanted fibrous tissue by
enzymatic action and phagocytosis.
Greater the forces, the wider are the area of
hyalinization. Thus larger areas of the ligament
become functionless, thereby showing large
areas of rearward resorption. If lighter forces
are used, the hyalinized functioning ligament is
available. This frontal resorption predominates
in case lighter forces are used.
THEORIES OF TOOTH MOVEMENT
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 that 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 piezoelectric theory.
Pressure Tension Theory
Oppenheim in 1911 was the first person to
study the tissue changes in the bone incident
to orthodontic tooth movement. Schwarz
(1932) is said to be the author of this theory.
According to Schwarz, whenever a tooth is
subjected to an orthodontic force, it results
in areas of pressure and tension. The area of
the periodontium in the direction of tooth
movement is under pressure while the area of
periodontium opposite the tooth movement
is under tension. According to him, the areas
of pressure show bone resorption while areas
of tension show bone deposition.
Fluid Dynamic Theory
This theory is also called the blood flow
theory as proposed by Bien. According to this
theory, tooth movement occurs as a result of
alterations in fluid dynamics in the periodontal
ligament. The periodontal ligament occupies
the periodontal space which is confined
between two hard tissues namely the tooth
and the alveolar socket. The periodontal space
contains a fluid system made up of interstitial
fluid, cellular elements, blood vessels and
viscous ground substance in addition to the
periodontal fibers. It is a confined space and
the passage of fluid in and out of this space
is limited. The contents of the periodontal
ligament thus create a unique hydrodynamic
condition resembling a hydraulic mechanism
and a shock absorber. When the force is
removed, the fluid is replenished by diffusion
from capillary walls and recirculation of the
interstitial fluid. When the force applied is of
short duration such as during mastication, the
fluid in the periodontal space is replenished as
soon as the force is removed. But when a force
of greater magnitude and duration is applied
such as during orthodontic tooth movement,
the interstitial fluid in the periodontal space
gets squeezed out and moves towards the apex
and cervical margins and results in decreased
tooth movement. This is called the ‘squeeze
film effect’ by Bien.
When an orthodontic force is applied,
it results in compression of the periodontal
ligament. Blood vessels of the periodontal
ligament get trapped between the principal
fibers and this result 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 vascular stenosis causes
blood gases to escape into the interstitial fluid
thereby creating a favorable local environment
for resorption.
Bone bending and piezoelectric theories
of tooth movement:
A century ago, Farrar (1876) first noted
deformation or bending of interseptal alveolar
walls. He was the first to suggest that bone
bending may be a possible mechanism for
bringing about tooth movement.
Piezoelectricity is a phenomenon obser­
ved in many crystalline materials in which
a deformation of the crystal structure
produces a flow of electric current as a result
of displacement of electrons from one part
of the crystal lattice to the other. A small
electric current is generated when bone is
mechanically deformed. The possible sources
of the electric current are:
i. Collagen: In bone, collagens exist in a
crystalline state and can thus be a source
of piezoelectricity when deformed.
ii. Hydroxyapatite: It also is crystalline
in form and therefore can produce
electricity when deformed.
iii. Collagen-hydroxyapatite interface: The
junction between the collagen and
hydroxyapatite crystals when bent can
be a source of piezoelectricity.
iv. The mucopolysaccharide fraction of
the ground substance although not
crystalline may also possess the ability
to generate electric current when
deformed.
When a crystal structure is deformed,
electrons migrate from one location to another
resulting in an electric charge. As long as the
force is maintained, the crystal structure is
stable and no further electric effect is observed.
Biomechanics 309
When the force is released the crystals return
to their original shape and a reverse flow of
electrons is observed. This rhythmic activity
produces a constant interplay of electric
signals whereas occasional application and
release of force produces occasional electric
signals.
Piezoelectric signals have two unusual
characteristics:
i. Quick decay rate: When a force is applied,
a piezoelectric signal is produced. This
electric charge quickly dies away to zero
even though the force is maintained.
ii. When the force is released, 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 with negative
charges and evoke bone apposition. Areas of
convexity are associated with positive charges
and evoke bone resorption.
When a force is applied, 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 concave and
an electric signal associated with resorption is
established.
PHASES OF TOOTH MOVEMENT
Studies have shown that tooth movement
progresses through three stages. Burstone
categories the stages as:
1. Initial phase
2. Lag phase
3. Postlag phase.
Initial Phase
During the initial phase, very rapid tooth
movement is observed over a short distance
which then stops. This movement represents
310 Essentials of Orthodontics

BIOCHEMICAL REACTION TO
ORTHODONTIC TOOTH MOVEMENT
(FLOW CHART 7.1)

It is known that bone cells respond to an

orthodontic force by proliferation in order to
bring about bone deposition and resorption.
However, the changes that occur at the cellular
level in response to a force are not totally
understood.
When a force is applied onto a tooth it
results in a number of biophysical events
Figure 7.5: Phases of tooth movement
such as compression of periodontal ligament,
bone deformation and tissue injury. These
biophysical events in turn lead to certain
displacement of the tooth in the periodontal biochemical reactions at a cellular level which
membrane space and probably bending of bring about bone remodeling. Thus, a process
alveolar bone to a certain extent. Studies have of transduction occurs where mechanical
shown that both light and heavy forces displace energy (orthodontic force) is converted into a
the tooth to the same extent during this initial cellular response.
phase of tooth movement (Fig. 7.5).
Flow chart 7.1: Summary of biochemical events
Lag Phase
During this phase, little or no tooth movement
occurs. This phase is characterized by formation
of hyalinized tissue in the periodontal ligament
which has to be resorbed before further tooth
movement can occur. The duration of the lag
phase depends on the amount of force used to
move the tooth. If light forces are used, the area
of hyalinization is small and frontal resorption
occurs. If heavy forces are used, the area of
hyalinization is large. Resorption in this case
is rearward and a longer lag period occurs to
eliminate the hyalinized tissue.

Postlag Phase
After the lag phase, tooth movement progresses
rapidly as the hyalinized zone is removed and
bone undergoes resorption. During this postlag
period, osteoclasts are found over a large
surface area resulting in direct resorption of
bony surface facing the periodontal ligament.

Bone deformation and compression of the
periodontal ligament leads to the release of
some extracellular signaling molecules called
first messengers. They include hormones
such as PTH, local chemical mediators such
as prostaglandins and neurotransmitters
such as substance P and vasoactive intestinal
polypeptide (VIP).
The first messengers bind to receptors
present on the cell surface of target cells and
initiate a process of intracellular signaling. The
intra-cellular signaling results in formation of
second messengers, which include cyclic AMP,
cyclic GMP and calcium.
The formation of second messengers inside
the cells is believed to initiate formation of
bone cells namely ostelclasts and osteoclasts
which are responsible for bone remodeling.
An alternative biologic pathway for ortho­
dontic tooth movement has been suggested by
some workers. According to them, orthodontic
force results in certain amount of tissue injury.
Subsequently, hydrolytic enzymes are released
which activate enzyme collagenase that contri­
butes to bone resorption.
BONE RESORPTION
Bone resorption is brought about by cells called
osteoclasts. They are multinucleated giant cells
and may have 12 or more nuclei. Osteoclasts
are irregularly oval or club-shaped with
branching processes. They occur in hay like
depressions in bone called Howship’s lacunae
and have prominent mitochondria, lysosomes
and vacuoles. Each of their nuclei has a single
nucle­olus. This part of the osteoclast in contact
with the resorbing bone has a ruffled border.
The osteoclasts are derived from:
i. Activation of previously present inactive
osteoclasts.
Biomechanics 311
ii. Migration from adjacent bone.
iii. Formation of new osteoclasts from local
macrophages of periodontal ligament.
iv. Influx of monocytes from blood vessels.
During bone resorption three processes
occur in more or less rapid succession. They
are:
1. Decalcification
2. Degradation of matrix
3. Transport of soluble products to the extra­
cellular fluid or blood vascular systems.
Organic acids such as citric acid and lactic
acid and hydrogen ions are secreted by the
ruffled border of the osteoclasts which increase
the solubility of hydroxyapatite leading to
decal­cification. The degradation of the matrix
is brought about by the activity of Cathepsin
B-1 (lysosomal acid protease). Finally, the
breakdown products of bone are transported
to the extracellular fluid and blood vascular
system.
BONE DEPOSITION
Bone formative changes are observed on the
tension side. As a forerunner to the process
of bone deposition, there seems to be an
increase in the number of osteoblasts which
are the bone forming cells. They are ovoid
cells with basophilic cytoplasm and have
an oval nucleus. They lie against the bone
surface where active bone formation is in
progress, i.e. periosteum or endosteum and
help in the formation of the organic matrix
and also control the deposition of mineral
salts. Osteoblasts increase in number by
proliferation of their precursor cells which are:
i. Fibroblasts in periodontal ligament
ii. Perivascular stem cells.
Osteoid tissue, deposited on the tension
side, gets calcified resulting in the formation of
312 Essentials of Orthodontics
bone lamellae. The periodontal fibers readapt
to the new position of the tooth by proliferation
of the intermediate zone.
Orthodontic Root Resorption
The loss of root structure due to orthodontic
tooth movement is referred to as external
apical root resorption. Detection of root
resorption is most obvious in the apical area;
however, a histologic investigation provides
evidence that the same resorptive process
also occurs on other areas of the root surfaces.
Factors which lead to root resorption include,
the magnitude of orthodontic force, treatment
mechanics, direction of tooth movement,
appliance type and treatment duration.
All permanent teeth may show microscopic
amounts of root resorption that are clinically
insignificant and radiographically undetected.
Root resorption of permanent teeth is a
probable consequence of orthodontic
treatment and active tooth movement. The
incidence of reported root resorption during
orthodontic treatment varies widely among
investigators. Usually, extensive resorption
does not affect the functional capacity or the
effective life of the tooth. Most studies agree
that the root resorption process ceases once
the active treatment is terminated.
Root resorption of the deciduous dentition
is a normal, essential, and physiologic
process. Permanent teeth have the potential
to clinically undergo significant external
root resorption when affected by several
stimuli. This resorptive potential varies in
persons and between different teeth in the
same person. This throws doubt on the role
of systemic factors as a primary cause of root
resorption during orthodontic treatment.
Tooth structure, alveolar bone structure at
various locations, and types of movement
may explain these variations. The extent of
treatment duration and mechanical factors
definitely influence root resorption. In most
root resorption studies, it is not possible to
compare the results and conclusions because
of their different methods. Further research in
this field is necessary to advance the service of
the specialty.
Root resorption is commonly associated
with excessive force particularly tipping
and torquing movements. Endodontically
treated tooth show more root resorption. Root
resorption is more common in upper lateral
incisors.
The question of whether there is an optimal
force to move teeth without resorption or
whether root resorption may be predictable
remain unanswered.
Effects of Orthodontic Tooth
Movement on Dental and
Periodontal Tissues
Enamel
The enamel organ was the most severely
affected tissue. Destroyed parts appeared in
the pressure and tension areas during force
application, the organ remaining intact in the
vicinity of the rotational fulcrum. Four distinct
degrees of enamel organ disintegration were
observed: (1) lysis of ameloblast cytoplasm,
leaving denuded, pyknotic nuclei; (2) dissolu­
tion of the cell membrane and clustering of
nuclei; (3) complete disappearance of the
ameloblastic layer, which left the enamel space
being bordered by a compressed papillary
layer; and (4) disintegration of the papillary
layer, with resultant direct contact between
enamel and periodontal connective tissue.
In some instances the denuded enamel was
covered by a layer of cementum.
As was to be expected, the damage to the
enamel organ was reflected in the enamel

tissue in the form of uncalcified enamel matrix
or partial or total lack of enamel development.
At the sites where the uncalcified enamel
matrix was denuded and came into direct
contact with the connective tissue, active
resorption of enamel had taken place.
Dentin
The main dentinal injury consisted of tissue
resorption, which was equally distributed on
the mesial, lingual and lateral tooth sides. On
the labial side, dentinal resorption was less
pronounced. Almost all teeth exhibited enamel
and/or dentinal tissue folds. The enamel folds
were formed by convoluted ameloblastic
layers, their cells secreting enamel matrix into
the thus created enclosed spaces. The dentinal
folds did not show any predilection for either
mesial, lingual, or lateral tooth side.
All afflicted areas in the incisors were
translated incisally by the process of continuous
tooth eruption. Thus, after 2 to 3 weeks of
recovery, the apical half of the tooth began to
display healthy tissues. However, toward the end
of the observation period, new lesions occurred,
which once again encompassed the entire tooth
length. The calculations of the earliest possible
onset of the dental lesions showed that the
enamel organ and, consequently, the enamel
became affected as late as 8 to 9 weeks after load
removal. New dentinal folds continued to be
formed for at least 6 weeks after force removal,
whereas folds in the enamel were created only
under direct tooth loading and 1 week into the
recovery period. New sites of tooth resorption
were evident up to 4 and 6 weeks after cessation
of force application in the enamel and dentin,
respectively.
Periodontal Ligament
Typical hyalinized areas and abscesses were
found in the apical part teeth. Necrotic areas
were also present in the crestal 3 mm of the
Biomechanics 313
PDL. The hyalinized areas always appeared
in conjunction with tooth or bone resorption.
The application of mechanical force
caused rupture of blood vessels and extensive
hemorrhage in both the pressure and tension
sites. Many accumulations of erythrocytes in
the periodontal connective tissue were present
along the tooth, but disappeared at the later
stages of recovery. Vascularization of the PDL,
on the other hand, increased with time on all
tooth sides as evidenced by two phenomena:
(1) The appearance of big blood vessels in the
incisal half of the PDL that, in the control teeth,
was characterized by very small arterioles and
venules, the big vessels in this group being
situated only in the apical half of the PDL; and
(2) the formation of large sinusoids completely
separating the tooth from the bone toward the
end of the observation time.
A large number of inflammatory cells
accompanied the pathologic changes in the
PDL. In the PDL cell frequency rose from 56
percent to a peak of 100 percent; thereafter
it gradually subsided, to totally disappear.
The macrophages amassed in the vicinity of
impaired and resorbing enamel.
The orientation and attachment of the
collagen fibers appeared normal, except in
the injured areas. Thereafter, the frequency of
fiber disarrangement and lack of attachment
to the bone steadily increased, and from the
4th recovery week onward encompassed 100
percent of the examined teeth. In the PDL that
had been under tension, additional lesions,
taking the form of scars, edema, and cell
denuded areas bordering big blood vessels and
looking like densely packed ground substance
were noted, and were located chiefly along the
middle-third of the tooth.
Pulp
Orthodontic tooth movement is usually a
slow response to light force. Nevertheless, the
314 Essentials of Orthodontics

process is considered by some to be a controlled ANCHORAGE IN

trauma to the tooth-supporting structures. ORTHODONTICS
Therefore, changes similar to those reported
after traumatic injuries may be common. DEFINITION (GRABER)
Varying degrees of vascular compression after
experimental tooth movement have been Anchorage in orthodontics refers to the nature
documented histologically. Studies using and degree of resistance to displacement
radiorespirometric techniques indicate that offered by an anatomic unit when used for the
orthodontic forces cause a depression of the purpose of effecting tooth movement.
oxygen utilization system within the pulp (White and Gardiner)
cells. In addition, histologic studies after tooth Anchorage is the site of delivery from which
movement have shown formation of secondary a force is exerted.
dentin, disruption of the odontoblastic layer,
and disturbances in the circulation. The CLASSIFICATION
clinical implication of these observations has
not been described. However, one speculation Anchorage can be classified in a number
is that alteration in pulpal respiration rate may of ways. The following is a comprehensive
have a deleterious effect on the long-term classification put forward by Moyers:
vitality of the tooth. Remodeling of periodontal I. According to the manner of force appli­
tissues during orthodontic tooth movement cation:
has been extensively studied. However, no 1. Simple anchorage
one has reported damage to the root structure 2. Stationary anchorage
other than surface resorption, particularly at 3. Reciprocal anchorage.
the apex. II. According to the jaws involved:
1. Intramaxillary anchorage
Alveolar Bone 2. Intermaxillary anchorage.
When crown is tipped lingually the alveolar III. According to the site of anchorage:
bone changes occurs with resorption at the 1. Intraoral anchorage
lingual cortical area and deposition in the 2. Extraoral anchorage
labial crest area. • Occipital
• Cervical
Temporomandibular Joint • Cranial
Orthodontic treatment has often been bla­med • Facial.
for causing occlusal and mandibular dysfun­ 3. Muscular anchorage.
ction. But definitive correlations between the IV. According to the number of anchorage unit:
ortho­dontic treatment and tem­poro­mandibular 1. Single or primary anchorage
joint (TMJ) dysfunction is still lacking. Special 2. Compound anchorage
care should be taken in patients with existing 3. Multiple or reinforced anchorage.
joint problems and occlusal disharmonies. Adult V. According to force:
patients are more prone for this mandibular 1. Maximum anchorage
dysfunction as their adaptability to the treatment 2. Minimum anchorage
is less when compared to children. 3. Moderate anchorage.
 Biomechanics 315

SOURCES OF ANCHORAGE

• Intraoral source
• Extraoral source.

Simple Anchorage (Fig. 7.6)

Simple anchorage is obtained by angagine
with the appliance a greater number of teeth
than are to be moved within the same dental
arch. The ratio of surface area of the roots of the
Figure 7.7: Transpalatal arch
anchor teeth to that of the teeth to be moved is
sufficiently high to ensure adequate stability of
the anchorage, bearing in mind the direction
of force. The ratio of surface area of roots of
anchor teeth to the teeth to be moved should
usually be at least 2:1, e.g. labial movement of
lingually placed central incisor.

Compound Anchorage
Anchorage where the resistance provided by
more than one tooth with greater support is
used to move teeth with lesser support is called Figure 7.8: Lower lingual arch
compound anchorage.

Reinforced Anchorage the reaction of the movable part. This is

(Figs 7.7 and 7.8)
It happens frequently that the stability of
simple anchorage is insufficient to withstand
Figure 7.6: Simple anchorage
particularly so when the upper molars are to
be moved distally. The anchorage may then
be augmented or stabilized in one of several
ways, namely:
1. Anterior inclined plane: The mandible
may be used to reinforce the anchorage
by the engagement of the lower incisors
on to upper inclined bite plane which
is constructed at an angle of 60o to the
occlusal plane. This exerts a backward pull
on the appliance through the mandible.
2. Sved type of plate: Occasionally further
reinforcement may be obtained by exerting
the inclined bite plane over the incisal
edges. This is known as Sved type plate
and has the advantage of splinting the
incisors to prevent them from being
316 Essentials of Orthodontics

inclined labially. They can only move

bodily forwards with the appliance.
3. A rigid labial bow: May be constructed to
engage the labial surfaces of the incisors
at the junction of cortical two-thirds and
incisal one-third of each crown. This labial
bow can be fitted to the contour of labial
surface of teeth which will splint the teeth
in the same say as Sved bite plate. This
labial bow is referred to as ‘fitted labial bow’.
4. The anchorage may be reinforced in the
case of fixed appliance by designing the
appliance so that only bodily movement
of the anchor teeth can occur. One method Figure 7.9: Correction of crossbite
or accomplishing this is to pass a bow
wire through horizontal tubes on bands
attached to adjacent teeth.
5. Use of extraoral anchorage.
6. In correcting anteroposterior relationship
of the upper and lower dental arches it is
necessary to reinforce the anchorage to
such an extent that the opposing jaw is used
as anchorage. In these cases there is some
movement in each arch, but the movement
is not equal. This is known as intermaxillary
anchorage and is infact a form of reinforced
anchorage.
Figure 7.10: Correction of midline diastema
Reciprocal Anchorage
The anchorage is said to be reciprocal in those • Class II elastic force
cases where it is designed that two teeth or • Class III elastic force
group of teeth shall move to an equal extent • Activator.
in opposite directions. It is necessary that each
group should offer equal resistance (Figs 7.9 Baker’s Anchorage
and 7.10). (Figs 7.11 and 7.12)
It is the other name for intermaxillary anch­
Intermaxillary Anchorage orage.
This is used when the teeth of the opposite Many noticed that a large percentage of
jaw are employed for anchorage. It is very patients seeking orthodontic treatment had
often used in correcting the anteroposterior relatively straight teeth, but the upper and
relationship of the upper and lower dental lower teeth are not related properly. In most
arches. For example: of these cases, the upper teeth protruded

Figure 7.11: Class II Baker’s anchorage
Figure 7.12: Class III Baker’s anchorage
excessively and the lower teeth and jaw seemed
to be underdeveloped. Baker’s anchorage was
made use to correct protrusion of upper teeth
and under development of lower teeth and
jaw. This was achieved by using inter maxillary
elastics. In Class III cases reverse elastics are
used (Fig. 7.12).
Intramaxillary Anchorage (Fig. 7.13)
This term means anchorage obtained from a
tooth or teeth of one jaw to move another tooth
or teeth in the same jaw. It may be:
Biomechanics 317
Figure 7.13: Incisor retraction intramaxillary
anchorage
• Simple anchorage
• Reinforced anchorage
• Reciprocal anchorage
For example, canine retraction
Stationary Anchorage
Stationary anchorage is that form of attachment
to a tooth that is essentially rigid so that the
tooth is not permitted to tip in its socket but
must move bodily, if at all through the alveolar
process. It gathers support for stability from
added mechanical advantage, for instance
a square or rectangular wire fitting into a
square or a rectangular tube, e.g. the pitting of
bodily movement of one tooth against tipping
movement of another, the tooth to be moved
bodily offers the greater resistance.
Prepared Anchorage (Fig. 7.14)
Prepared anchorage is a special type of
anchorage advocated by Tweed in his Edgewise
Figure 7.14: Prepared anchorage
318 Essentials of Orthodontics
appliance. His concept is to distally tip the
mandibular molars the to pit it against the
retraction of maxillary anteriors.
Extraoral Sources (Fig. 7.15)
They are mainly used when adequate resistance
cannot be obtained from intraoral sources for
the purpose of anchorage. Certain extraoral
areas can be utilized as sources of anchorage
to bring about orthodontic or orthopedic
changes. They are mainly used when adequate
resistance cannot be obtained from intraoral
sources for the purpose of anchorage. The
extraoral sources of anchorage include the
cranium, the back of the neck and the facial
bones.
The cranium (Occipital or parietal anchorage):
Extra-oral anchorage can be obtained by using
headgears that derive anchorage from the
occipital or parietal region of the cranium.
These devices are used along with a face bow
to restrict maxillary growth or to move the
dentition or maxillary bone distally.
Cervical area: Extraoral anchorage can
alternatively be obtained from the neck or
cervical region. Such a type of headgear is
called cervical headgear.
Facial bone: The frontal bone and the
mandibular symphysis offer anchorage during
face mask therapy in order to protract the
maxilla. Such a type of headgear that makes
Figure 7.15: Extraoral anchorage
use of anchorage from the forehead and chin
for maxillary protraction is called reverse pull
headgear.
Factors Affecting Anchorage
Teeth
Whenever some teeth are moved ortho­
dontically, the remaining teeth of the oral
cavity can act as anchorage or resistance units.
This is due to the fact that the teeth themselves
can resist movement. The anchorage potential
of teeth depends on a number of factors such
as root form, root size, number of roots, root
length and root inclination.
a. Root form: The anchorage potential of a
tooth depends largely on its root form.
Cross-sections of roots can be of three
types; round, flat and triangular. Round
roots as seen in bicuspids and palatal root
of maxillary molars can resist horizontally
directed forces in any direction. Flat
rots, for example those of mandibular
incisors and molars and the buccal roots
of maxillary molars, can resist movements
in the mesiodistal direction but have
little resistance to movement on the thin
edges found on their buccal and lingual
sides. Triangular roots of canines and
maxillary central and lateral incisors offer
the maximum resistance to displacement
compared to round or flat root forms.
b. Size and number of root: Multirooted teeth
with large roots have a greater ability to
withstand stress than single rooted teeth.
The greater the surface area, the more
periodontal ligament fibers it can support
to increase its stability.
c. Root length: In physiological conditions,
the root 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 greater is its resistance to
displacement, e.g. maxillary canines.
d. Position of tooth in dental arch: The position
of the tooth and the basal bone is important
in determining the anchor value of a
tooth. Although without much root length
comparable to canine the mandibular
second molar is located between two ridges
of basal bone, mesial to retromolar pad of
mandible. Because of this position it seems
to offer more resistance to bodily mesial
movement than any other tooth.
e. Inclination of tooth: The axial inclination of
a tooth is important in assessing its value as
a source of anchorage. A greater resistance
to displacement is offered when the force
exerted to move teeth is opposite to that of
their axial inclination. This is because parts
of the force is expended down the axis of
tooth, to bone beneath thus tensing move
of the tooth periodontal ligament fibers
and cause the roots to dig in.
f. Ankylosed 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.
Mutual Support
In addition to the resistance offered by an
individual tooth, each tooth in the arch is
supported by contact with another on either
side of it, the exception of the last molar on
each side. Also the mandibular arch is confined
by the maxillary arch by one cusp buccally
and labially. The maxillary molars support
the mandibular arch posteriorly from lingual
pressures by holding the buccal cusps of the
mandibular molars between their buccal and
lingual cusps. A mechanism of adjustment
to wear, the anterior component of force,
Biomechanics 319
normally keeps these teeth in tight contact.
Thus no tooth can be considered as anchorage
without considering its relationship to other
teeth in dental arches.
Basal Bone
Certain areas of the basal jaw bones are
available intraorally as sources of anchorage.
These areas include the hard palate and the
lingual surface of the mandible in the region
of the roots. These intraoral hard areas of basal
bone can be used to augment intramaxillary or
intermaxillary anchorage.
The Musculature
The normal tonus of the facial and masticatory
muscles plays an important role in the normal
development of dental arches. Abnormal
hypotonic musculature causes flaring and
spacing of teeth, while hypertonic muscles
exert restrictive forces in a lingual direction.
Dental anchorage may be increased by making
use of hypertonic labial musculature as in the
case of a lip bumper.
• Manner of force application
• Duration of force
• Site of anchorage
• Magnitude of anchorage.
Anchorage Planning
Anchorage planning is of utmost importance
for the success of orthodontic treatment.
Prior to initiation of orthodontic therapy, it
is essential to carefully assess the anchorage
demands of an individual case so that
appropriate treatment modalities can be
executed. The anchorage requirement
depends on a number of factors which are
listed below.
Number of teeth being moved: The greater the
number of teeth being moved, the greater is
the demand on the anchorage.
320 Essentials of Orthodontics

Type of teeth being moved: The movement of

slender anterior teeth offers lesser strain on
the anchorage than robust multirooted teeth.
Type of tooth movement: Whenever bodily
tooth movement is required, there is greater
strain on the anchorage. In contrast, tipping
tooth movements offer a relatively lesser stain
of the anchor units.
Duration of tooth movement: Treatment of a
prolonged duration places an undue strain on
the anchorage.
Based on the above-mentioned factors, the
anchorage demand of a particular patient is
determined. Cases that have a high anchorage
requirement need reinforcement of the
anchorage by one or more of the various means Figure 7.16: Maximum anchorage
mentioned earlier. In spite of the precaution
taken in planning anchorage, a certain
amount of unwanted movement of the anchor
teeth invariably occurs during orthodontic
treatment. Such unwanted movements of
anchor teeth are called ‘anchorage loss.’

Maximum, Minimum and

Moderate Anchorage

Maximum Anchorage (Fig. 7.16)

The reaction force should not move teeth, i.e. it
should remain in place. This situation is called
maximum anchorage situation suggesting a
permanent position of the anchor unit.

Minimum Anchorage (Fig. 7.17)

The reaction force should move the teeth
to the same extent as the action force. This
circumstance is appropriately termed as
minimum anchorage.
Moderate Anchorage (Fig. 7.18)
A number of conditions exist between these
extremes and can be probably grouped as
moderate anchorage.
Figure 7.17: Minimum anchorage
IMPLANTS AS ANCHORAGE IN
ORTHODONTICS
Although the principle of orthodontic
anchorage has been implicitly understood
since the 17th century, it does not appear

Figure 7.18: Moderate anchorage
to have been clearly articulated until 1923
when Louis Ottofy defined it as “the base
against which orthodontic force or reaction of
orthodontic force is applied.”
Although the concept of temporary implant
anchorage has only recently been described, it
was envisioned as early as 1945. A temporary
anchorage device (TAD) is a device that is
temporarily fixed to bone for the purpose of
enhancing orthodontic anchorage either by
supporting the teeth of the reactive unit or
by obviating the need for the reactive unit
altogether and which is subsequently removed
after use.
Classification
1. Intraosseous/Endosseous or in-bone impl­
ants: Intraosseous implants consist of pegs,
screws and cage like structure, which are
placed in normal or artificial tooth sockets.
These are partly submerged and anchored
within the bone.
Biomechanics 321
2. Transosseous or through-bone implants:
These implants penetrate completely
through the bone of the mandible.
This design is limited to placement in
the anterior symphyseal region of the
mandible. It provides a series of posts on
which prosthesis is attached and retained.
3. Subperiosteal or on-bone implants: Subper­
io­steal implants are set on the surface of
bone beneath the mucoperiosteum. Muller
conceived the basic idea half a century ago
in 1937.
4. Submucosal implants/Mucosal inserts: This
method involves implanting small button-
like retention elements under the mucous
membrane, with the purpose of providing
retention for a total prosthesis particularly
in the maxilla. Submucosal implants have
not gained wide acceptance.
1. Endosteal Implants
Root Form Implants
Given sufficient width and height of the bone
available, root forms [submergible, two-stage,
and one-piece] is the first choice in selecting
an implant. The following types are available:
A. Press-fit (unthreaded but covered with
a roughened hydroxyapatite [HA] or
titanium plasma spray [TPS] coating)
B. Self-tapping (threaded)
C. Pretapping (threaded).
Crete Mince (Thin Ridge) and other Mini
implants
Crete Mince implants are threaded, self-
tapping, titanium spirals.
Blade Implants
Blade implants are available as submergible,
two-stage and single-stage, one-piece devices
as follows:
• Prefabricated
322 Essentials of Orthodontics
• Custom-cast
• Alterable (by cutting, bending, and shaping
at chairside).
Ramus Blade and Ramus Frame
The ramus implant is a one-piece blade
made for use in the posterior mandible when
insufficient bone exits in the body of the jaw.
The ramus frame is a three-blade, one-piece
device designed for relatively atrophied
mandibles for which the subperiosteal implant,
because of cost or operator preference, is not
desirable.
2. Transosteal Implants
A submental skin incision is required under
operating room conditions when this modality
has been selected. One advantage of using the
transosteal implant is predictable longevity.
Several designs are available:
• Single component
• Multiple components, staple designs
(several varieties).
3. Subperiosteal Implants
They are available as complete, universal, and
unilateral.
Subperiosteal implants are generally quite
reliable, when sufficient bone is unavailable
for the use of endosteal varieties. However,
when extreme mandibular atrophy exists,
mandibular augmentation further improves
the prognosis.
Subperiosteal implants are always custom
made. They may be fabricated either by
making a direct bone impression or by using
stereo­lithographic technology. They may
be used in any part of either jaw, and will
serve as abutments for a variety of prosthetic
configurations, although the over denture
is the most widely used to complement the
complete subperiosteal implant.
4. Endodontic Stabilizers
Endodontic stabilizers are highly successful as
tooth root lengthening implants. One reason
for their success is that they have no site of
permucosal penetration because they are placed
into bone through the apices of natural teeth.
This implant offers a one-stage treatment
for the stabilization of teeth that suffer from
inadequate crown-root ratios. Their percentage
of success when periodontal problems have
been treated approaches that of conventional
endodontic therapy.
5. Intramucosal Inserts
Intramucosal inserts are button-like, nonim­
planted retention devices that can be used to
stabilize full and partial maxillary and mandi­
bular removable denture prostheses. Because
of the simple and relatively noninvasive
nature of the procedure placement, they are
of particular value for patients who are poor
and medical risks.
1. Based on the implant morphology:
A. Implants disks
i. Onplant
B. Screw designs­—these include:
i. Mini-implant
ii. Orthosystem implant system
iii. Aarhus implant
iv. Microimplant
v. Newer systems such as the Spider screw,
the OMAS system, the Leone mini-
implant, the Imtec screw, etc.
C. Plate designs—These include:
i. Skeletal anchorage system (SAS)
ii. Graz implant supported system
iii. Zygoma anchorage system.
2. They can also be classified depending on
the area of placement as:
A. Subperiosteal implants
B. Osseous implants
C. Interdental implants.

Subperiosteal Implants
The onplant: This is a classic example of
a subperiosteal implant in Orthodontics.
Developed by Block and Hoffman in 1995, this
system consists of a circular disk 8 to 10 mm
in diameter with a provision for abutments
in the center of the superficial surface. These
abutments would enable the Orthodontist to
carry out tooth movement against the onplant.
The undersurface of this Titanium disk is
textured and coated with Hydroxyapatite (HA).
The HA, being bioactive help in stabilization
of the implant by improving integration with
bone. The average thickness (height) of the
implant is 3 mm.
Method of placement: The onplant is placed
by a surgeon through a specialized procedure
known as Tunneling. After making an
incision in the posterior region of the palate,
subperiosteal tunnel flap is created extending
till the desired location, using an elevator.
Care is taken to position the onplant as close
to the midline as possible. The onplant is not
disturbed for a period of 3 to 4 months to allow
biointegration. Later, the superficial surface of
the onplant is exposed using a trephine and the
desired abutment is then threaded on.
Studies on onplants: Extensive animal studies
have been carried out on patients. They point
out to the fact that on plants biointegrate
and can tolerate a maximum force of 161
lbs. Block and Hoffman further suggest that
these onplants could be used not only for
dental anchorage, e.g. retraction of anterior or
distalising posteriors, but also for orthopedic
traction. Human trials are however, limited.
Disadvantages of Onplants
a. A long waiting period prior to orthodontic
force application.
b. Excessive surgical intervention—Two
sur­g e­r ies are necessary after onplant
placement; one to uncover the onplant
Biomechanics 323
cover screw and the other to remove
the onplant itself following orthodontic
treatment.
c. Cost factor.
Osseous Implants
Osseous implants are those that are placed
in dense bone such as the zygoma, the body
and ramus area or the midpalatal areas. The
implant systems under this category are the
skeletal ancho­rage system, the orthosystem
the Graz implant supported system and the
zygoma anchorage system.
Skeletal Anchorage System
Umemori and Sugawara developed the
skeletal anchorage system. It essentially
consists of titanium miniplates, which are
stabilized in the maxilla or the mandible using
screws. The earlier of these miniplates were
the conventional surgical miniplates, which
are used by Oral Surgeons for rigid fixation.
The recent versions of these mini­plates have
been modified for attaching orthod­o ntic
elastomeric or coil springs.
Different designs of miniplates are available
and this fact offers some versatility in placing
the implants in different sites. The ‘L’ shaped
minip­lates have been the most commonly
used ones, while the ‘i’ shaped ones have been
proposed for usage while intruding anterior
teeth. The screws used for fixing the miniplate
are usually 2 to 2.5 mm in diameter.
Method of placement: A surgical flap has to
be raised at the site of implant placement.
The implant site has to be carefully assessed
radiographically for erupting teeth, sinus lining
(in the maxilla) and the inferior alveolar canal
(in the mandible). The miniplate is adapted
to the bony contour and the end loop of the
miniplate is bent outward to remain exposed
into the oral cavity. This loop ultimately acts
as the site of attachment for orthodontic
324 Essentials of Orthodontics
force application. Force application is usually
deferred by 3 to 4 weeks to ensure adequate
healing. When used for achieving molar
intrusion, an additional buccal root torque
should be incorporated in the archwire to
minimize buccal flaring.
The Orthosystem Implant
Developed by Wehrbein, this is a titanium
screw implant with a diameter of 3.3 mm
inserted into the median palate or the
retromolar regions of the mandible or the
maxilla. The implants are surface treated with
sand blasting and acid etching to improve
integration. They are available in two sizes of 4
mm and 6 mm length, an 8 week waiting period
has been suggested before applying forces onto
this implant.
Graz Implant Supported System
Introduced by Karcher and Byloff, this
anchorage system consists of a modified
titanium miniplate, with provision for four
miniscrews, and two oval shaped cylinders.
This was used mainly as support for the Nance
button of a pendulum app­liance in the palate.
The Zygoma Anchor System
Hugo De Clerck and Geerinckx of Belgium
introduced this system in 2002. It is a curved
titanium miniplate with provision for three
screws of 2.3 mm diameter each to offer it
the necessary stability. The lower end of the
miniplate projects outward and contains a
vertical slot for ligatures or other orthodontic
attachments. The plate is designed for use
in the zygomaticomaxillary buttress area.
Placement is identical to that of the SAS plate.
The authors have successfully used this
system on 27 patients for achieving anterior
retraction as well as molar distalization.
Advantages of osseous implants: The osseous
implants, specially the miniplate designs offer
the Orthodontist a fair chance of success in
effecting complex tooth movements such as
molar intru­sion. True intrusion of upper and
lower molars in moderate anterior open bite
cases converts a borderline orthognathic case
into an pure orthod­ontic one. This emerging
new area of implant application has been
termed as Orthognathic Orthodontics.
Limitations of osseous implants:
a. They need a fairly complex surgery and
therefore have to be placed by a surgeon.
b. The chances of infection are greater than
the screw implants.
c. Their removal is as difficult as the place­
ment.
They are favored over the retromolar
implants due to the following reasons:
a. Placement is very simple and can be done
under LA.
b. They seem to be equally effective in
resisting forces as the larger root form
implants.
c. They can be used for bringing about all
types of tooth movement.
d. Removal is an uneventful procedure.
An earlier variant of these implants was
the impacted titanium post, introduced by
Bousquet et al in 1996.
Interdental Implants
(Figs 7.19 and 7.20)
i. The mini-implant : Ryuzo Kanomi
introduced the mini-implant in 1997.
The implant is a modified surgical
miniscrew of 1.2 mm diameter and 6
to 7 mm length, which can be placed
interdentally this procedure, is carried
out under local anesthesia.
ii. The Aarhus implant : Birte Melsen
developed the Aarhus implant.
iii. M i c r o i m p l a n t s : M i c r o i m p l a n t
anchorage (MIA) is a customized

Figure 7.19: Palatal implants
Figure 7.20: Buccal implants
implant system developed by a team of
Korean Orthodontists. These are small
diameter implants, which can be placed
interdentally either in the buccal sulcus
or palatal interdentally areas. The screws
are available in different lengths and
diameters. The maxillary implants are
longer than the mandibular ones owing
to the differences in the thickness of
cortical bone. The microimplants are
made of titanium and the procedure
Biomechanics 325
of their placement is similar to that of
Aarhus implants. In mobile mucosal
areas, such as the buccal aspect in the
maxillary arch, it has been suggested
that the implants be placed directly
without placing an incision. The pilot
drill is usually 0.2 to 0.3 mm smaller
than the desired implant size and is
drilled at a slow speed. The implants are
driven at an angle of approximately 45o
to the long axis of maxillary teeth and
10o to the mandibular teeth to ensure
optimum retention by augmenting the
area of contact between the implant and
adjacent bone.
Newer interdental systems: These are the
Spider screw and the OMAS (Orthodontic
Minianchor System). They are identical to the
microimplants discussed earlier. The variation
is in the form of minor modifications in the
implant head. The principles are however
the same. The trend presently seen is toward
immediate loading of the screws.
ANCHORAGE LOSS
Anchorage loss is the unwanted movement
of the anchor unit instead of the teeth to be
moved.
Signs of Anchorage Loss
• Tipping of anchor teeth
• Closure of extraction space by movement
of anchor teeth
• Proclination of anterior teeth
• Spacing of teeth
• Increase in overjet
• Change in molar relation
• Buccal cross bite of upper posteriors.
326 Essentials of Orthodontics
CHAPTER
Preventive
8 and Interceptive
Orthodontics
PREVENTIVE ORTHODONTICS
Preventive orthodontics is that part of orth­
o­­d­ontic practice which is concerned with
the patient’s and parents education, super­
vision of the growth and development of the
dentition and the craniofacial structures, the
diagnostic procedures undertaken to predict
the appearance of malocclusion and the
treatment procedures instituted to prevent the
onset of malocclusion.
DEFINITION
Graber defined preventive orthodontics as, “It
is the action taken to preserve the integrity of
what appears to be normal at a specific time.”
Preventive orthodontics is a long-term
approach and it is largely a responsibility of
the general dentist. Many of the procedures
are common in preventive and interceptive
ortho­dontics but the timings are different.
Preventive procedures are undertaken in
anticipation of development of a problem.
Interceptive proced­ures are undertaken when
the problem has already manifested.
The following are some of the procedures
undertaken in preventive orthodontics:
Patients and Parents Education
Preventive dentistry should ideally begin much
before the birth of the child. The expecting
mother should be educated on matters such
as nutrition to provide an ideal environment
for the developing fetus. Soon after birth,
the mother should be educated on proper
nursing and care of the child. In case the
child is being bottle-fed the mother is advised
on the use of physiologic nipple and not the
conventional nipple. The conventional nipples
are nonphysiologic and do not permit suckling
by movement of the tongue and the lower jaw.
They rather cause suckling of the milk which
may lead to various orthodontic problems of
the teeth. The physiologic nipples on the other
hand are designed to permit suckling of the
milk which more or less resembles the normal
functional activity as in breastfeeding.
The parents should be educated on the
need for maintaining good oral hygiene. The
parents should be taught the correct method
of brushing teeth. Audiovisual programs for
 Preventive and Interceptive Orthodontics
children like regular dental check ups, scaling,
fluoride application and pit and fissure seal­
ants can also be implemented.
CARIES CONTROL
Caries involving proximal surface of deciduous
teeth if not restored leads to loss of arch length
by movement of adjacent teeth into that space.
Caries should be detected by clinical and
radiographic examination. Bite wing radio­
graphs are valuable aid in detection of caries.
Once the caries is detected, proper rest­or­ ­ation
of the affected teeth should be undertaken
immediately to prevent loss of arch length.
Care of Deciduous Dentition
Preventive orthodontics includes care of
deciduous dentition by way of prevention and
timely restoration of carious teeth. The deciduous
teeth are excellent natural space maintainers
until the developing permanent teeth are ready
to erupt into the oral cavity. Thus all efforts
should be taken to prevent early loss of the
deciduous teeth. Simple preventive procedures
such as application of topical fluoride and pit and
fissure sealants help in preventing caries.
Extraction of Supernumerary Teeth
Presence of supernumerary and supplemental
teeth can interfere with the eruption of nearby
normal teeth. They can deflect adjacent teeth
to erupt in abnormal positions. Presence of
an unerupted mesiodens prevents the two
maxillary central incisors from approximating
each other. Thus, supernumerary teeth should
be identified and extracted before they cause
displacement of other teeth.
327
Eliminating Occlusal Interference
All functional prematurities should be elimi­
nated as they can lead to deviations in the
mandibular path of closure and also predispose
to bruxism. Using articulating paper, the prem­
ature contact areas are detected and selective
grinding is carried out. Sometimes abnormal
anatomical features like enamel pearls, may
cause premature contact. They should be
eliminated by grinding.
Maintenance of Tooth Shedding
Timetable
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:
i. Presence of overretained deciduous
teeth or roots
ii. Supernumerary tooth
iii. Cysts
iv. Overhanging restoration in deciduous
dentition
v. Fibrosis of gingival
vi. Ankylosed primary teeth.
Management of Ankylosed Teeth
Ankylosis is a condition characterized by
absence of the periodontal membrane in a
small area or the whole of the root surface.
Ankylosed deciduous teeth do not get resorbed
and therefore either prevent the deciduous
teeth from erupting or deflect them to erupt
in abnormal locations. These ankylosed teeth
should be diagnosed and surgically removed at
an appropriate time to permit the permanent
teeth to erupt.
328 Essentials of Orthodontics
Management of Abnormal
Frenal Attachments
The presence of a thick and fleshy maxillary
labial frenum that is attached relatively
low prevents the maxillary central incisors
from approximating each other. This kind of
abnormal frenal attach­ment in most patients is
caused due to hereditary factors. They should
hence be diagnosed and treated at an early age.
Presence of ankyloglossia or tongue tie
prevents normal functional development
due to lowered position of the tongue and
abnormalities in speech and swallowing.
This condition should be surgically treated to
prevent full-fledged malocclusion.
ORAL HABITS CHECK-UP AND
EDUCATING PATIENTS AND
PARENTS
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 physiolo­
gically designed nursing nipple and pacifier to
enhance normal functional and deglutitional
activity.
Preventing Milwaukee Brace Damage
Milwaukee brace is an orthopedic 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
and possible deformities. Whenever such
an appliance is used, occlusion should be
protected using functional appliances or
positioners made of soft materials.
Deeply Locked Permanent First
Molars
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 second
deciduous molar helps in guiding the eruption
of the first permanent molars.
Muscle Exercises
Muscle exercises can be used to prevent
the tongue thrusting and lip biting habits.
Patients are thought for the proper muscle
exercises and proper position of tongue during
deglutition.
SPACE MAINTAINERS
Premature loss of deciduous teeth can cause
drifting of the adjacent teeth into the space.
It can result in abnormal axial inclination of
teeth, spacing between teeth and shift in the
dental midline. Premature loss of deciduous
anter­iors leads to very little orthodontic chan­
ges. If the deciduous first molars are lost prem­
aturely, lateral shift of anteriors takes place. In
case of premature loss of deciduous second
molars, the first permanent molars migrate
mesially thereby leaving insufficient space
for the erupting second premolars which can
get impacted within the jaw or get deflected
and erupt in an abnormal location. Space
maintainer is a device used to maintain the
space created by the loss of a deciduous tooth.
Space maintainer is an appliance which
maintains the mesiodistal width of the lost
primary tooth and the lost function to an
extent.
 Preventive and Interceptive Orthodontics 329

Classification which take place during the transition from

Several authors have classified space maintai­ deciduous to permanent dentition.
ners as follows: 8. The space maintainer should not come in
I. Hitchcock: the way of other functions.
1. Removable or fixed or semifixed
2. With bands or without bands Indications of Space Maintainers
3. Functional or nonfunctional 1. Restoration of function
4. Active or passive 2. Esthetics
5. Combinations of above. 3. Psychological reasons
II. Raymond C Thurrow: 4. To prevent drifting of teeth
1. Removable 5. Prevent sequelae of periodontal and caries
2. Complete arch problem
a. Lingual arch 6. Prevent space loss or to maintain the space
b. Extraoral anchorage 7. To protect ectopic eruption of teeth
3. Individual tooth. 8. To prevent undesirable habits.
III. Hinrichsen:
1. Fixed space maintainers Contraindications of Space
Class I Maintainers
a. Nonfunctional types 1. When the mesiodistal width of underlying
i. Bar type permanent tooth is less than the space
ii. Loop type present.
b. Functional types 2. When the tooth is near the crest of ridge
i. Pontic type 3. When underlying permanent tooth is
ii. Lingual arch type missing
Class II: Cantilever type (Distal shoe, band 4. When we want the molars to drift forwards.
and loop). Type of space maintainer to be used
2. Removable space maintainers depends on:
A space maintainer should fulfill the following 1. Tooth loss
requirements: 2. Age of the patient
1. It should maintain the entire mesiodistal 3. Status of remaining tooth
space created by a lost tooth. 4. Type of occlusion
2. It must restore the function as far as possi­ 5. Patient cooperation
ble and prevent overeruption of opposing 6. Preference of operator.
teeth.
3. It should be simple in construction. Removable Space Maintainers
4. It should be strong enough to withstand They are space maintainers which can be
the functional forces. removed and reinserted into the oral cavity
5. It should not exert excessive stress on adjo­ by the patient. Removable space maintai­
in­ing teeth. ners can be classified as functional and
6. It must permit maintenance of oral hygi­ene. nonfun­ctional space maintainers. Functional
7. It must not restrict normal growth and space main­tainers incorporate teeth to aid in
deve­lop­m ent and natural adjustments mas­ti­cation, speech and esthetics whereas
330 Essentials of Orthodontics
nonfunctional space maintainers have only an
acrylic extension over the edentulous area to
prevent space closure.
Advantages of Removable
Space Maintainers
1. They are easy to clean and permit main­
tenance of proper oral hygiene.
2. They maintain or restore the vertical
dimension.
3. They can be work part time allowing
circulation of the blood to the soft
tissues.
4. They serve other important functions like
mastication, esthetics and phonetics.
5. Dental check up for caries detection can
be undertaken easily.
6. Room can be made for permanent
teeth to erupt without changing the
appliance.
7. They stimulate eruption of permanent
teeth.
8. Band construction is not required.
9. Helps in preventing development of
tongue thrust habit into the extraction
space.
10. Easier to fabricate and less chair time.
Disadvantages of Removable
Space Maintainers
1. They may be lost or broken by the patient.
2. Uncooperative patients may not wear the
appliance.
3. Lateral jaw growth may be restricted, if
clasps are incorporated.
4. They may cause irritation of the underlying
soft tissues.
Indications for Removable
Space Maintainers
1. Removable dentures are indicated when
esthetics is of prime concern.
2. In case the abutment teeth cannot support
a fixed appliance it is recommended to use
removable space maintainers.
3. In cleft palate patients who require obtur­
ation of the palatal defect.
4. In case of radiograph reveals that the
une­ru­pt­ed permanent tooth is not going
to erupt in less than five months time, a
removable appliance is given.
5. If the permanent teeth have not fully
erupted it may be difficult to adapt bands.
6. Multiple losses of deciduous teeth which
may require functional replacement in the
form of either partial or complete denture.
Contraindications of Removable
Space Maintainers
1. In patients without cooperation.
2. Patients who are allergic to acrylic materials
3. Epileptic patients who have uncontrolled
seizures.
Some commonly used removable space
maintainers.
Acrylic Partial Dentures
Acrylic partial dentures have been used suc­
cess­­fully in patients who have undergone
multiple extractions. This appliance can be
readily adjusted to allow the eruption of teeth.
The inclination of artificial teeth in the denture
restores masticatory function. Clasps can be
fabricated on deciduous canines and molars
for retention.
Complete or Full Dentures
Sometimes all the primary teeth of a preschool
child may require extraction due to rampant
caries of teeth that cannot be restored. Although
this procedure was more common in the
prefluoridation era, even today some children
may require complete extraction of their
deciduous teeth. These cases are managed by
 Preventive and Interceptive Orthodontics
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 approximating the mesial surface
of the unerupted first permanent molar. The
denture will have 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 and first permanent
molars have erupted, a partial denture space
maintainer can be used until the remaining
permanent teeth erupt.
Removable Distal Shoe Space
Maintainer
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
molar is lost shortly before the eruption of
the first permanent molar. The tooth to be
extracted is cut away from the stone model
and a depression is cut into the stone model to
allow the fabrication of the acrylic extension.
The acrylic will extend into the alveolus
after the removal of the primary tooth. The
extension may be removed after the eruption
of the permanent tooth.
Fixed Space Maintainers
Space maintainers which are fixed or fitted onto
the teeth are called fixes space maintainers.
Advantages of Fixed Space Maintainers
1. Bands and crowns are used which require
minimum or no tooth preparation.
2. They do not interfere with passive eruption
of abutment teeth.
3. Jaw growth is not hampered.
331
4. The succedaneous permanent teeth are
free to erupt into the oral cavity.
5. They can be used in uncooperative patients.
6. Masticatory function is restored if pontics
are placed.
Disadvantages of Fixed Space Maintainers
1. Elaborate instruments with expert skill is
needed.
2. They may result in decalcification of tooth
material under the bands.
3. Supraeruption 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 Maintainers
Band and loop space maintainer (Fig. 8.1):
Band and loop space maintainers are one
of the most common space controlling
appliances 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 mesial
to the extraction space. It is a unilateral fixed
Figure 8.1: Band and loop space maintainer
332 Essentials of Orthodontics
appliance indicated for space maintenance
in the posterior segments when a single tooth
is lost.
Crown and loop appliance: Crown and loop
appliance are similar to band and loop space
maintainers in all respects except that a
stainless steel crown is used for the abutment
tooth. The crown is used in preference to
the band when the abutment tooth is highly
carious, exhibits marked hypoplasia or is
pulpotomized.
The lingual arch space maintainer: The lingual
arch is the most effective appliance for space
maintenance in the lower arch. The classical
mandibular lingual arch consists of two bands
cemented on the first permanent molars or on
the second deciduous molars, which are joined
by a stainless steel wire contacting the lingual
surface of the four mandibular incisors. The
appliance is usually indicated to preserve the
spaces created by multiple losses of primary
molars. It helps in maintaining the arch
perimeter by preventing both mesial drifting
of the molars and also lingual collapse of the
anterior teeth (Fig. 8.2).
They are similar to the lingual arch described
above. Palatal arches are designed to prevent
mesial migration of the maxillary molars. They
are constructed using 0.036 inch diameter hard
stainless steel wire. The Nance holding arch is a
maxillary lingual arch that does not contact the
Figure 8.2: Lower lingual arch
Figure 8.3: Nance palatal arch
anterior teeth, but approximates the anterior
palate. It incorporates an acrylic button in the
anterior region that contacts the palatal tissue
(Fig. 8.3).
Transpalatal Arch
More recently, the transpalatal arch has been
recommended for stabilizing the maxillary first
permanent molars when the primary molars
require extraction. The transpalatal arch
consists of a thick stainless steel wire that spans
the palate connecting the first permanent
molar of one side with the other. The best
indication for transpalatal arch is when one
side of the arch is intact, and several primary
teeth on the other side are missing.
Distal Shoe Space Maintainer
(Figs 8.4A and B)
Distal shoe space maintainer is otherwise
known as the intraalveolar appliance. The
distal surface of the second primary molar
guides the unerupted first permanent molar.
When the second primary molar is removed
prior to the eruption of the first permanent
molar, the intraalveolar appliance provides
greater control of the path of eruption of the
unerupted tooth and prevents undesirable
mesial migration. The appliance which is used
 Preventive and Interceptive Orthodontics
A B
Figures 8.4A and B: Distal shoe space maintainers
in practice now is Roche’s distal shoe or its
modification using crown and band appliances
with a distal intragingival extension.
It was described by Steffen, Miller and
Johnson in 1971. Its method of construction
is simple and also provides an esthetic
component. The space maintainer consists of
a plastic tooth fixed onto a lingual arch which
in turn, is attached to molar band.
Band and Bar Type Space Maintainer
(Fig. 8.5)
This is fixed space maintainer in which the
abutment teeth on either side of the extraction
space are banded and connected to each other
by a bar. Alternately stainless steel crowns can
be used on the abutments. This type of space
maintainer is called crown and bar space
maintainers.
Figure 8.5: Band and bar space maintainer
333
INTERCEPTIVE
ORTHODONTICS
Interceptive orthodontics basically refers to
measures undertaken to prevent a potential
malocclusion from progressing into a more
severe one.
There are number of procedures that can
be undertaken by the orthodontist, so as to
intercept a malocclusion that is developing.
Unlike preventive orthodontic procedures that
are aimed at elimination of factors that may lead
to malocclusion, interceptive orthodontics is
undertaken at a time when the malocclusion has
already developed or is developing. The terms
preventive and inter­ceptive orthodontics are
sometimes used synonymously. But it should
be understood that preventive orthodontic
procedures are undertaken when the 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.
DEFINITION
Interceptive orthodontics has been defined as
that phase of the science and art of orthodontics
employed to recognize and eliminate poten­
tial irregularities and malpositions of the
developing dentofacial complex.
The procedures undertaken in interceptive
orthodontics include:
1. Serial extractions
2. Correction of developing crossbite
3. Control of abnormal habits
4. Space regaining
5. Muscle exercises
334 Essentials of Orthodontics
6. Interception of skeletal malrelation
7. Removal of soft tissue or bony barrier to
enable eruption of teeth.
SERIAL EXTRACTIONS
(FIGS 8.6A TO D)
Serial extraction is an interceptive orthodontic
pro­c edure usually initiated in the early
mixed dentition when one can recognize
and anticipate potential irregularities in the
dento­facial complex and is corrected by a
procedure that includes the planned extraction
of certain deciduous teeth and later specific
permanent teeth in an orderly sequence and
predetermined pattern to guide the eruption
permanent teeth into a more favorable position.
Definition
Serial extractions involve the orderly removal
of selected primary and permanent teeth in a
predetermined sequence (Dewel).
A planned sequence of selective, timed
extra­ction of deciduous and subsequently
A B
C D
Figures 8.6A to D: Serial extractions
permanent teeth, with the objective of relieving
severe crowding early and facilitating the
eruption of remaining teeth into improved
positions (AAO). Close supervision and
control of ensuing eruption are essential to
avoid unfavorable sequelae, such as closure
of the spaces by mere mesial migration or
tipping of the posterior teeth. Comprehensive
orthodontic treatment is almost always req­
uired for space management, control of
the tipping and increase of overbite usually
induced by the procedure, and for other
malrelationships that may be present. Serial
extraction is preferably perfor­med on patients
with minimal overbite, symm­etrical buccal
segments and a Class I molar relationship. It
is often indicated in patients with large tooth
size rather than small bony bases (Tweed):
Planned and sequential removal of primary
and permanent teeth to intercept and reduce
dental crowding problems.
History
Kjellgren in 1929 used the term serial extra­
ction to describe a procedure where some
deciduous teeth followed by permanent
teeth were extracted to guide the rest of the
teeth into normal occlution. Nance during
the 1940’s popularized this technique in the
United States and termed it ‘Planned and
progressive extraction’. Hotz in 1970 called
such a procedure ‘active supervision of teeth
by extraction’.
Rationale
Serial extraction is based on two basic principles:
Arch length tooth material discrepancy:
Whenever there is an excess of tooth material
as compared to the arch length, it is advisable
to reduce the tooth material in order to achieve
stable results. This principle is utilized in serial
extraction procedures where tooth material is
 Preventive and Interceptive Orthodontics
reduced by selective extraction of teeth so that
the rest of the teeth can be guided to normal
occlusion.
Physiologic tooth 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.
Davis rules: Davis proposed some rules which
are to be present ideally in a case to be selected
for serial extraction, they are:
1. Skeletal Class I malocclusion
2. Normal profile
3. Well-supported lower incisor segment
4. Flat occlusal plane
5. Normal overbite, overjet and midline
relation
6. Arch length discrepancy of 10 to 12 mm
7. Favorable eruption sequence.
Indications for Serial Extractions
1. Class I malocclusion showing harmony
between skeletal and muscular system.
2. Arch length deficiency as compared to
the tooth material is the most important
indication for serial extraction. Arch length
deficiency is indicated by the presence of
one or more of the following features:
i. Absence of physiologic spacing, and
crowding in deciduous dentition.
ii. Unilateral or bilateral premature loss of
deciduous canines with midline shift.
iii. Malpositioned or impacted lateral inci­
sors that erupt palatally or lingually out
of the arch.
iv. Markedly irregular or crowded upper
and lower anteriors.
v. Localized gingival recession in the lower
anterior region is a characteristic feature
of arch length deficiency.
335
vi. Ectopic eruption and mesial migration
of buccal segment.
vii. Abnormal eruption path, pattern and
sequence.
viii. Lower incisor flaring.
ix. Ankylosis and abnormal resorptions of
one or more teeth.
x. Hereditary tooth size to jaw size discre­
pancy.
3. Where growth is not enough to over come
the discrepancy between tooth material
and basal bone.
4. Patients with straight profile and pleasing
appearance.
Contraindications
1. Class II and Class III malocclusion with
skeletal problems.
2. Spaced dentition.
3. Anodontia or oligodontia.
4. Open bite and deep bite.
5. Midline diastema.
6. Class I malocclusion with minimal space
deficiency.
7. Severe crowding.
8. Unilateral malformed teeth.
9. Extensive caries or heavily filled perma­
nent first molars.
10. Impacted canines.
11. If we cannot use fixed appliance for arch
collapse.
Advantages of Serial Extractions
1. Unerupted or erupted teeth which can
be guided into proper occlusion.
2. Avoids loss of alveolar bone.
3. Reduces severity of malocclusion.
4. Reduces the mechanotherapy.
5. Reduces the chair side time.
6. No TMJ problems.
7. Less pain and discomfort.
336 Essentials of Orthodontics

8. Psychological effect as the malocclusion comprehensive assessment of the skeletal,

is treated early. dental and soft tissues. A tooth material arch
9. Reduces retention time after treatment. length discrepancy must ideally exist.
10. More stable results are achieved. Model analysis: According to most authors, an
arch length deficiency if not less than 5 to 7
Limitations of Serial Extractions mm should exist to undertake this procedure.
1. Chances of increasing overbite. Study model analysis should be carried out
2. Failure of 3’s to migrate distally. to determine the arch length discrepancy.
3. Lingual tipping of teeth. Carey’s analysis in the upper arch should be
4. Enhances impaction of third molars. carried out. Mixed dentition analysis helps
5. Ditching or spaces can be left behind in determining the space required for the
between canines and premolars. erupting buccal teeth.
6. Timing of tooth removal is specific. Radiographs: The eruption status of the
7. Occasionally it will be failure needing dentition is evaluated from a full mouth
full fledged treatment. intraoral periapical or orthopantogram. The
8. The axial inclination correction may skeletal tissue assessment should involve
require later fixed appliance treatment. comprehensive cephalometric examination
9. Patient cooperation is required as total to study the underlying skeletal relation. Serial
treatment time is prolonged. extraction produces the best results in a Class
10. Patient may develop tongue thrust habit I skeletal pattern. Presence of skeletal Class
in extracted areas. II or Class III is contraindications for serial
extraction procedure.
Precautions to be Taken during Photographs: Pre- and post-treatment photo­
Serial Extractions graphs are particularly useful in evaluating
1. Presence of permanent tooth the eruption pattern, to observe extraoral
2. Healthy eruptive pattern is ascertained changes, to assess muscular patterns and as
3. Proper morphology motivational tool.
4. Proper position. Teeth to be removed in serial extractions:
1. Deciduous canines (C)
Changes that Occur during Serial 2. Deciduous first molars (D)
Extractions 3. Permanent first premolars (4).
1. Prevents rotation
2. Deep bite Procedure
3. Space creation. A number of methods or sequences of
extraction have been described. Three popular
Objectives methods are:
Objectives of serial extraction are to make
treatment easier and the mechanotherapy less Dewel’s Method (C, D, 4)
complicated. Dewel has proposed a 3 step serial extraction
procedure. In the first step the deciduous
Diagnosis canines are extracted to create space for the
Clinical examination : The diagnostic alignment of the incisors. This step is carried
exercise prior to treatment should involve out at 8 to 9 years of age. A year later, the
 Preventive and Interceptive Orthodontics
deciduous first molars are extracted so that the
eruption of first premolars is accelerated. This
is followed by the extraction of the erupting
first premolars to permit the permanent
canines to erupt in their place.
In some cases a modified Dewel’s technique
is followed wherein the first premolars are
enucleated at the time of extraction of the first
deciduous molars. This is frequently necessary
in the mandibular arch where the canines
often erupt before the first premolars.
Tweed’s Method (D, 4, C)
This method involves the extraction of the
deciduous first molars around 8 years. This is
followed by the extraction of the first premolars
and the deciduous canines.
Nance’s Method (D, 4, C)
This is similar to Tweed’s technique and
involves the extraction of the deciduous first
molars followed by the extraction of the first
premolars and the deciduous canines.
Grewe’s Method
Grewe advocated serial extractions in Class I
and mild Class II malocclusions.
i. Class I with crowding (CD4): The decid­
uous canines are first extracted followed
by deciduous first molars and followed
by extraction of first premolars.
ii. Class I with premature loss of mandibular
deciduous canines (CD4): The maxillary
deciduous canines are extracted to
make the arch symmetrical, then D and
4 are sequentially extracted at periodical
intervals.
iii. Class I with bimaxillary protrusion or
crowding in posterior tooth (D4C): In
cases of bimaxillary dental protrusions
or in posterior crowding deciduous
first molars are extracted first followed
337
by enucleation of first premolars then
canines are extracted last.
iv. Class II with normal overjet (CD4): In these
cases with maxillary crowding deciduous
canines are extracted first followed by
deciduous first molars then the cases
are reevaluated for molar relation and if
required first premolars are removed.
v. Class II with increased overjet (DE5):
These cases are managed with extraction
of deciduous first molars followed
by deciduous second molars and
finally second premolars are removed,
if required deciduous canines are
removed to correct the overjet. This
technique is not commonly followed.
Postserial extraction fixed appliance therapy:
Most cases of serial extraction need fixed
appliance therapy for the correction of axial
inclination and detailing of the occlusion.
Removable appliances like Hawley’s appliance,
anterior bite planes and canine retractors are
occasionally used.
DEVELOPING ANTERIOR
CROSSBITE CORRECTION
Anterior crossbite is a condition characterized
by reverse overjet where in one or more
maxillary anterior teeth are in lingual relation
to the mandi­bular teeth.
Anterior crossbites should be intercepted
and treated at an early stage so as to prevent a
minor orthodontic problem from progressing
into a major dentofacial anomaly. An old
orthodontic axiom states, “The best time to
treat a crossbite is the first time it is seen”.
Anterior crossbite should be treated early
for the following reasons:
i. This type of malocclusion is self-per­
petuating, i.e. if the crossbite is present
338 Essentials of Orthodontics

in the deciduous dentition, it may

manifest in the mixed and permanent
dentition as well.
ii. Simple anterior crossbites that are
not treated early have the potential of
growing into skeletal malocclusion that
later need complicated orthodontic
treatment com­b ined at times with
surgical procedures.
Anterior crossbites can broadly be classified A

as:
1. Dentoalveolar anterior crossbite
2. Skeletal anterior crossbite
3. Functional anterior crossbite.

Dentoalveolar Anterior Crossbite

Anterior crossbite in which one or more maxi­­
llary anterior teeth are in lingual relation to the
mandibular anteriors is termed dento­alveolar
anterior crossbite. This kind of anterior crossbite
is often manifested as single tooth crossbite and
usually occurs due to overretained deciduous
teeth that deflect the erupting permanent teeth
into a palatal position. These dentoalveolar
crossbites can be effectively treated using
tongue blades (Fig. 8.7). Catalan’s appliance
(Figs 8.8A and B) and double cantilever springs
with posterior bite plane.
B
Figures 8.8A and B: Catalan’s appliance
Functional Anterior Crossbites
Some anterior crossbites are referred to as
functional crossbites. This type of crossbite is
the so called pseudo Class III malocclusion
where the mandible is compelled to close in
a position for­ward of its true centric relation.
Functional cross­b ites occur as a result of
occlusal prema­turities that cause a deflection
of the mandible into a forward position during
closure. These are to be treated by eliminating
the occlusal prematurities.

Figure 8.7: Tongue blade therapy
Interception of Habits
Habits in the orthodontic sense refer to certain
actions involving the teeth and other oral or
perioral structures which are repeated often
enough by some patients to have a profound
and deleterious effect on the positions of
teeth and occlusion. Some of the habits that
can affect oral structures are thumb sucking,
tongue thrusting and mouth breathing.
 Preventive and Interceptive Orthodontics
Thumb Sucking
One of the habits that is most frequently practi­
ced by children and is capable of producing
dama­g ing effects on the dentoalveolar
structures is the thumb sucking habit. The
presence of this habit up to 2½ to 3 years of
age is considered quite nor­mal. Persistance of
this habit beyond 3½ to 4 years of age can have
a damaging influence on the dentoalveolar
structures and should be inter­cepted.
Tongue Thrusting
Tongue thrusting is defined as a condition
in which the tongue makes contact with
any teeth an­terior to the molar during teeth
swallowing. This is a deleterious habit that can
clinically present with open bite and anterior
proclination. The tongue thrust habit should
be intercepted by using habit breakers. The
patient should be trained and educated on the
correct technique of swallowing.
Mouth-Breathing
Mouth-breathing habit has a profound effect
on the dentofacial region. It can be obstructive
or habitual in nature. Obstructive mouth-bre­
athing is usually a result of nasal polyps, nasal
tumors, chronic nasal inflammatory condi­
tions and deviated nasal septum. Habitual
mouth-breathing is one where oral breathing
persists as a habit after the removal of the nasal
obstruction.
Mouth-breathing affects the orofacial
equilibrium due to lowered mandibular and
tongue posture and can therefore produce
severe malocclusion. Interceptive procedures
should involve identification and removal of
the cause persistence of habitual oral breathing
is an indication to use a vestibular screen to
intercept the habit.
339
Space Regaining
If a primary molar is lost early and space
maintainers are not used, a reduction in arch
length by mesial movement of the first molar
can be expected. In such patients, the space
lost by mesial movement of the molar can be
regained by distal movement of the first molar.
Not all patients who have lost arch length by
mesial molar movement are ideal candidates
for space regaining. The space regaining
procedures are preferably undertaken at an
early age prior to the eruption of the second
molar. The following are some of the commonly
used space regainers.
Gerber Space Regainer
A seamless orthodontic band or a crown is
selected for the tooth to be distalized. This
space regainer consists of ‘U’ shaped hollow
tubing and a ‘U’ shaped rod that enters the
tubing. The rod is soldered or welded on the
mesial aspect of the first molar to be moved
distally. The ‘U’ shaped wire or rod is fitted into
the tube, in such a way that the base of the ‘U’
rod contacts the tooth mesial to the edentulous
area. Open coil springs of adequate length are
placed around the free ends of the ‘U’ shaped
rod and inserted into the tubing assembly. The
forces generated by the compressed open coil
springs bring about a distal movement of the
first molar.
Space Regainers Using Jack Screws
Space regaining can be brought about using jack
screws placed in such a way that an increase
in arch length is obtained by distalization of
the molar. The appliance consists of a split
acrylic plate with a jack screw in relation to
the edentulous space and is retained using
Adam’s clasp.
340 Essentials of Orthodontics

PREORTHODONTIC TRAINERS

Preorthodontic trainers are interceptive appli­

ances used to intercept the mild skeletal and
dental problems. Farrell of Australia used the
Computer aided Technique to fabricate these
appliance with silicone or nonthermoplastic
polyurethane materials.

Indications
1. Mild-to-moderate anterior crowding
Figure 8.9: Space regainer 2. Mild Class II division 1 and 2
3. Developing anterior open bites
4. Dental deep bites
Space regaining using cantilever spring: The 5. Mild dental Class III or pseudo Class III
molar can be distalized to regain space by 6. Oral habits.
using removable appliances that incorporate
simple finger springs (Fig. 8.9). Contraindications
Interception of skeletal malrelations: Skel­etal 1. Posterior crossbite
malocclusion if diagnosed at an early age can 2. Severe Class III
be intercepted so as to reduce the severity 3. Nasal obstruction
of the malocclusion that may occur. These 4. Noncooperative child
growth malo­cclusion procedures are aimed at 5. Skeletal malocclusion.
normalizing the skeletal relationship.
Interception of Class II malocclusions: Class Design
II malocclusion usually occurs as a result of The appliance is oral screen like enveloping the
either excessive maxillary growth, deficiency in teeth labially, and lingually. Occlusal bite plane
mandibular growth or a combination of both. is also present to increase the functioning
Maxillary growth can be restricted by use of space.
face bow with headgear. Class II malocclusion Small projections in the labial surface of
due to deficient mandibular growth is usually appliance functions as lip bumper. The labial
treated by myofunctional appliances. bow types of extensions are present in both
Interception of Class III malocclusions: Class III upper and lower anteriors for closing the
malocclusion occurs as a result of mandibular residual space and alignment.
prognathism, maxillary retrognathism or a Tongue tag is present to position the tongue
combination of both. Chin cup with headgear at the correct place for correcting the tongue
helps in restriction of mandibular growth while habits. Tooth channels are made such that the
Frankel III or face mask therapy is used for occlusion is kept at edge-to-edge bite similar to
cases of maxillary deficiency. activator. They are available in different sizes.
 Preventive and Interceptive Orthodontics
Phases of Treatment
Phase 1 (Blue): The softer blue trainer is used
first which allowed for correction of abberant
musculature and mild tooth movements. They
are worn for 6 to 8 months.
Phase 2 (Pink): This trainer exerts more forces
for increased tooth movement.
CLINICAL MANAGEMENT
The appliance is worn for 1 hour daily initially
and may be increased upto 6 to 8 hours. Blue
trainer is worn for 6 to 8 months followed
by pink trainer for 12 months or until the
treatment objectives are attained. Appliance is
kept clean by washing with water and soft soap.
Generally these appliances do not require any
adjustments other than trimming the edges
for ease of wearing and applying gels in sharp
areas.
Removal of Soft Tissue and
Bony Barriers
Whenever a permanent tooth fails to erupt
at the appropriate time, its eruption may be
stimulated by surgically exposing the crown.
Over retained primary teeth, ankylosed pri­
mary teeth and supernumerary teeth are other
possible causes of noneruption of succed­
aneous teeth, which should be ruled out prior
to this procedure.
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 be such
that the greatest diameter of the crown of the
tooth is exposed. In other words the surgically
created opening in the tissue is slightly larger
than the greatest dimension of the tooth. The
surgical wound is given a cement dressing for
a period of two weeks.
341
MUSCLE EXERCISES
The dental tissues are blanketed from all direc­
tions by muscles. Normal occlusal develop­
ment depends upon the presence of normal
orofacial muscle function. Muscle exercises
help in improving aberrant muscle function.
Exercise for the Temporalis Muscle
An exercise to strengthen the masseter muscle
involves the clenching of teeth by the patient
while counting to ten. The patient is asked to
repeat this for some duration of time.
Exercises for the Lips
(Circumoral Muscles)
A number of exercises have been suggested for
the lips and cheek muscles.
i. Stretching of the upper lip to maintain
lip seal is an important therapeutic
measure in patients having short
hypotonic lips. To aid in the stretching,
the patient is asked to hold a piece of
paper between the lips.
ii. Patients can be asked to stretch the upper
lip in a downward direction towards the
chin.
iii. Holding and pumping of water back and
forth between the lips.
iv. Massaging of the lips.
v. Button pull exercise: A button of 1.5 inch
diameter is taken and a thread passed
through the button hole. The patient is
asked to place the button behind the
lip and pull the thread, while restricting
it from being pulled out by using lip
pressure.
vi. Tug of war exercise: This is similar to the
button pull exercise. This involves use
of two buttons, with one placed behind
the lips while the other button is held by
another person to pull the thread.
342 Essentials of Orthodontics
Exercises for the tongue: One elastic swallow—
this exercise is used for correction of improper
positioning of the tongue. A 5/16 inch intraoral
elastic is placed on the tip of the tongue and the
patient is asked to raise the tongue and hold
the elastic against the rugae area and swallow.
Tongue hold exercise: A 5/16 inch elastic is
positioned over the tongue in a designated
spot for a prescribed period of time with the
lips closed. The patient is then asked to swallow
with elastic in place and lips apart.
Two elastic swallow: Two 5/16 inch elastics are
placed over the tongue, one in the midline and
the other on the tip and the patient is asked to
swallow with the elastics in position.
The hold pull exercise: The tip of the tongue and
the midpoint are made to contact the palate
and the mandible is gradually opened. This
exercise helps in stretching the lingual frenum.
Exercises for Masseter Muscles
These exercises are advocated to strengthen
the masseter muscles. The patient is asked to
clench the teeth, count upto 10 and then relax.
These exercises are repeated for 15 to 20 times
daily until masseter muscle becomes strong.
Exercises of pterygoid muscles: In Class II cases
with mandibular retrognathism patient is asked
to protrude the mandible as much as possible
and then retracted. These exercises are repeated
until the muscles become tired. Mandibular
position usually improves in 3 to 4 months.
Limitations of Muscle exercises
1. Patients cooperation is essential.
2. Faulty exercise may lead to problems.
3. Most of the times no significant changes
are seen.
4. They are not substitutes for regular orthod­
ontic treatment.
5. Not adviced in muscular dystrophy and
neural problems.
Musical Instruments and
Muscle Exercises
Orthodontists and all members of the dental
profession should have a good basic knowledge
of the relationship of the mouth to various
types of musical wind instruments so that they
can give valid advice to those who seek it.
Rogers demonstrated that certain corrective
muscle exercises would aid the normal
development of the dentofacial complex.
Some have called this myofunctional therapy.
Many of these same muscles, especially the
orbicularis oris in the lips and the ones which
radiate from it, are used in the playing of
wind instruments, and in the development of
embouchure, which is the manner in which
the mouth is applied to the mouthpiece. The
tonicity of these muscles permits a finely
controlled airstream to be emitted through the
lips. The development of the embouchure is of
prime importance to any musician because
it controls sound production, tone, quality,
articulation and dynamics. Porter also stressed
the importance of the embouchure and the fact
that the forces produced had a definite effect
on the dentition.
The positions of teeth depend on the forces
and pressures exerted on them. A balance of
forces is needed for the stability of any tooth.
The playing of wind instruments introduces
another set of pressures which certainly should
be evaluated, measured and understood for us
to be able to advise those who may be intere­
sted in instrumental study. Engelman used
a transducer to measure perioral pre­ssures
involved in the playing of wind instruments. He
asserted that “the effect of musical instruments
on the dentition warrants investigation,
since the forces produced by them may be of
sufficient magnitude, duration, and direction
to help produce a malocclusion or conceivably
to help correct one”.
 Preventive and Interceptive Orthodontics
Strayer was one of the first to recommend
the use of specific instruments for what
he believed to be their beneficial effects in
certain malocclusions. He divided the wind
instruments into four categories according to
the type of mouthpiece used:
1. Class A: All cup-shaped mouthpieces, as
in the trumpet, trombone, tuba, all horns,
and brasses.
2. Class B: Single-reed mouthpieces, as in the
clarinet and the saxophone.
3. Class C: Double-reed mouthpieces, as in
the oboe and bassoon.
4. Class D: Mouthpieces with a small aperture
or opening at the head, as in the flute and
piccolo.
The following recommendations can be
made by dentists when they are asked to
suggest instruments which are dentally suited
for children, especially in the 11 to 13 year age
group:
A. Group A: Cup-shaped mouthpieces, as in
the trumpet and horns.
1. To reduce overjet, especially in Class II
cases.
2. Tend to decrease in overbite in a 2-year
period.
343
B. Group B: Single-reed mouthpieces, as in
clarinet or saxophone.
1. To increase overjet.
2. Tend to increase overbite.
C. Group C: Double-reed mouthpieces, as in
oboe and bassoon.
1. Tend to reduce overjet.
2. To increase the overbite.
D. Group D: Mouthpieces with small openings
at head of instrument, as in the flute or
piccolo.
1. To reduce overjet.
2. To increase overbite.
The dentist can now suggest more than
one instrument to help with most changes in
overbite or overjet. Thus, the preferences of
student, teacher and parent can be given more
consideration in instrument selection.
The playing of the correct musical wind
instrument is not only a wonderfully rewar­
ding and satisfying vocation for the student,
but it can serve as an adjunct to the dentist or
orthodontist in trying to accomplish certain
tooth movements.
344 Essentials of Orthodontics

CHAPTER
Orthodontic
9 Appliances

Orthodontic treatment aims at improving the Mechanical Appliances

esthetics and function of the orofacial region.
Most of these changes are brought about
using devices which move teeth or modify the
growth of the jaws. These devices are called
orthodontic appliances.
Orthodontic appliances are devices
by means of which mild pressure may be
applied to a tooth or group of teeth and their
supporting structures so as to bring about
necessary changes within the bone which will
allow tooth movement.
These appliances exert mild pressure on a
tooth or a group of teeth and their supporting
structures in a predetermined direction with
the help of active components which are part
of the appliance itself.
Myofunctional Appliances
They are loose fitting or passive appliances
that harness the natural forces of the orofacial
musculature which are transmitted to the teeth
and alveolar bone through the medium of the
appliance.

CLASSIFICATION OF Removable Appliances

ORTHODONTIC APPLIANCES They are appliances which can be inserted
into and removed from the oral cavity by the
Broadly the appliances can be classified into patients.
two groups: Fixed appliances: They are appliances that are
1. Mechanical appliances fixed onto the tooth surface and can only be
• Removable removed by the operator.
• Fixed. Semifixed appliance: It is a combination of
2. Functional appliances fixed and removable appliance, a part of the
• Removable appliance only can be removed by the patient,
• Fixed. e.g. whip spring.

Sectional fixed appliance: A section of the arch
is treated by fixed appliance, e.g. pin and tube
appliance.
Active appliances: Active appliances exert a
force on the teeth or the supporting structure
to bring about the necessary tooth movement.
Passive appliances: Passive appliances do not
exert any force and are mostly used to retain
teeth which are moved to ideal position, or to
maintain space.
IDEAL REQUIREMENTS OF AN
ORTHODONTIC APPLIANCE
Appliances which are used for orthodontic
pur­poses should fulfill certain requirements:
1. Biological requirements:
i. The appliance should bring about the
desired tooth movements.
ii. The orthodontic appliance should not
produce pathologic changes such as
root resorption, periodontal damage or
non-vitality of the teeth.
iii. The appliance should not interfere with
normal growth.
iv. It should not interfere with normal
function.
v. The appliance should not bring about
unwanted tooth movement and sudden
changes.
vi. The material used in its fabrication
should be biocompatible and should
not produce toxic effects.
vii. The appliance should not disintegrate
in oral fluids.
2. Mechanical requirements:
i. The appliance should simple to fabricate
ii. It should not be bulky; the patient
should be comfortable using them.
iii. The appliance should be strong enough
to withstand masticatory forces.
Orthodontic Appliances 345
iv. The appliance should be able to deliver
contro­lled force. It should apply a force of
desired intensity, direction and duration.
v. The appliance should be universally
applicable, i.e. it must be able to handle
various malocclusions.
3. Hygienic requirements: The orthodontic
appliance should ideally be self cleansing.
If not it should be easy to clean them. The
appliance should not interfere with oral
hygiene maintenance.
4. Esthetic requirement: The orthodontic
appliance should be esthetically acceptable.
It is desirable to have an appliance that is
an inconspicuous as possible.
REMOVABLE APPLIANCES
Removable orthodontic appliances are devices
that can be inserted into and removed from the
oral cavity by the patient at will.
INDICATIONS FOR REMOVABLE
APPLIANCES
According to Proffit there are three instances
where we can use removable orthodontic
appliances:
1. Minor tooth movements. (e.g. finger spri­
ngs for midline diastema).
2. Retention appliance following fixed appli­
ance treatment. (e.g. Hawley’s retainer).
3. Functional appliances (e.g. activator,
bionator, twin blocks).
ADVANTAGES OF REMOVABLE
APPLIANCES
Removable orthodontic appliances have follow­
ing advantages:
346 Essentials of Orthodontics
i. The removable nature of the appliance
makes it possible for the patient to
maintain good oral hygiene during
orthodontic therapy. In addition the
appliance can be kept clean by the
patient.
ii. Most malocclusions requiring simple
tipping type of tooth movement can be
carried out with removable appliance.
iii. Many tooth movements like tipping,
overbite reduction can be undertaken.
iv. Bite planes can be incorporated with
removable appliances.
v. Simple tooth movements are undertaken
hence the control is less complex and
there is less strain on anchorage.
vi. These can be handled by general prac­
ti­t ioner for correcting simple malo­
cclusions.
vii. Takes less chairtime and is less expen­
sive.
viii. If there is any damage or problem,
patient can remove the appliance.
ix. Fabrication of removable appliances is
simple and requires fewer inventories.
x. They are less conspicuous than fixed
appliances.
DISADVANTAGES OF
REMOVABLE APPLIANCES
i. As the appliance can be removed,
patient cooperation is vitally important
for the success of treatment.
ii. Only simple tipping can be possible other
corrections require fixed appliances.
iii. In complex cases treatment is prolonged
as only few movements can be carried
out at a time.
iv. In extraction cases if excess spaces are
left behind, posterior segments cannot
be brought forward.
v. Cases other than 4s extraction are very
difficult to treat with removable appli­
ances.
vi. Lower removable appliances are not
well-tolerated.
vii. Multiple rotations are difficult to treat.
viii. Cannot be given in severe Class II and
Class III cases.
ix. Cannot be used in severe high angle and
severe low angle cases.
x. As the appliances are removable, there
is a greater chance of patient misplacing
or damaging them.
COMPONENTS OF REMOVABLE
APPLIANCES
Removable appliances are made-up of three
basic components:
1. Retentive components
2. Active components
3. Base plate.
I. Retentive Components
They are components that help in keeping the
appliance in place and resist displacement
of the appliance. The success of a removable
appliance is to a large extent dependent upon
good retention of the appliance. Appliances
that are loosely fitting and do not have adeq­
uate intraoral anchorage cannot bring about
the necessary tooth movements. Adequate
retention of a removable appliance is achieved
by incorporating certain wire components
that engage undercuts on the teeth. These
wire components that aid in retention of a
removable appliance are called clasps.
Principles of Retention
When using pressure against a tooth an equal
and opposite force is exerted on the body of
the appliance and on the base plate to the
 Orthodontic Appliances 347

clasps. The surface of the incisor tooth, where iv. They should not by themselves apply
it is engaged by spring in rarely vertical to any active force that would bring about
the occlusal plane. If it wire, reaction should undesirable tooth movements of the
simple be formed or backward thrust on this anchorage teeth.
base plate, there should be no downward and v. It should be easy to fabricate.
upward movement. vi. It should not impinge on the soft tissues.
vii. It should not interfere with normal
Mode of Action of Clasps occlusion.
Clasps act by engaging certain constricted
areas of the teeth that are called undercuts. Classification of Clasps
When clasps are fabricated, the wire is made I. Free ended clasp: (One end embedded in
to engage these undercuts so that their displa­ the acrylic portion and free end on the tooth
cement is prevented. There are two types of surface).
undercuts that are found in natural dentition. For example:
Buccal and lingual cervical undercuts: The • Circumferential clasp
buccal and lingual surfaces of molars have • Duyzing clasp
a distinct undercut at the cervical margin. • Crozat clasp
These can be seen from the mesial aspect • Triangular clasp
of a molar. Examples of clasp that engage • Ball end clasp
these buccal and lingual cervical undercuts • Hand wrought Roach clasp
are the circumferential clasp and Jackson’s • Arrow pin clasp.
clasp. These undercuts are available for clasp II. Continuous or looped clasps: (Both ends
fabrication only in those teeth that are fully are embedded in the acrylic portion or base
erupted. plate).
Mesial and distal proximal undercuts: The For example:
molars are widest mesiodistally at the contact • Molar clasp
point and gradually taper towards the cervical • Visick clasp
margin. These surfaces slopping from the • Arrowhead clasp
mesial and distal contact areas towards the • Adam’s clasp
neck of the teeth are called the mesial and • Eyelet clasp
distal proximal undercuts. They can be seen • Southend clasp.
when the molar is viewed from the buccal
aspect. These proximal undercuts are more Circumferential Clasp
pronounced than the cervical undercuts and (C Clasp or ¾th Clasp) (Fig. 9.1)
therefore offer more retention. Examples of The circumferential clasp is simple clasp that
clasps that engage these undercuts are the are designed to engage the buccocervical
Adams’ clasp and Crozat clasp. undercut. Wire is engaged from one proximal
Requirements of an ideal clasp: undercut along the cervical margin then
i. It should offer adequate retention. carried over the occlusal embrasure to end
ii. It should permit usage in both fully as a single retentive arm on the lingual aspect
erupted as well as partially erupted teeth. that gets embedded on the acrylic base plate.
iii. It should offer adequate retention even Advantage of this clasp is its simplicity
in the presence of shallow undercuts. of design and fabrication. Disadvantage of
348 Essentials of Orthodontics
Figure 9.1: Circumferential clasp
this clasp is that it cannot be used in partially
erupted teeth wherein the cervical undercut is
not available for clasp fabrication.
Jackson’s Clasp (Full Clasp) (Fig. 9.2)
This clasp was introduced by Jackson in
the year 1906. It is also called full clasp or
‘U’clasp. This clasp engages the buccocervical
undercut and also the mesial as well as distal
proximal undercuts. Wire is adapted along the
buccocervical margin and both the proximal
undercuts and then carried over both the
occlusal embrasures to end as retentive arms
on both sides of the molar. The advantage of
this clasp is that it is simple to construct and
offers adequate retention. The disadvantage
of Jackson’s clasp is that it offers inadequate
retention in partially erupted teeth.
Adams’ Clasp (Fig. 9.3)
The Adams’ clasp was first described by
Professor Philip C Adams’. It is also known as
liverpool clasp, universal clasp and modified
arrowhead clasp. When properly constructed
this clasp offers maximum retention. The
clasp is constructed using 0.7 mm hard round
stainless steel wire.
Figure 9.2: Jackson’s clasp
Figure 9.3: Adams’ clasp
The Adams’ clasp is made of the following
parts:
i. Two arrowheads
ii. Bridge
iii. Two crossover wires
iv. Two retentive arms.
The two arrowheads engage the mesial and
the distal proximal undercuts. The arrowheads
are connected to each other by a bridge which
is at 45o to the long axis of the tooth.
Advantages:
The Adams’ clasp offers a number of advan­
tages:
i. It is rigid and offers excellent retention.
ii. It can be fabricated on deciduous as well
as permanent tooth.
iii. They can be used on partially or fully
erupted teeth.
iv. It can be used on molars, premolars and
on incisors.
v. No specialized instruments are required
to fabricate the clasp.
vi. It is small and occupies minimum space.
vii. The clasp can be modified in a number
of ways.
viii. It can be easily adjusted.
ix. If it is broken it can be repaired by sold­
er­ing.

Construction of Adams’ Clasp
(Figs 9.4 and 9.5)
1. Preparation of cast: On the dental cast, trim
the interdental papilla so that mesial and
distal undercuts are made accessible on the
teeth to be clasped. This is best done with
very sharp chisel about 3 mm wide.
2. Wires: Molar and premolar—0.7 mm hard
stain­less steel wire (120–130 mm per size
inten­sible strength) Canine—0.6 mm SS wire.
Figure 9.4: Stages in Adams’ clasp fabrication
Figure 9.5: Fabrication of Adams’ clasp
Orthodontic Appliances 349
3. The stages in the formation of Adams’ clasp.
a. The first bend is a little more than right
angle. Two such bends are made, conn­
ected by a bridge sufficiently long to
span the tooth that is being clasped.
b. The second bond, made in two stages of
90° each. This second bend forms a ‘U’
turn in the wire 180° made outside the
tips of plier, so that right acute bend is
formed.
c. Third bend brings the tags of the clasps
over the embrasure between the teeth
and onto the lingual side of the dental
arch to be embedded in the base plate.
To make the third bend, the arrowhead
is grasped from the inside of the clasp
with a half of length of the arrowhead
between the peaks of the plier. The tag is
then bend firmly upwards, using thumb
and the bend continued until the tag is
at a little less than 90° to the arrowhead.
Essential Feature of the Adams’ Clasp
• Bridge is straight, not curved or bent
• Bridge stand clear of the tooth and the
gums
• Bridge is not fitted against the buccal
surface of the tooth
• Arrowheads are parallel, do not converge
or diverge
• The arrowhead slope to correspond with the
curve of the gum margin into the interdental
papilla
• The arrowhead are not twisted into a verti­
cal plane or laid in a horizontal plane
• Tag fits closely across the contact point
and one brought down into the interdental
embrasure lingually so as to avoid the bite
of the opposing teeth.
Modifications (Figs 9.6A to G)
The Adams’ clasp can be modified in a number
of ways. These modifications permit additional
350 Essentials of Orthodontics
A B
C D
E F
G required. They can be constructed to span a
Figures 9.6A to G: Modification of Adams’ clasp
uses or enhanced retention. The following are
some of the modifications.
Adams’ clasp with single arrowhead: The
Adams’ clasp can be modified to have a single
arrow­head. This type of clasp is indicated in a
partially erupted tooth which usually is the last
erupted molar. The single arrowhead is made
to engage the mesioproximal undercut of the
last erupted molar. The bridge is modified to
encircle the tooth distally and ends on the
palatal aspect as a retentive arm.
Adams’ clasp with J hook: A J hook can be sold­
ered on to the bridge of the Adams’ clasp. These
hooks are useful in engaging elastics.
Adams’ clasp with incorporated helix: A helix
can be incorporated into the bridge of the
Adams’ clasp. This also helps in engaging
elastics.
Adams’ clasp with additional arrowhead:
Adams’ clasp can be constructed with an
additi­­­onal arrowhead. The additional arrow­
head 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.
Adams’ clasp with soldered buccal tube: A
buccal tube can be soldered on to the bridge
of the Adams’ clasp. This modification permits
use of extraoral anchorage using face bow
headgear assembly.
Adams’ clasp with distal extention: The Adams’
clasp can be modified so that the distal arrow­
head has a small extension incorporated
distally. This distal extension helps in engaging
elastics.
Adams’ clasp on incisors and premolars: Adams’
clasp can be fabricated on the incisors and
premolars when retention in those areas is
single tooth or two teeth.
Resta clasp: Resta clasp is a modified Adams
clasp. It uses the arrowhead retentive point from
the Adams’ clasp and the ball from a ball clasp
to engage two undercut areas on the buccal
surface of the anchor tooth. The clasp passed
over the occlusal surface of the clasped tooth
either on its mesial or on its distal side. The
clasp is useful when interocclusal clearance or
space is available on only the meaial or distal
side of the tooth to be clasped. Although not
as retentive as an Adams’ clasp, the Resta clasp
has the ability to perform well in retainers. The
making of a Resta clasp is easier and quicker
than the forming of an Adams’ clasp. The
Resta clasp can be modified to be part of a
wraparound retainer design. The Resta clasp is
formed from preformed stainless steel ball clasp
wires having diameters of 28 mil (0.7 mm) for
premolars and 30 to 32 mil (0.8 mm) for molars.
Steps in Construction of Adam’s Clasp
1. Take about 4 inches of 0.7 mm stainless
steel wire.
2. Make a ‘L’ shaped bend.
3. Mark two perpendicular vertical lines from
mesial and distal sides on the buccal side
of the tooth.
4. Draw a horizontal line at the gingival
margin connecting these two lines.

5. Then, draw a bisector of these two lines,
extend it on to the surface of the tooth.
Mark the point, it corresponds to the posi­
tion of arrowheads. The distance between
these two points on buccal side gives us the
bridge length.
6. Then make the arrowheads.
7. Give a 45o bend to these arrowheads to the
bridge.
8. Then position it on to the tooth and adapt
the retentive arms.
Points to be checked in a completed
Adams’ clasp:
1. Arrowheads should be positioned at the
buccal proximal undercuts.
2. Bridge is placed in the middle-third of the
buccal surface of the tooth. It should be
placed at about 2 mm from the surface of
the teeth. It should be parallel to the buccal
surface or the central groove. Then viewed
from the side the bridge should be at an
angle of 45o to the tooth surface.
3. Retentive arms should not interfere with
occlusion.
4. Tags should be placed for retention into
acrylic.
Southend Clasp (Fig. 9.7)
The southend clasp is used when retention
is required in the anterior region. The wire is
adapted along the cervical margin of both the
central incisors. The distal ends are carried
over the occlusal embrasures to end as
retentive arms on the palatal side.
Figure 9.7: Southend clasp
Orthodontic Appliances 351
Figure 9.8: Triangular clasp
Triangular Clasp (Fig. 9.8)
They are small triangular shaped clasps that
are used between two adjacent posterior teeth.
Thus they engage the proximal undercuts
of two adjacent teeth. Triangular clasps
are indicated when additional retention is
required.
Ball End Clasp (Fig. 9.9)
This clasp is fabricated using stainless steel
wires having a knob or a ball-like structure on
one end. The ball can be made at the end of
the wire using silver solder. Preformed wires
having a ball at one end are also available.
The ball engages the proximal undercuts
between two adjacent posterior teeth as in a
triangular clasp. The distal end of the wire is
carried over the occlusal embrasure to end on
the palatal aspect as a retentive arm. The ball
end clasp is indicated when additional retention
is required.
Eyelet Clasp (Figs 9.10A and B)
This clasp is fabricated using 0.6 or 0.7 mm
stainless steel wire. Eyelet like retentive tags
Figure 9.9: Ball end clasp
352 Essentials of Orthodontics
A B
Figures 9.10A and B: Eyelet clasp
are bend and they are adapted interdentally
perpen­dicular to the tooth surface, the eyelet
engages the proximal undercuts and the distal
end of the wire is carried over the occlusal
embrasure to and on the palatal aspect as
retentive arm. They are usually used in lower
anterior teeth.
Arrow Pin Clasp (Fig. 9.11)
Arrow pin clasp is a solid arrow bent to
penetrate into the interdental space. It provides
a firm grip on the teeth. The patients cannot
easily dislodge it ever by a tug on the clasp. It
can be dislodged only by pulling on another
appurtenance of the plate, such as the labial
wire. It is a device worth considering in special
cases.
Schwarz Clasp (Fig. 9.12)
The Schwarz clasp or the arrowhead clasp
can be said to be the predecessor of the
Adams’ clasp. The clasp is designed in a way
that a number of arrowheads engage the
interproximal undercuts between the molars
Figure 9.11: Arrow pin clasp
Figure 9.12: Schwarz clasp
and between premolars and molars. This
clasp is not used routinely due to a number
of drawbacks.
i. Needs special arrowhead forming pliers
to fabricate.
ii. Occupies a large amount of space in the
buccal vestibule.
iii. The arrowheads can injure the inter­
dental soft tissues.
iv. It is difficult and time consuming to
fabricate.
Duyzing Clasp (Fig. 9.13)
The clasp described above was anchored at both
its ends by embedding in the plastic base. The
Duyzings clasp is composed of two separate
parts, i.e. two free ended clasps used together.
Each component passes first above and then
below the greatest curvature of the tooth. The
gingival arm may be bent inwards to grasp the
Figure 9.13: Duyzing clasp

tooth firming. The clasp is made from 0.7 to 0.8
mm hard stainless steel wire.
Visick Clasp (Figs 9.14A and B)
All other clasps described make use of only one
side of the tooth for active retention, the fit is
sufficient to counter the pressure of the buccal
wire HC. Visick adopted a modification of the
molar clasp, with a spur on the palatal side,
which passes down between the tooth and
gingiva and hence grasps the tooth below its
greatest palatal curvature. One end of a piece
of 0.7 mm stainless steel wire is beaten flat,
smoothed and curved slightly so as to fit the
palatal surface of the tooth. A loop is formed
at the end of the wire kinked for retention in
the appliance. A space of 1 mm should be
B
Figures 9.14A and B: Visick clasp
Orthodontic Appliances 353
present where the wires cross. A hole is made
to receive the flattened portion, usually in the
most palatal part of the gingival margin.
A small blob of plaster covers the hole and
the wire and the buccal part of the clasp is bent
up as for the molar clasp. The whole being
waxed up in the usual way. After processing the
plastering cleared away and the lingual spur
freed so that it can spring unimpeded over the
palatal bulge of the tooth.
The Visick clasp can be adopted for use
on premolar but it is sometimes difficult to
prevent the spur slipping around the palatal
curve to the tooth to the mesial or distal
aspect. Although the palatal spur fits below
the gingival margin it seems to cause very
little damage to the tissues. Presumably this
is because a small pockets is almost invariably
present to receive it.
Hand Wrought Roach Clasp
(Fig. 9.15)
It provides additional retention in the bicuspid
area. This Roach type clasp was part of the
design of the original Hawley retainers. It has
a special advantage of being completely free
of occlusal interference because it does not
Figure 9.15: Roach clasp
354 Essentials of Orthodontics

cross over the occlusal surface. It particularly

resists the vertical displacement of the
appliance which can be caused by soft and
sticky food. To make the horizontal bar of
the clasp a piece of 0.030 inch stainless steel
wire is bent to fit the convexity of the labial
surface of the bicuspid tooth, first gingival to
its greatest contour. It should extend across
the labial surface from the mesiolabial to the
distolabial line angles. ‘J’ shaped wire is now
bent into cusp of approx. The same height as
the cuspid loop of the labial arch. The batt joint Figure 9.17: Delta clasp
is made and care should be taken to surround
the joined wire with solder.

Crozat Clasp (Fig. 9.16)

This clasp resembles a full clasp but has
an additional piece of wire soldered which
engages into the mesial and distal proximal
undercut. Thus it offers better retention than
the full clasp.

Delta Clasp (Fig. 9.17)

Delta clasp is a modified Adams’ clasp used
in Twinblock appliance. In delta clasp the
arrowheads are modified to form a coil similar
to the letter delta. Advantages include ease of
fabrication and less stress fracture and easy
to adjust.
Smart Clasp (Modified Adams’ Clasp)
(Fig. 9.18)
The modified Adams’ clasp the smart clasp was
developed for use with the magnetic activator
device.
Figure 9.16: Crozat clasp
Figure 9.18: Smart clasp
Construction
The smart clasp is made of .028” wire and
fabricated similarly to the Adams’ clasp. If the
tooth to be clasped is only partially erupted,
trim the model as usual with mesial and distal
undercuts.
Carefully measure the mesiodistal width of
the tooth. Instead of bending the interdental
arrowheads at 45° angles to the bridge in the
vertical and horizontal planes, bend them
perpendicular to the bridge. Bend a 2 mm
loop on each side, then cross the tags over the
contact points as usual, conforming them as
closely as possible to the tooth surfaces.

The Smart clasp can be modified to serve
as a double clasp between the molars and
premolars. Unlike the Adams’ clasp for extraoral
traction, which has a straight bridge between
the two arrowheads, the bridge of the double
Smart clasp has an additional arrowhead
between the molar and premolar.
Another type of Smart clasp is fabricated by
using a 45° bridge-arrowhead angle, as in the
standard Adams’ clasp, and adding coils to each
side of the wire before it passes over the contact
points.
The coils of the Smart clasp increase its
springback property, reducing the likelihood
of wire fracture and the need for retightening.
If the clasp does need to be tightened, it is
activated like a spring, by holding the coils
with a birdbeak plier and pushing the bridge-
arrowhead components inward.
The Smart clasp can be used with any type
of removable appliance, including bite blocks
and palatal expanders.
II. Active Components
They are components of the appliance which
exert forces to bring about the necessary tooth
movement.
Classification of Active Components
I. Continuous force produced:
• Springs
• Elastics
• Spring loaded screws.
II. Intermittent force:
• Screw
• Hickery bags
• Gutta-percha
• Bows.
The active components include:
1. Bows
2. Springs
Orthodontic Appliances 355
3. Screws
4. Elastics.
1. Bows
Bows are active components that are mostly
used for incisor retraction. There are various
types of bows routinely used by the orthodontist.
The following is a list of some of the commonly
used labial bows:
1. Short labial bow
2. Long labial bow
3. Split labial bow
4. Reverse labial bow
5. Mills retractor
6. High labial bow
7. Fitted labial bow.
Short Labial Bow
This type of labial bow is constructed using 0.7
mm hard round stainless steel wire. The short
labial bow consists of a bow that makes contact
with the most prominent labial teeth and two
U loops that end as retentive arms distal to the
canines. This type of labial bow is very stiff and
exhibits low flexibility. Thus they are indicated
only in cases of minor overjet reduction and
anterior space closure. The short labial bow
can also be used for purpose of retention at
the termination of fixed orthodontic therapy.
The short labial bow is activated by com­
pressing the U loops. The activation should be
such that the labial bow is displaced palatally
by 1 mm.
Long Labial Bow
This labial bow is similar to short labial bow
except that it extends from one first premolar
to the opposite first premolar. The distal arms
of the U loops are adapted over the occlusal
embrasure between the two premolars to get
embedded in the acrylic plate.
356 Essentials of Orthodontics
The indications of long labial bow are:
i. Minor anterior space closure
ii. Minor overjet reduction
iii. Closure of space distal to canine
iv. Guidance of canine during canine retr­
action using palatal retractor
v. As a retaining device at the end of fixed
appliance treatment.
The activation is similar to that described
for short labial bow. A modified form of the
long labial bow can be made by soldering the
distal arm of the U loops on to the bridge of the
Adams’ clasp.
Split Labial Bow
This is a labial bow that is split in the middle.
These results in two separate buccal arms
having a U loop each. This type of labial bow
exhibits increased flexibility as compared to
the conven­tional short labial bow.
The split labial bow is used for anterior
retraction. A modified form of split labial bow
can be used for closure of midline diastema. In
this form, the free ends of 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 to 2 mm at a time.
Reverse Labial Bow
This is also called reverse loop labial bow.
Here the U loops are placed distal to the
canine and the free ends of the U loops are
adapted occlusally between the first premo­
lar and canine. 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 activation of this
labial bow is done two steps. First, the U loop
is opened. This results in lowering of the labial
bow in the incisor region. A compensatory
bend is then given at the base of the U loop to
maintain proper level of the bow.
Roberts’ Retractor
This is a labial bow made of thin gauge stainless
steel wire having a coil of 3 mm internal
diameter mesial to the canine. The use of thin
0.5 mm diameter wire along with increased
wire length due to the incorporation of a coil
makes the labial bow highly flexible.
As very thin wire is used for its fabrication,
the bow is hightly 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 Roberts’ retractor is indicated in
patients having severe anterior proclination
with overjet of over 4 mm. As the bow is highly
flexible it generated lighter forces. Thus they
can be used in adult patients in whom lighter
forces are desired.
Mills Retractor
This is a labial bow having extensive looping
of the wire so as to increase the flexibility and
range of action (ability to remain active over
extended periods of time).
Mills retractor or extended labial bow as it is
sometimes called is indicated in patients with
a large overjet. The disadvantages of the Mills
retractor include difficulty in construction and
poor patient acceptance due to the complex
design of the bow.
High Labial Bow with Apron Springs
It consists of a heavy wire bow or 0.9 mm
thickness that extends into the buccal
vestibular. Apron springs made of 0.4 mm
wire are attached to the high labial bow. The
apron springs can be designed for retraction
of one or more teeth. This type of labial bow
is highly flexible and is thus used in cases of
large overjet. As very light forces are generated
by them they can be used in adult patients.
The apron springs is the active component
that is activated by bending it towards the

teeth. As it is highly flexible activation of upto
3 mm at a time can be done. The disadvantages
include difficulty inconstruction and risk of
soft tissue injuries.
Fitted Labial Bow
In this type of labial bow the wire is adapted to
confirm to the contours of the labial surface.
The U loop is usually small. The fitted labial
bow cannot be used to bring about active tooth
movement.
They are used as retainers at the completion
of fixed orthodontic therapy.
2. Springs
Springs are active components of removable
orthodontic appliances that are used to effect
various tooth movements.
There are a number of ways by which
springs can be classified.
Based on the presence or absence of helix
they can be classified into:
1. Simple—without helix
2. Compound—with helix.
Based on the presence of lips or helix they
can be classifies as:
1. Helical springs—have a helix
2. Looped springs—have a loop.
Based on the nature of stability of the spring
they can be classified as:
1. Self-supported springs: They are usually
made of thicker gauge wire. Thus they can
support themselves.
2. Supported or guided springs: They are
made of thinner gauge wire and thus lack
adequate stability. Hence a section of the
spring is encased in a metallic tubing to
give it adequate support.
3. Auxiliary springs: They are used as an
auxiliary to other active components such
as labial bows, e.g. Apron springs.
Orthodontic Appliances 357
Ideal Requirements of a Spring
Springs that are designed to bring about
various tooth movements should possess
certain ideal requisites. They are:
1. The spring should be simple to fabricate
2. It should be easily adjusted
3. It should fit into the available space without
discomfort to the patient
4. It should be easy to clean
5. It should apply force of required magnitude
and direction
6. It should not slip or dislodge when placed
over a sloping tooth surface
7. It should be robust
8. It should remain active over a long period
of time.
Factors to be considered in designing a
spring.
Diameter of wire: The flexibility of the spring
to a large extent depends upon the diameter of
wire used. Thus, the force generated.
D4
Fα
L3
Where,
F = Force
D = Diameter of wire
L = Length of wire
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 diameter the force applied
is lesser and therefore the spring remains more
flexible and active over a longer period of time.
Length 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 and
loops can be incorporated into spring to make
them more active. By doubling the length the
force can be reduced by 8 times.
358 Essentials of Orthodontics
Force to be applied: The force that should be
generated by the spring is calculated based on
the number of teeth to be moved, root surface
area and patient comfort. On an average,
forces of about 20 gm/cm2 of root area are
recommended for most tooth movement.
Patient comfort: The spring should not offer any
patient discomfort by way of its design, size
or the force it generates. The patient should
be able to insert the appliance with the spring
in the proper position so as to bring about the
desired tooth movement.
Direction of tooth movement: The direction of
tooth movement is an important consideration
in designing a spring. The direction of tooth
movement is determined by the point of
contact between the spring and the tooth.
Palatally placed springs are used for labial and
mesiodistal tooth movement. Buccally placed
springs are used when the tooth is to be moved
palatally and in mesiodistal direction.
Finger Spring (Fig. 9.19)
The finger spring is also called cantilever spring
as one end is fixed in acrylic and the other end
is free. It is constructed using 0.5 mm or 0.6 mm
hard round stainless steel wire.
The finger spring is used for mesiodistal
movement of teeth. It can be used only on those
teeth that are located correctly in the buccolingual
direction, i.e. the teeth should be within the line
of the arch.
Figure 9.19: Finger spring
The finger spring consists of an active arm
of 12 to 15 mm length which is towards the
tissue, a helix of 3 mm internal diameter and
a retentive arm of 4 to 5 mm length which is
kept away from the tissue and ends in a small
retentive tag.
The finger spring should be constructed in
such a way that the coil should lie along the long
axis of the tooth to be moved, perpendicular
to the direction of movement. The direction of
the coil is opposite to that of intended tooth
movement. Prior to acrylization, the helix and
the active arm are boxed on wax so that the
spring lies in a recess between the mucosa and
the base plate.
The finger spring is activated by moving
the active arm towards the teeth intended to
be moved. This is done as close to the coil as
possible. Activation of upto 3 mm is considered
ideal when 0.5 mm wire is used for fabrication.
Whenever 0.6 mm wire has been used the
activation should be half of that.
Z-Spring (Fig. 9.20)
The ‘Z’ spring is also called double cantilever
spring. The Z-spring is used for labial
movement of incisors. They can also be used
for bringing about minor rotation of incisors.
The Z-spring is made of 0.5 mm hard
round stainless steel wire. The spring can be
made for movement of a single incisor or two
Figure 9.20: Z-spring

incisors. The spring consists of two coild of
very small internal diameter. The spring should
be perpendicular to the palatal surface of the
tooth. It has a retentive arm of 10 to 12 mm
length that gets embedded in acrylic. Z-spring
should be boxed in wax prior to acrylization.
The Z-spring is activated by opening both
the helices by about 2 to 3 mm at a time. In case
of minor rotation correction, one of the helices
is opened.
T-Spring (Fig. 9.21)
Buccal movement of premolars and sometimes
canines can be brought about using a T-spring.
It is made of 0.5 mm hard round stainless steel
wire. The spring consists of a T-shaped arm
whose ends are embedded in acrylic. Loops
can be incorporated in both the arms of the T
so that as the tooth moves buccally the head
of the T can be made to remain in contact with
the crown by slightly opening the loops.
The spring is activated by pulling the free
end of the T towards the intended direction of
tooth movement.
Coffin Spring
This is a removable type of arch expansion
spring that was introduced by Walter Coffin. It
is used to bring about slow dentoalveolar arch
Figure 9.21: T-spring
Orthodontic Appliances 359
expansion in patients where the upper arch is
constricted or there is a unilateral crossbite.
The Coffin spring is made of 1.2 mm hard
round stainless steel wire. It consists of a U-or
ω-shaped wire placed in the midpalatal region
with the retentive arms incorporated into base
plates. The appliance gains retention from
Adams’ clasp on the first molars and the first
premolars or deciduous molars.
The Coffin spring can be activated manually
by holding both the ends at the region of the clasps
and pulling the sides gently apart. Activation of
1 to 2 mm at a time is considered appropriate.
Canine Retractors
Canine retractors are springs that are used to
move canines in a distal direction. The canine
retractors can be classified by a number of
ways:
Based on their location they can be
classified as:
1. Buccal—buccally placed
2. Palatal—palatally placed.
Based on the presence of helix or lip they
can be classified as:
1. Canine retractor with helix
2. Canine retractor with loop.
Based on their mode of action they can be
classified as:
1. Push type
2. Pull type.
U Loop Canine Retractor (Fig. 9.22)
U loop canine retractor is made of 0.6 mm
or 0.7 mm wire. It consists of a U loop, an
Figure 9.22: U loop canine retractor
360 Essentials of Orthodontics

active arm and a retentive arm which is distal.

The base of the U loop should be 2 to 3 mm
below the cervical margin. The mesial arm of
the U loop is bent at right angles and adapted
around the canine below its mesial contact
point. Mechanically it is least effective and is
used when minimal retraction of 1 to 2 mm is
required. It is activated by closing the loops by
1 to 2 mm or cutting the free end of the active
arm by 2 mm and readapting it. Advantages
of this retractor are ease in fabrication and Figure 9.24: Buccal canine retractor
less bulk.
indicated in case of buccally placed canines
Helical Canine Retractor (Fig. 9.23) and canines placed high in the vestibule. It
It is also called reverse loop canine retractor and is called self-supported because it is made
is made of 0.6 mm wire. It consists of a coil of of thicker diameter wire which can resist
3 mm diameter, an active arm (towards distortion. It is activated by closing the helix
the tissue) and a retentive arm. The mesial 1 mm at a time.
arm (retentive arm) is adapted between the
premolars. The distal arm is active and is bent Palatal Canine Retractor (Fig. 9.25)
at right angles to engage the canine below the It is made-up of 0.6 mm stainless steel wire. It
height of contour. The coil is placed 3 to 4 mm consists of a coil of 3 mm diameter, an active
below the gingival margin. arm and a guide arm. The active arm is placed
It is activated by opening the helix by 2 mesial to canine. The helix is placed along
mm or by cutting 2 mm of the free end and the long axis of the canine. It is indicated in
readapting it around the canine. It is indicated retraction of canines that are palatally placed.
in patients with shallow sulcus. Activation is done by opening the helix 2 mm
at a time.
Buccal Self-supporting Canine Retractor
(Fig. 9.24)
It is made of 0.7 mm wire. It consists of a helix of
3 mm diameter, an active arm (away from
the tissue) and a retentive arm. The coil is
placed distal to the long axis of canine. It is

Figure 9.23: Helical canine retractor Figure 9.25: Palatal canine retractor

Figure 9.26: Robert’s retractor
Roberts’ Retractor (Fig. 9.26)
A closely allied spring, developed by GH
Roberts consists of apron spring of 0.5 mm
wire with open coils. The high labial arch is
eliminated and replaced by stainless steel
tubes (0.5 mm internal diameter) which are
placed and slipped on the spring after it has
been bent as far as the coil. Tube and wire
are bent together and embedded in the base
plate after passing behind the canine teeth. It
is mainly indicated in patients having severe
anterior proclination. As the bow is highly
flexible it generates lighter forces.
Reverse Labial Bow (Fig. 9.27)
This is also called reverse loop labial bow. ‘U’
loops are placed distal to canine and free ends
expected occlusally in mesial to first premolar.
Activation of this labial bow is done in two
steps first the ‘U’ loops is opened, with this
results in lowering of the labial blow in the
incisor region. A compensatory bend is then
Figure 9.27: Reverse labial bow
Orthodontic Appliances 361
Figure 9.28: Mills retractor
given at the base of the ‘U’ loop to maintain
proper level of the bow.
Mills Retractor (Fig. 9.28)
This type of labial bow having extreme looping
of the wire or to increase the flexibility and
range of action (ability to remain active
overextended period of time). Indicated in
patients with large overjet.
Disadvantages
1. Difficulty in construction.
2. Poor patient acceptance due to complex
design.
3. Screws
Screws are active components that can be
incorporated in a removable appliance. Screws
can be used to bring about many types of tooth
movements. The screws are activated by the
patient at regular intervals using a key that
is supplied for this purpose. Thus appliances
incorporating screws are a valuable aid in
patients who cannot visit the dentist frequently
for reactivation of the appliance.
Removable appliances having screws
usually consist of a split acrylic plate and
Adams’ clasp on the posterior teeth. The screw
is placed connecting the split acrylic plates.
These appli­ances can bring about various types
of tooth movements based on the location of
acrylic split, the location of the screw and the
number of screws used in the appliance (Figs
9.29A to C).
362 Essentials of Orthodontics
B
Figures 9.29A to C: Jack screws
Broadly the removable appliances that
make use of screws can bring about three types
of tooth movements:
i. Expansion of arch.
ii. Movement of one or a group of teeth in
a buccal or labial direction.
iii. Movement of one or more teeth in a
distal or mesial direction.
4. Elastics
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 the canines. Latex elastics are stretched
between them and lie over the incisors. The
disadvantages of such appliances are:
i. The elastic tends to slip gingivally and
cause gingival trauma.
ii. Risk of the arch form getting flattened.
Pegs and Gutta-percha
Pegs and gutta-percha are attached by being
embedded in a hole in the base plate. They
are functional only when appliance is being
pressed by the teeth of the opposite jaw. After
preparing an undercut trough with large
C
inverted cone bur, the heat softened gutta-
percha is pressed and a slight excess in the
form of bulge is allowed to protrude from the
surface. It can be easily be removed or added
to by means of a hot instrument.
III. Base Plate (Fig. 9.30)
The bulk of the removable appliance is made of
the acrylic base plate. The prime function of the
base plate is to incorporate all the components
(active and retentive) together into a single
functional unit. The base plate also helps in
retention of appliance and for anchorage.
Uses of Base Plate
i. The base plate unites all the components
of the appliance into one unit.
ii. Helps in anchoring the appliance in
place.
iii. It provides support for the wire com­
ponents.
Figure 9.30: Base plate

iv. Helps in distributing the forces over a
larger area.
v. Bite planes can be incorporated into
the plate to treat specific orthodontic
problems.
Thickness of Base Plate
The base plate should be of minimum
thickness to help in patient acceptance. Thick
plates are not tolerated by patients. Base
plates of 1.5 to 2 mm thickness offer adequate
strength and at the same time are tolerated
well by patients.
Requirements and choice of material for
base plate preparation.
1. Readily cleanable by the patient and
remain clean in the mouth.
2. Should be strong.
3. Sufficiently hard to resist the abrasion.
4. The material must resist attack by the oral
fluids and it should be of such a color that
food debris is readily visible on it.
5. It should readily represent the pressure
points.
Extension of Base Plate
The maxillary base plate usually covers the
entire palate till the distal of the first molar.
This full coverage helps in gaining adequate
strength. Narrow maxillary base plates
resembling a horse shoe are less stable and
are likely to get dislodged during movements
of the tongue.
The mandibular base plate is usually
shallow to avoid irritation to the lingual sulcus.
To compensate for this it should be made
thicker to increase the strength.
Materials used for Base Plate
The base plate is made of cold cure acrylic or
heat cure acrylic. Cold cure acrylic is more
frequently used as it is less time consuming
Orthodontic Appliances 363
and simpler to use. The disadvantages of cold
cure acrylic are that there is more chance of
porosity and it is not stable as the heat cure
acrylic.
Delivery of Removable Appliance
There are a number of factors that should be
looked into at the time of appliance delivery,
they are:
1. The tissue surfaces of the appliance should
not have any sharp areas or nodules.
They should be trimmed to avoid tissue
irritation.
2. The base plate may need some trimming
to help in easy insertion and removal of
the appliance. This is mostly so in case of
undercuts being present.
3. The clasps should be examined for adequate
retention. If not they should be adjusted
to engage the undercut, so as to increase
retention.
4. The active components should rest at the
desired location. They should not impinge
on the gingival, sulcus or the frenum.
5. The patient should be educated on how to
insert and remove the appliance.
6. The active components can be activated
after a few days once the patient gets used
to the appliance.
Instructions to the Patient
1. Patient should be instructed on the number
of hours of wear. Most appliances are to be
worn both day and night for 24 hours.
2. The appliance and the teeth should be
cleaned after every meal. They should also
be cleaned before retiring to sleep.
3. The patient is asked to clean the appliance
using detergent solution and a brush.
While cleaning the appliance care should
be taken not to bend or dislodge any of the
components of the appliance.
364 Essentials of Orthodontics
4. In case of removable appliances that incor­
porate screws, the patient and parents
should be given clear instructions on how
to activate the appliance.
5. The patient is instructed to report immedi­
ately to the clinic in case of appliance
damage or any other problem while
wearing them.
6. The patient should be instructed not to leave
the appliance out of the mouth for a ling
period of time as it increases the risk of loss
and damage.
Problems during Removable
Appliance Therapy
Oral hygiene maintenance: Patient who fails 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 lead to
tissue irritation and ulceration. Care should be
teken to avoid sharp nodules and irregularities
in the appliance. In addition wire components
that extend deep into the vestibule offer risk of
vestibular irritation and injury.
Caries: 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.
Tooth mobility: Presence of traumatic occlusion
or the use of excessive force during therapy can
cause abnormal mobility of the teeth.
FIXED APPLIANCES
Appliances that are fixed or fitted onto the teeth
by the operator and cannot be removed by the
patient at will are called fixed appliances.
An 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 for the
patient. Most malocclusions require some
form of fixed therapy for their correction.
Unlike removable appliances that are capable
of only tipping type of tooth movements,
fixed appliances can bring about various
other types of tooth movement including
bodily movement, rotation, tipping, intrusion,
extrusion and even root movements. Fixed
appliances are therefore very versatile and can
be used to treat most malocclusions.
ADVANTAGES OF FIXED
APPLIANCES
1. Patient cooperation is dispensed with to a
large extent in the use of fixed appliances. The
orthodontist does not depend on the patient
for timely wear and management of the
appliance.
2. It is possible to bring about various types
of tooth movements such as tipping,
bodily movement, rotation, intrusion and
extrusion.
3. Multiple tooth movements are possible
simultaneously. As many tooth movements
are undertaken at the same time, the treat­
ment duration is considerably reduced.
4. More precise tooth movements and detai­
ling of occlusion is possible using fixed
appliances.
5. Fixed appliances can be used to treat most
malocclusions including very complicated
ones.
6. Fixed appliances offer better control over-
anchorage.

DISADVANTAGES OF FIXED
APPLIANCES
Although fixed appliances have a number
of advantages as compared to removable
appliances, they nevertheless have a number
of disadvantages which include:
1. 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 and cleaning of teeth
becomes more difficult for the patient due
to their entrapment around the various
attachments.
2. Fixed appliances are more time cons­
uming to fix and adjust. Thus they take
up more chair side time unlike removable
appliances which can be fabricated at the
laboratory.
3. Fixed appliances are more conspicuous
than removable appliances. Unless modern
tooth colored appliances are used, they
may not be pleasing esthetically.
4. Fixed orthodontic appliances require sp­e­cial
training of the operator and are invariably
handled by specialized orthodo­ntist.
5. Damaged appliances that apply misdirected
forces cannot be removed by the patient.
6. The patient has to visit the orthodontist at
regular intervals.
7. Fixed appliances are by far more expensive
than removable appliances.
8. Unless the treatment is done be a skilled
operator who has been trained to use fixed
appliances, there is a greater possibility of
producing adverse tooth movements.
Tooth Movement Possible by
Fixed Appliances
A great advantage of fixed appliance is their
ability to bring about more than one type
Orthodontic Appliances 365
of tooth movement at the same time. The
various tooth movements possible using fixed
appliances are:
Tipping
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 arount 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 tooth
movement can be used to treat only certain
malocclusions. Most fixed appliances are
capable of producing tipping. However, very
rarely can a malocclusion be treated entirely
by tipping movements.
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
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
appliances.
Uprighting
Uprighting refers to mesiodistal movement of
the roots. Finer detailing of roots by moving
them mesiodistally can be brought about by
fixed appliances.
Rotations
Teeth that are rotated around their long axes
can be derotated using fixed appliances. The
degree of rotational control possible with fixed
appliances is not possible using removable
appliances.
366 Essentials of Orthodontics
Extrusion and Intrusion
Extrusion and intrusion refer to vertical
movement of teeth along their long axis.
Extrusion and to a lesser extent intrusion of
teeth of groups of teeth is possible using fixed
appliances.
Method of Fixing Attachments
onto the Teeth
The various attachments that are used in
fixed appliance therapy such as brackets and
molar tubes can be fixed directly onto the
teeth with composite adhesives or can be
attached to metallic bands that are cemented
onto the teeth. The method of fixing the
attachments directly to the teeth is called
bonding. Whenever, the attachments are fixed
to bands which are cemented around the teeth,
the technique is referred to as banding.
BANDING
Banding involves the use of thin stainless steel
strips called bands that are pinched tightly
around the teeth and then cemented to the
teeth. The stainless steel tape is available
in different widths and thicknesses to suit
different teeth. While the molar band material
is wide and stiffer, the anterior band material
is relatively thinner and narrower in width.
The outer surface of the band material is
smooth and glossy while the inner surface is
comparatively rough and dull, so as to aid in
retention of the cement.
Indications
The following are some of the situations where
banding is preferred:
1. Banding is preferred overbonding in case
of posterior teeth. The banded attach­
ments are better capable of resisting
occlusal forces than bonded attachments.
In addition, bonding needs thorough
moisture control which is not possible 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 case of extraoral devices such as
headgears.
4. Although it is possible to bone attachments
on teeth that have porcelain or gold
restorations or crowns, banding is preferred
in these cases.
5. It is preferable to band teeth that show
recurrent breakage of the bonded attach­
ments due to bond failure.
6. It is preferable to use banded attachments
whenever they are likely to contact the
opposing dentition when the jaws are
closed.
Steps in Banding
Separation of teeth: Due to the presence of
tight inter- dental contact between the teeth;
it may not be possible to force the band past
the contact area. It is not advisable to force the
band through a tight interdental contact as it is
uncomfortable for the patient and also difficult
for the operator. Tight contacts should hence
be broken using tooth separators prior to band
pinching. Most separators have to be left in
the mouth for 24 hours or more to bring about
sufficient separation of the interdental contact.
Types of Bands
1. Custom made bands
2. Preformed bands.
Custom Made Bands
Selection of band material: Based on which
tooth is being banded; the band material of
appropriate thickness and width is selected.

Pinching of the band: Band material of adequate
length is taken and the two ends are tack
welded together. The band is passed through
the separated interdental contact around the
tooth to be banded. Using band pinching
pliers, the band is tightly drawn around the
tooth to form a ring. The neck of the band is
spot welded to retain the tight fit. The excess
band material is them cut off and the ends are
adapted close to the band. The bent portion is
spot welded and the gingival margins of the
band are trimmed to conform to the contour of
the gingival margin. The weld spots and rough
margins are then smoothed and polished.
Preformed Bands
Preformed bands are available in various sizes.
Proper size of band should be selected by trial
and error method by placing the bands on the
models till they fit snugly.
Fixing the attachments: Once the band
pinching is completed or proper preformed
band is selected, the appropriate attachments
are fixed onto the band. The attachments
include brackets for the anterior teeth and
buccal or molar tubes for the posterior teeth.
These attachments are fixed to the band by spot
welding or by soldering.
Cementation of the band: The final step involves
cementation of the band around the tooth. The
inner surface of the band is rough in order to
aid in retention. A well-pinched band is one
that has adequate retention even without the
use of cement. Nevertheless, cementation is
required to eliminate the space between the
band and tooth into which cariogenic material
may seep in and stagnate.
During cementation, adequate moisture
control is necessary by means of saliva eje­
ctors and cotton rolls. Cements that can be
used include zinc phosphate, zinc polycar­
boxylate, glass ionomer cement, etc. Pre­for­
Orthodontic Appliances 367
med seemless bands are now available in
various sizes. They have eliminated the need
to pinch custom made bands.
BONDING
The method of fixing attachments directly
over the enamel using adhesive resing is
called bonding. The elimination of bands
greatly enhances esthetics and oral hygiene
maintenance and has led to its popularity
overbanding.
Types of Bonding
1. Direct bonding: Bonding the brackets
directly onto the tooth.
2. Indirect bonding: Bonding the brackets to
the model and transferring it to the tooth.
Advantages
Bonding offers numerous advantages over-
banding which can be listed as:
1. It is esthetically superior.
2. It is faster to bond than to pinch bands
around teeth.
3. It enables maintenance of better oral
hygiene.
4. It is possible to bone on teeth that have
aberrant shapes or forms. It might be
impossible to band such teeth.
5. It is easier to bond than band in case of
partially erupted and fractured teeth.
6. The risk of caries under loose bands is
eliminated.
7. Interproximal areas are accessible for
restoration and proximal stripping.
Disadvantages
1. Bonded attachments are weaker than
banded attachments and hence are more
prone to bond failure.
368 Essentials of Orthodontics
2. Bonding involves etching of the enamel
with an acid which may lead to enamel loss
and an increased risk of demineralization.
3. Enamel fracture can occur during debon­
ding.
Bondings are two types:
1. Direct bonding: It refers to the direct place­
ment of brackets onto the etched enamel.
The direct bonding is the most popular
method for its simplicity and reliability.
2. Indirect bonding: It refers to the technique
where brackets are first positioned on study
casts with a water-soluble adhesive and
then transferred to the mouth with custom
tray. One main advantage of indirect
bonding is that bracket placement is more
accurate.
Steps in Bonding
Bonding is done in following steps:
Moisture control: The crowns of the teeth to
be bonded are cleaned using pumice and
bristle brush so as to remove plaque and other
organic debris present on the enamel surface.
After thorough cleaning, the teeth are washed
with low pressure water spray combined with
high volume suction is used and dried. During
the bonding procedure, adequate moisture
control should be maintained by the use of
saliva ejectors and cotton rolls.
Acid etching: 35 to 37% unbuffered phosphoric
acid in gel or liquid form is used to etch
enamel. This etching is usually done for 15 to
30 seconds (60–120 sec for deciduous tooth)
after which the etchant is washed off with
water. The properly etched surface should
have a lightly frosted, mattle, dull, or whitish
appearance. The teeth are then dried and once
again isolated using fresh cotton rolls.
Application of primer: Sealant is applied onto
the etched enamel surface.
Bonding: Adequate quantity of bonding adhe­
sive is placed on the base of the brackets. The
bracker is placed on the tooth and is firmly
pressed into position. Excessive adhesive that
appears as flash is removed using a scaler. The
bond is allowed to strengthen for a period of
time before placing the arch wires.
Debonding
The removal of brackets and adhesive without
altering the enamel surface at the end of fixed
orthodontic treatment is called debonding.
Methods of Debonding
1. The use of pistol grip debonding instru­ments
that are positioned over the brackets with
its jaws aligned horizontally. Debonding
occurs when the handles are sqeezed.
2. A sharp edged instrument may be placed at
the enamel adhesive interface to produce
the wedging effect by application of little
force for debonding.
3. Ultrasonic scaler or electrothermal debon­
der may be used to debond the fixed
appliances.
4. Recently laser debonding have been
introd­uced to heat up the composite and
debond the fixed appliances.
COMPONENTS OF FIXED
ORTHODONTIC APPLIANCES
The components of fixed appliance can be
broadly classified as active components and
passive components:
I. Active components:
1. Arch wires
2. Springs
3. Elastics
4. Separators.
II. Passive components:
1. Bands
2. Brackets
3. Buccal tubes
 Orthodontic Appliances 369

4. Lingual attachments
5. Lock pins
6. Ligature wires.

I. ACTIVE COMPONENTS

Arch Wires (Figs 9.31 to 9.34)

Arch wires are one of the active components of
fixed appliances. They can bring about various
tooth movements through the medium of
brackets and buccal tubes which act as handles
on the teeth.
Figure 9.33: Round wire

Figure 9.34: Square wire

Figure 9.31: Co-axial wire

In early days (prior to 1940), pure gold arch

wires are used. Their high cost and mechanical
inefficiency led to the used of stainless steel
arch wires. In the 1970s and 80s, number of
titanium based arch wires were introduced
into orthodontics. These arch wires exhibit
superior elastic properties. A number of
multistranded arch wires are also being used
effectively.

Elastics and Elastomerics

Elastics are routinely used as active compo­
nents of fixed orthodontic appliances. The
Figure 9.32: Rectangular wire elastic products used in orthodontics include
370 Essentials of Orthodontics
Figure 9.35: Elastics
simple elastics, elastic chains, elastic thread
and elastic modules.
Elastics (Fig. 9.35)
They are elastics that resemble a rubber band.
They are made of latex rubber and are available
in various diameters. The force applied by
these elastics depends upon their diameter.
They are color coded for easy identification.
Elastics are used in orthodontics for a
number of purposes such as closure of space,
to correct open bites, treatment of cross bite
and to correct interarch relationship. The
follow­ing are some of the applications of
elastics:
Class I elastics: They are intraarch elastics
stretched between the molars and the
anteriors. They are generally used for closure
of space and retraction of teeth.
Class II elastics: They are intermaxillary elastics
stretched between the lower molars and the
upper anteriors. They are used in the treatment
of Class II malocclusion. They bring about
reduction of upper anterior proclination and
mesial movement of the lower molars.
Class III elastics: They are intermaxillary
elastics which are stretched between the upper
molars and the lower anteriors. They are used
in treatment of Class III malocclusion to bring
about mesial movement of upper buccal teeth
and retraction of lower anteriors.
Crossbite elastics: They are through the bite
intermaxillary elastics used to treat molar
cross- bites. They extend between the palatal
surface of the upper molar and the buccal
surface of lower molar or vice versa.
Box elastics: This form of elastic is used to
correct anterior open bites. Elastic is stretched
between the upper and lower anteriors like a
box. The open bite gets corrected by forced
eruption of the upper and lower anteriors.
Elastic Chains (E-chains) (Fig. 9.36)
They are elastics that are available as long
chains of interconnected rings. They are usually
made of synthetic polyurethane material and
are available in different forms based on the
distance between the rings. E-chains are
used in the closure of space between teeth by
stretching the rings between them.
Elastic Thread
Elastic thread is made of a core of latex rubber,
surrounded by a sleeve of woven silk and is
available in a spool. It is cut to desired length and
ties between two teeth or two groups of teeth to
close space. They can also be used to derotate
a tooth.
Elastic Modules (Figs 9.37A and B)
They are made of two elastic rings separated
by a variable distance. Elastic modules are
available in various sizes based on the interring
Figure 9.36: Elastic chains
 Orthodontic Appliances 371

A B
Figures 9.37A and B: Elastic modules

distance. They are generally used to close space

and for derotation of teeth. B C
Figures 9.39A and B: Torquing springs
Springs
Springs are the other active components that
can be used to bring about various tooth
movements. The following springs are used in
fixed appli­ances.
Uprighting springs: They are springs which Figure 9.40: Open coil springs
move the root in a mesial or distal direction
(Figs 9.38A to C).
Torquing springs: They are springs which move
the root in a lingual or palatal direction (Figs
9.39A and B). A
Open coil springs: They are springs that are
compressed between two teeth to open up
space between them (Fig. 9.40).
Closed coil spring: They are stretched between
teeth to close space (Figs 9.41A and B).
B
Separators Figures 9.41A and B: Closed coil springs
In many patients the presence of a tight inter­
dental contact results in difficulties during banding. While attempting to pass a band
through the interdental contact, the band
tends to get distorted. In addition, the patient
may experience some amount of discomfort.
The teeth should therefore be separated
to break the tight interdental contact. This
is usually achieved using various types of
A B C
Figures 9.38A to C: Uprighting springs separators available.
372 Essentials of Orthodontics
A B C
Figures 9.42A to C: Placement of brass separators
Brass Wire Separators
(Figs 9.42A to C)
Soft brass wire of 0.5 or 0.6 mm diameter is
passed around the contact and the ends are
twisted together. The ends are cut short and
are tucked between the teeth.
Ring Separators (Fig. 9.43)
They are small elastic rings that are passed
through the contact using special pliers. The
stre­tched elastic ring encircles the interdental
contact and as it contracts, the teeth are separ­
ated.
Dumb-bell Separators
It is a dumb-bell-shaped piece of elastic that is
stretched and passed through the interdental
contact. The stretched separator tries to regain
its original length and in doing so brings about
separation of teeth.
Figure 9.43: Elastic ring separators
A B
C D
Figures 9.44A to D: Kesling’s spring separators
Spring Separators (Kesling’s
Separator) (Figs 9.44A to D)
They are the springs made of 0.018 or 0.020
inch stainless steel wire used in separation.
II. PASSIVE COMPONENTS
Bands (Fig. 9.45)
Bands are passive components that help in
fixing the various attachments onto the teeth.
They are available in various sizes to suit
different teeth. They are made of soft stainless
steel. The attachments like molar tubes and
brackets are soldered or welded over these
bands which are cemented in position around
the teeth.
Figure 9.45: Bands

Brackets
Brackets act as handles to transmit the force
from the active components to the teeth.
Brackets have one or move slots that accept
the arch wire. There are a number of bracket
designs available. Brackets can be classified in
a number of ways.
Classification of brackets according to the
type of slot:
1. Ribbon arch brackets
2. Edgewise brackets.
Classification based on mode of attachment
to teeth:
1. Weldable brackets
2. Bondable brackets.
Classification based on the material used
to fabricate the bracket:
1. Metallic brackets
2. Ceramic brackets
3. Plastic brackets.
Classification based on ligation of arch
wires:
1. Conventional brackets
2. Self-ligating brackets.
Ribbon Arch Brackets
They are brackets which possess a vertical
slot facing the occlusal or gingival direction.
The slot is also narrow mesiodistally. The kind
of bracket is used with round wires to bring
about tipping of teeth in labiolingual as well
as mesiodistal direction. Ribbon arch brackets
are used in the Begg’s fixed appliance.
Edgewise Brackets
Brackets used in the edgewise and straight wire
technique have a horizontal slot facing labially.
These brackets with rectangular slots are so
called because they accept wires of rectangular
dross-section with the larger dimension being
horizontal. These brackets provide greater
Orthodontic Appliances 373
control overtooth movement and do not per­
mit tipping of teeth.
Weldable and Bondable Brackets
As mentioned earlier of this chapter, the bracket
can be either bonded directly onto the teeth
using bonding adhesives or they can be welded
on bands which in turn are cemented around
the teeth. Brackets that are bonded directly
over the enamel are called bonded brackets,
while those that are welded or soldered over
bands are called weldable brackets. The under
surface of bondable brackets has a meshwork
or grooves to help in interlocking with the
adhesive. Weldable brackets have a metal
flange that can be welded to the band.
Metallic Brackets
Most brackets in current use are of the metallic
variety. Of these stainless steel brackets are
most commonly used. The advantages of metal
brackets include:
i. They can be recycled
ii. They can be sterilized
iii. They resist deformation and fracture
iv. They exhibit the least friction at the wire
bracket interface
v. They are not very expensive.
The disadvantages of metal brackets are:
i. They are esthetically not pleasing. The
patient tends to have a metallic smile.
ii. They can corrode and cause staining of
teeth.
Ceramic Brackets
Ceramic brackets were introduced to orthod­
ontics in the late 1980s. They are made of
alum­­i­n um oxide or zirconium oxide. The
advan­tages of ceramic brackets are:
i. They are dimensionally stable and do
not distort in oral cavity.
374 Essentials of Orthodontics

ii. They are durable and resist staining in

the oral cavity.
The disadvantages of ceramic brackets are:
i. They are very brittle and therefore
fracture or crack when undue forces are
applied.
ii. To compensate for their brittleness, their
size is increased which tends to increase
their bulk.
iii. They exhibit greater friction at the wire
bracket interface than metallic brackets.

Plastic Brackets
Most of the plastic brackets are made of polycar­
bonate or a modified form of polycarbonate.
These plastic brackets were introduced to
improve the esthetic value of the appliance.
Plastic brackets are available in tooth colored
or transparent forms.
The disadvantages of plastic brackets are:
i. They tend to discolor particularly in
patients who smoke or drink coffee.
ii. They offer poor dimensional stability.
iii. Their slot tends to distort.
iv. The friction between plastic brackets
and metal arch wire is very high.
Buccal Tubes
Brackets are usually fixed on the anterior
teeth and premolars. The attachment that is
generally used on molars is the buccal tube or
the molar tube. The buccal tube can be weldable
or bondable. Buccal tubes can be round or
rectangular in cross-section. The buccal tube
may sometimes have double or triple tubes.
These additional tubes are for additional arch
wires and for extraoral anchorage (face bow).
Lingual Attachments (Fig. 9.46)
Brackets and buccal tubes are attached on the
labial or buccal aspect of the teeth. Sometimes
it may be necessary to have attachments on
the lingual side as well. There are various
Figure 9.46: Lingual attachments
attachments available that can be fixed on
the lingual aspect and are called lingual
attachments. They are usually required for
engaging elastics.
Examples of lingual attachments include,
lingual buttons, lingual cleats, eyelets and ball end
hooks.
Ligature Wires
They are soft stainless steel wires of 0.009 to
0.011 inch diameter and are used to secure
the arch wire to the brackets. This process
of securing the arch wire to the brackets is
called ligation. Ligation is usually necessary
in edgewise type of brackets that have labially
facing slot.
Lock Pins (Fig. 9.47)
They are small pins that are used to secure the
arch wire to brackets with vertical slots such as
ribbon arch brackets. The lock pins are usually
made of brass and they are available in various
shapes to control the tooth movement.

Figure 9.47: Lock pins
FIXED APPLIANCE TECHNIQUES
Over the years a number of fixed appliance
tech­n­i­ques have evolved. It is not within the
scope of this book to discuss in detail the
various techniques as numerous philosophies
and mechanical principles are involved. Thus
the discussion is limited to few of the more
popular techniques that have been widely used
by the practitioners.
Pierre Fauchard in 1726 deviced the first
orthodontic appliance to expand the dental
arch. The concept of fixing orthodontic
attachments to teeth took a definite shape in
the late nineteenth century. Edward H Angle
introduced the E-arch or the expansion arch
in the late 1800. The appliance used bands on
the molars with an expansion arch threaded
to the buccal aspect of the molar bands.
In 1912, Edward H Angle introduced
the pin and tube appliance. The appliance
consisted of bands with a vertical tube placed
on all teeth. The arch wire carried soldered
pins that inserted into the vertical tubes.
Tooth movement was achieved by altering the
placement of these pins (Figs 9.48A and B).
Orthodontic Appliances 375
B
Figures 9.48A and B: Pin and tube appliance
In 1925, Edward H Angle introduced the
ribbon arch appliance. This was the first
appliance to use a true bracket having a vertical
slot facing occlusally. Angle used gold arch
wires and lock pins with this technique. The
ribbon arch technique enabled rotation control
as well as buccal lingual and incisogingival
tooth movement. However, mesiodistal tipping
movements were considered difficult with this
technique.
Edgewise Appliance
(Figs 9.49A and B)
Angle’s last contribution to orthodontics was
the introduction of the edgewise technique
in 1928. He diviced a metal bracket having a
rectangular slot of 0.022” × 0.028” dimension
facing labially. This slot received a rectangular
A B
Figures 9.49A and B: Edgewise appliance
376 Essentials of Orthodontics
arch wire of 0.022” × 0.028” dimension. The
wire is inserted into the bracket with the
narrow dimension placed occlusogingivally.
This mode of insertion of the wire is called
edgewise and therefore the technique was
called edgewise technique. The unique
feature of having a rectangular arch wire in
a rectangular slot enabled control of tooth
movement in all the three planes of space.
For this purpose Angle described the use of an
ideal arch wire that incorporated certain bends
called the first, second and third order bends.
The first order bends or in-out bends are
placed to compensate for differences in the
buccolingual prominence of the teeth. They
comprise of the lateral inset, the canine offset
and the molar offset. The second order bends
are placed to achieve correct mesiodistal
axial inclination of teeth. They comprise of
the tipback bends placed in the posterior
segments. The third order bends or torqueses
are placed to get correct buccolingual position
by moving the roots. They are placed by
twisting the arch wires.
The advantages of the edgewise technique
includes:
i. Ability to move teeth in all the three
planes of space
ii. Good control over tooth movement
iii. Bodily tooth movement is possible
iv. Precise finishing is possible
The disadvantages of the edgewise tech­
nique include:
i. The need to apply heavy forces
ii. The need for complex wire bending
iii. Increased friction between the arch-
wire and the bracket
iv. The need for extraoral forces for ancho­
rage
v. Difficulty to open deep bites.
Charles H Tweed modified this technique
and advocated extraction of teeth in selected
cases for better stability. He also introduced
the concept of anchorage preparation wherein
the terminal molars were initially tipper
distally to better resist the traction forces that
were used in the later stages. Over the years a
number of modifications have been proposed
in this technique.
Begg’s Technique (Figs 9.50A to D)
Raymond P Begg received his training in
orthodontics from the Angle school during
the early 1900s. He later returned to Australia
in 1925 and practiced the edgewise technique.
In the mean time Begg modified the Angle’s
ribbon arch technique and introduced the
Begg light wire differential force technique.
This appliance used the concept of differential
force and tipping of teeth rather than bodily
movement. The Begg appliance used high
strength stainless steel wires along with a
number of auxillaries and springs to achieve
the desired tooth movement.
The treatment using Begg appliance is
carried out in three different stages. Stage
one is concerned with alignment, correction
of crowding, rotation correction, closure of
anterior spaces and achieving an edge-to-edge
anterior bite. In the stage two the remaining
extraction spaces are closed while maintaining
the previous corrections that have been achi­
eved. In the final stage uprighting and torq­
uing is carried out to achieve normal axial
inclination of the teeth.
A B C D
Figures 9.50A to D: Begg’s appliance

The advantages of the Begg appliance
include:
i. The use of light forces which are within
the physiological limits.
ii. Relatively continuous force application.
iii. Minimal friction between the wire and
the brackets.
iv. Rapid alignment and overbite correction.
v. The appliance does not strain the
anchorage.
vi. Extraoral forces were not required to
conserve anchorage.
Tweed Technique
Charles H Tweed was the first person to use
the edgewise appliance in conjunction with
extrac­tion, and this treatment method has
been the classic edgewise technique for many
years. At the diagnosis and treatment planning
stage, considerable emphasis is placed on the
use of serial cephalometric radiographs to
identify the facial growth trend. The concept
of ideal arch form was used as a basis for
arch wire design. Assurate measurements of
arch length and tooth width are taken. These
measurements are used to construct Bonwill
Hawley arch graph which is then used as a
template for successive arch wire fabrication.
Single 0.022 inch slot edgewise brackets
were used with mesial and distal eyelets to
facilitate rotation and molars bands were fitted
with rectangular tubes. Round arch wires were
used initially inorder to facilitate leveling and
correction of gross displacements.
One of the important concepts of this
technique was that anchorage preparation in
which extraoral forces and class III traction
was used to prepare the lower arch as a site
for anchorage. Relatively rigid arch wires were
used both for canine retraction and overjet
reduction.
Orthodontic Appliances 377
Combination Techniques
The Begg and edgewise techniques are
fundamentally different in their mechanical
approaches to treatment. The free tipping
which allows rapid correction of crowding and
the ability to use accessory springs to achieve
apical movement are some advantages of
Begg technique. The wide edgewise brackets
restricts tipping, but the close fit of edgewise
arch in the bracket channel allows precise final
control of tooth position.
In order to achieve advantages of both
the systems, attempts have been made to
unite them into a single technique with the
simplicity and precision of edgewise brackets
and rectangular arch wire combination, and
the rapid unraveling which is seen when using
light forces of Begg mechanism.
In light wire appliance described by Jarabak
the bracket used is basically of edgewise type,
incorporating a rectangular arch wire channel.
However, a large part of treatment is achieved
using small diameter light wires incorporating
carefully positioned vertical and horizontal
loops and helices. The anterior teeth carry
modified brackets with vertical slots enabling
round arch wire to produce tipping, rotation
and bodily movement.
Labiolingual Technique
As described by Trapley, Mershon developed
this technique with relatively rigid mandibular
and maxillary lingual arches attached to molar
bands. These arches carried springs similar to
modern removable appliances. The lower arch
was used for tooth movement in the upper
arch by means of class II elastic traction. From
a mechanical point of view the labiolingual
technique as it is called offered much less
control over tooth position than edgewise
technique. At the present time, the labiolingual
378 Essentials of Orthodontics
appliances have been largely superseded by
the modern straight wire appliances.
Lingual Appliance
In 1976, Craven Kurz submitted specific design
and concept of the unique lingual appliance.
The routine use of banded attachments has
enabled the development of appliance used
on lingual and palatal aspects of teeth. The
main attraction of this appliance is cosmetic
and they may be indicated in adult patients.
A number of differing attachments have been
developed and are based on principles that
apply in normal fixed appliance technique.
Both edgewise and Begg based methods of
treatment are used. The main problems with
this appliance are that it interferes with speech
after it is first fitted and is much more difficult
to clean than the conventional appliance. The
considerable disadvantage from orthodontists
point of view is that the access is extremely
difficult, both from the aspect of initial
banding and for changing arch wires. It is
therefore a time consuming appliance. Both
the edgewise and the Begg principles can be
employed in treatment. Lingual appliances
are highly esthetic but have the disadvantage
of poor access and difficulty in speech and
maintaining the oral hygiene.
Universal Appliance
It is the design of Spencer Atkinson. It is a
multibanded precision appliance consisting
of one flat 0.012 × 0.028 inch and one round
0.014 inch wire used in combination. The flat
wire is placed incisally. At different stages of
treatment, various combinations of round and
flat wires may be used according to the type of
movements desired. The control provided by
the bracket in three planes of space is such that
canines can be retracted bodily with a minimum
of mechanical effort and maximum of control.
The wires are held in place by a small lock pins.
Because of many adjuncts used and the possible
combination of arch wires, the appliance is very
versatile. Its greatest advantage would seem to
be its value in treat­ment of permanent dentition
than mixed dentition.
Tip Edge Technique
Kesling describes the tip edge brackets as
dynamic in action. This facilitates both appli­
ance manipul­ation and tooth movement.
The progressi­vely increasing control is partly
automatic because of the design of the arch
wire slot and is partly selective due to the
application of a unique elastomeric tip edge
ring, an uprighting spring, and a rectangular
arch wire. The initial use of a 0.016 inch round,
high tensile arch wire permits tipping in all
directions yet provides rotational control.
Therefore, the tooth crown can move along
individual path of least resistance in response
to relatively light forces generated by the arch
wires and elastics. Subsequent use of larger
(0.022”) arch wires provide increased vertical
and horizontal fixation during space closure
and major root uprighting.
Straight Wire Appliance
(Preadjusted Edgewise Appliance)
(Figs 9.51A and B)
The straight wire technique is a recent modific­
ation of the edgewise appliance introduced by
Lawrance F Andrews in the 1970s based on his
six keys to normal occlusion. The basic concept
was to program the brackets to have the first,
second and third order components so that
A B
Figures 9.51A and B: Preadjusted edgewise appliance

the wire need not have any complex bending
as required in edgewise appliance. Thus, the
straight wire technique made it possible to
substantially reduce the wire bending required
and also enabled good finishing of cases.
ORAL HYGIENE IN FIXED
APPLIANCE TREATMENT
Once the orthodontic fixed appliances are
placed, the patient needs to be instructed in
how to manage the new oral environment and
how to maintain the health of the dental and
periodontal structures.
Microbiology of Orthodontic
Appliances
Clinical reports have shown that patients
who receive orthodontic treatment are more
susceptible to enamel white spot formation.
Metallic orthodontic brackets have also been
found to inflict ecologic changes in the oral
environment, such as decreased pH and
increased plaque accumul­ation. Changes
manifested in the oral flora included elevated
Streptococcus mutans coloni­zation, imposing
a potential risk for enamel decal­cification.
In general, adhesion of microorganisms
to surfaces is a result of specific lectin-like
reactions, electrostatic interactions, and van
der Waals forces. Although it is clear that initial
attachment is an important factor governing
fur­ther colonization, the mechanisms of the
attachment and those of subsequent adhe­
sion may differ significantly. Specifically, a
significant correlation between the surface free
energy of a material and its plaque-retaining
capacity has been established, with the
higher energies showing a favorable effect on
bacterial adherence. Also, topical application
of fluoride solutions has been proven to reduce
Orthodontic Appliances 379
the surface energy of enamel, making the
bacterial colonization unfavorable. This effect,
along with the well-substantiated biologic
action of fluorides, may further support the
role of surface physical properties on oral
microbiota attachment.
It is likely that the regulatory effect of
sub­strate surface properties is critical during
the early stages of bacterial adhesion; once
attachment is established; additional factors
may dictate further colonization.
Since, it has been proposed that streptococci
bind to specific receptor sites available in
salivary constituents, decreased wettability
may inhibit direct adhesion and colonization
of bacteria onto appliances.
Caries and Decalcification during
Orthodontic Therapy
Properly made orthodontic bands are caries
resistant. Food debris and white spots must be
removed. Sometimes areas of decalcification
are found on the teeth. Protection of enamel
by topical application of fluoride is used.
Recementations of loose and deformed bands
are done immediately and any impingement
on gingival tissues are to be relieved.
Periodontal Problems
Mild to moderate gingivitis is common in most
of the cases treated with fixed orthodontic
appliances. They usually appear within 4
weeks of starting the treatment and persist
till the appliance removal. Alveolar bone loss
is also one of the problems associated with
fixed appliances and they commonly occur
in the extraction sites. These periodontal
problems are usually prevented by proper oral
hygiene instructions and patient education.
Routine prophylactic scaling procedures are
to be carried out till the end of the orthodontic
treatment.
380 Essentials of Orthodontics
Traumatic Ulcerations
Traumatic ulcerations in the gums, lips, cheeks
and tongue are one of the most common
problems associated with fixed orthodontic
appliances. Bands, arch wires, lock pins
and brackets are common causes for these
traumatic ulcerations. Nickel sensitivity
should be ruled out before these traumatic
ulcerations are treated. Management of these
ulcerations includes applications of analgesic
and anti-inflammatory agents over the ulcers,
local anesthetics can also be used for relief of
pain. Sharp ends of the fixed appliance must
be trimmed off and the distal ends of the arch
wires are cut. Relief silicons or relief waxes
are used over the sharp edges to prevent any
further damage to the ulcers. Relief silicon is
preferred over relief wax as it does not melt
or freeze or dry out with change in storing
temperature.
Oral Hygiene
Proper oral hygiene during orthodontic
therapy cannot be overemphasized. Combined
effect of orthodontist, dentist, hygienist, parent
and patient to establish proper oral hygiene
is important. The patient must be visiting
dentist every three months. Radiographs must
be taken to note any decalcification and root
resorption.
If gingival inflammation occurs it must be
detected early and it must be controlled careful
scaling, root planning, removal of debris
from pockets and actual removal of fibrous
proliferation must be done. Cases of vitamin
deficiency and dilating hyperplasia are treated
appropriately.
Tooth Brushing
Tooth brushes used should have soft bristles
with rounded ends to minimize gingival and
tooth abrasion. Orthodontic tooth brushes
(brushes with the middle row of bristles shorter
than the outer rows) may be more effective.
Motivated patients usually develop a high
personal preference to brush head size and
shape, handle and design. Electronic powered
tooth brushes can be used for uncooperative
or physically or mentally challenged patients.
Emphasize patient on cleaning behind arch
wires and interproximal areas by attempting
to get bristles into these areas. The modified
bass method, with the bristles at 45o angle to
the sulcus is only necessary for adults with
deepened pockets. Patient is asked to vibrate
gently in one place and avoid scrubbing,
which can cause cervical abrasion and gingival
recession. Tooth brushes are let to airdry
for 24 hours between uses. Let the patients
demonstrate the efficiency of brushing at
each regular visit until they have mastered
the technique. The patient must know when
appliances are clean by looking in the mirror.
Plaque removal effectiveness is checked every
visit, and additional methods to improve oral
hygiene such as flossing can be advocated.
Mouthwashes
In addition to the tooth brushes, patients
can use a number of agents to help improve
their gingival health; they are Stannous
fluoride gels, Listerine rinse, tryclosan,
chlorhexidine rinses, and other antiplaque
agents. Stannous fluorides are effective against
gingivitis, and are anticariogenic. Listerine
oils can be used twice daily for 1 minute.
Tryclosan has mild antigingivitis effect, good
taste and supragingival calculus control,
and tryclosan containing toothpastes can
be routinely recomm­ended for orthodontic
patients. Chlorhexidine is the best for optimum
management of severe gingivitis in adolescent
orthodontic patients, they are also useful in
patients after orthognathic surgery, it can be

used twice daily and the main problem with
chlorhexidine is the ability to stain the tooth.
Other antiplaque agents such as baking
soda toothpaste, alkaloid sanguinaria, and
peroxide showed mild antigingivitis effect are
rarely used.
A final effective method for home care for
patients in periodontal maintenance is the use
of an oral irrigator with regular tap water at high
pressure with a conventional irrigator tip. If
gingival bleeding on probing persists, a way of
enhancing the effect of oral irrigation would
be to add two capfuls of chlorhexidine rinse
to approximately 150 ml of water and irrigate
the pockets directly using a specially modified
irrigating tip.
Nickel Hypersensitivity
Various wires are used in orthodontics, such
as stainless steel, cobalt-chromium, nickel-
titanium, and beta-titanium; the majority of
these alloys have nickel as one of their compo­
nents. The percentage of this metal in the alloys
varies from 8%, as in stainless steel, up to more
than 50%, as in the nickel-titanium alloys.
The association of different metals in the oral
environment, where saliva is the connecting
medium, may produce electrogalvanic
currents that produce a discharge of ions and
metallic compounds when combined with the
chemically corroded metal. These products
may be swallowed or may become attached
to the mucosal or dental surfaces. Masticatory
forces may also produce a discharge of these
ions, as a result of wearing restorations. The
discharge of nickel ions, which is a strong
immunologic sensitizer, may result in contact
hypersensitivity.
Orthodontic Appliances 381
The hypersensitivity reaction to nickel is
due to a direct relationship with the presence
of this metal in the environment, and may be
caused by ingestion or direct contact with the
skin and/or mucosa. It is estimated that 4.5% of
the population have hypersensitivity to nickel,
with a higher prevalence in females.
Hypersensitivity to nickel in females
is thought to be related to environmental
exposure as a result of contact with detergents,
jewelry, earrings, and other metallic objects. In
males, the hypersensitivity is usually related to
occupational exposure, especially in industries
that use nickel as raw material. Environmental
exposure may also result from contact with
wristwatches, metal buttons, metallic frames
of glasses, buckles, and other metallic objects.
It is thought that the frequency of hyper­
sensitivity reaction should increase in patients
with prosthodontic or orthodontic appliances,
especially those made of nickel-titanium
alloys. The longer the exposure to this metal,
the larger the risk of sensitization. The age
range affected by the hypersensitivity reaction
is between 10 and 20 years, which correspond
to the period in which orthodontic treatment
is usually undertaken. However, there is no
evidence that stainless steel orthodontic
appliances produce this type of allergic
reaction.
Patients under orthodontic treatment
may constitute an important clinical model to
evaluate whether direct contact with nickel-
containing metallic alloys may sensitize or
aggravate pre-existing allergic reactions or
whether the elimination of this contact may
decrease an allergic reaction.
382 Essentials of Orthodontics
CHAPTER
Dentofacial
10 Orthopedics
ORTHOPEDIC APPLIANCES
In orthodontic practice forces employed are
basically of two types. One is an orthodontic
force that moves teeth efficiently and the other
an orthopedic force that affects the deeper
craniofacial structures. Orthodontic forces
are those that are applied to the teeth by
means of wires and other active components
of a removable or fixed appliance. The forces
produced by these appliances are light and
range from 50 to 100 gm. The orthopedic
forces on the other hand are heavy forces of
over 400 gm.
BASIS FOR ORTHOPEDIC
APPLIANCES
Forces applied to the teeth have the potential
to radiate outwards and affect the nearby
skeletal structures. For such skeletal changes
to occur, the forces employed should be over
400 gm. Thus the orthopedic appliances utilize
the teeth as handles to transmit the forces
to the adjacent skeletal structures. In order
to produce skeletal changes, consideration
should be given to the amount of force applied
and the duration of force.
Amount of Force
Heavy forces of over 400 gm totally compress
the periodontal ligament on the pressure side
and cause hyalinization which prevents tooth
movement. These heavy forces are conducted
to the skeletal structures to produce an
orthopedic effect.
Duration of Force
Intermittent forces ranging from 12 to 14 hours
a day are believed to bring about minimum
tooth movement but maximum skeletal
change. Thus most extraoral orthopedic appli­
ances are worn 12 to 14 hours a day. Increase
in the duration of wear results in an increase
in the dental effects.
Components of Extraoral Appliance
Basically the extraoral orthopedic appliance
consists of three elements:
I. Force delivery unit: Face bow, J hooks,
chin cup, removable appliance, fixed
appliance, etc.

II. Force generating unit: Extraoral elastics,
springs, bands, force modules, etc.
III. Anchor unit: Headcaps, neck straps, face
masks, etc.
Concepts of Extraoral Anchorage
Certain extraoral areas can be utilized as
sources of anchorage to bring about orthod­
ontic or orthopedic changes.
Intraoral appliances must depend at least
on adjacent teeth for anchorage, thus causing
unwanted movement of the anchorage teeth.
In order to eliminate this problem, extraoral
anchorage can be used.
Indications for use of
Extraoral Force
1. Reinforce intraoral anchorage
2. For correction of skeletal malocclusion
3. Molar distalization
4. Dental correction.
BIOMECHANICAL CONSIDERATION
I. Teeth
1. Root form: Basically, roots have three
forms:
Round: Teeth with round roots resist hori­
zon­tally directed forces in any direction.
Flat: It can resist movements in the mesi­
odistal direction but have little resistance
to movement on thin edges found on their
buccal and lingual side.
Triangular: These permit maximum resi­
stance to displacement.
2. Size and number of roots: Tooth with
greater root surface area will have larger
periodontal support. So multirooted tooth
have greater ability to withstand stress than
single rooted tooth.
Dentofacial Orthopedics 383
3. Root length: Deeper the root is embedded,
stronger will be its resistance to dislodge­
ment.
4. Position of tooth in dental arch: Position
of tooth offers resistance, e.g. mandibular
second molars are located between two
ridges of basal bone, mesial to retromolar
fossa of mandible.
5. Inclination of tooth: When the axial inclin­
ation is in a direction opposite to the force
acting upon it, offers a great resistance to
dislodgement.
6. Mutual support: In addition to resistance
offered by an individual tooth, each tooth
is supported by contact with tooth on either
side.
No tooth can be considered as an anchorage
unit without considering its relationship to
other teeth.
II. Basal Bone
Basal bone areas such as hard palate and
buccal and lingual cortical plate of mandible
can be used to augment intramaxillary and
intermaxillary anchorage.
III. Musculature
The stability of the anchorage of the dental
arch may be marginally increased by the
temporary utilization of the hypertonic labial
muscle.
IV. Site of Anchorage
Site of anchorage plays a role in orthopedic
treatment for instance.
1. Anchorage from occipital region will
produce a superior and distal force of on
maxilla.
2. Anchorage from cervical region will
produce inferior and distal force on
maxilla.
384 Essentials of Orthodontics
V. Manner of Force Application
Forces passing through center of resistance
of maxilla produces translation of maxilla in
distal direction (center of resistance is located
above the roots of premolar teeth).
If forces are passing above or below this
point causes rotation of maxilla.
VI. Magnitude of Force
Heavy forces of 400 to 600 gm are required to
produce orthopedic effect.
VII. Duration of Force
Forces 12 to 14 hours/day of appliance wear
is required to produce maximum skeletal
changes.
Determination of Force Magnitude
The factors which help in determining the
magnitude of force to be applied depends on:
1. The individual variation between patients.
2. The timing and severity of malrelationship.
3. The amount of active growth occurring.
4. The direction of growth.
5. The sensitivity of receptor tissue­—chin,
maxillary teeth.
6. The length of time of appliance worn during
the 24 hours of a day.
7. The patient’s cooperation.
In general, a force of about 2 to 3 pounds
(900-1350 gm) can be applied against the
symphysis in cases of mandibular prognathism.
If the patient wears chin cup for 16 to 18 hours
per day, then 1 to 2 pounds of force is adequate.
If the patient wears chin cup for about 10 to 12
hours per day more force should be applied.
If growth increments are large and growth
direction is primarily horizontal as in cases of
class III malocclusion, greater force should be
applied for longer time for 24 hours of day.
For redirecting the maxillary growth, a
force of about 400 to 800 gm on each side is
adequate, if the patient is wearing the appli­
ance for about 12 to 14 hours/day.
Extraoral anchorage is obtained by:
• Headgear
• Face mask
• Chin cup.
HEADGEAR
Headgear is a common term for an extraoral
appliance that is used for producing orthopedic
changes.
Objective
The objective of orthopedic treatment with the
headgear is to alter the growth by rendering
or restricting or accelerating the normal
growth of maxilla and mandible. This is done
with the help of extraoral anchorage from
cranium, back of the neck. The intention is for
mandible to “catch up” with maxilla, correcting
anteroposterior skeletal discrepancy.
Biomechanics
An important principle in analyzing force
system from a headgear is the relationship
between the line of force action and its
relationship to the center of resistance of
maxilla or first molar.
A force passing through the center of
resistance causes pure translation in direction
of line of force. Any other force produces
translation and a rotation with a moment.
To analyze force systems on an upper first
molar, first draw an imaginary line connecting
the point of attachment on strap and outer
bow of headgear when the appliance is in
place. Drop a perpendicular line from the
center of resistance of upper first molar to
the line of force. The magnitude of moment
of force is the product of magnitude of force

and perpendicular distance from center of
resistance to line of force.
Mechanism of Action
A headgear is designed to deliver an adequate
extraoral orthopedic force to compress
maxillary structures, modifying the pattern
of bone apposition at these site. The force
need to be of sufficient magnitude, applied
in appropriate direction, and delivered for
an adequate length of time during a period
of active mandibular growth for there to be a
positive treatment prognosis.
Types
• High pull headgear
• Cervical pull headgear
• Combination pull headgear
• Reverse pull headgear
• Chin cup with headgear.
Parts
Intraorally: There are two different components
available in headgear for delivering extraoral
force to maxilla.
Face bow (Fig. 10.1): It is large gauge wire frame­­
work consisting of an outer bow for extra­oral
attachment soldered to an inner bow that
attaches intraorally in tubes attached to maxi­
llary first permanent molars.
It can be used either with a maxillary fixed
or removable appliance.
Figure 10.1: Face bow
Dentofacial Orthopedics 385
Because the intraoral point of attachment
is usually localized to the bands on maxillary
first permanent molars, it is usually the molar
center of resistance that is considered when
determining the direction or vector of force.
If face bow is attached to a removable
appliance, center of resistance is more forward
between anterior and posterior maxillary
teeth.
J-hook headgear: It is two separate curved,
large wires that are formed on their ends into
small hooks, both of which attach directly to
anterior part of maxillary arch wire.
More commonly used for retraction of
canines or incisors rather than orthopedic
purposes.
It is limited to area only with a maxillary
fixed appliance with a continuous arch wire.
Intraoral point of attachment is directly to
maxillary arch wire, which usually is attached
to all of the maxillary teeth. As a result, center of
resistance is the midpoint between the anterior
and posterior teeth.
Extraorally
• Cervical headgear
• Occipital headgear
• Combination.
Indications for Use of Headgear
for Cervical Pull
• Deep bite care.
• Class II division 2 with low mandibular
flare angle.
• Retraction of upper incisors.
• Skeletal Class II malocclusion with low
mandibular flare angle.
• Skeletal deep bite.
High Pull (Fig. 10.2)
• Vertical maxillary excess
• Intrusion or retraction of incisor in high
mandibular plane angle
386 Essentials of Orthodontics
Figure 10.2: High pull headgear
• Retraction of canine
• Prognathic maxilla with high mandibular
plane angle
• Class II division 1 malocclusion.
Protraction Headgear
It is used for skeletal and dental protraction
of maxilla in Class III malocclusion caused by
maxillary deficiency.
Cervical Attachment or Neck Strap
(Fig. 10.3)
Because the point of attachment is usually
below the occlusal plane, the extraoral force
is directed inferiorly as well as posteriorly.
This force vector may help anteroposterior
Figure 10.3: Neck strap
correction but may amplify vertical maxillary
excess problems.
With the face bow the cervical attachment
creates an extensive distal force to the maxillary
molars, whereas this same attachment to a
J-hook promotes extrusion and retraction of
the maxillary incisors.
They also result in the backward rotation
of the mandible. Therefore the cervical strap
should only be considered for individuals
with flat mandibular and occlusal planes in
which an increase in facial vertical dimension
is desired.
Occipital Attachment or Headcap
(Fig. 10.4)
With the point of attachment well above the
occlusal plane, the extraoral force is directed
superiorly and posteriorly.
This high attachment permits the creation
of a forced vector that contributes to correction
of not only anteroposterior maxillary excess
but also to vertical maxillary excess.
The higher angle of the force vector created
results in a distal and intrusive force to the
maxillary molars.
When the occipital attachment is used with
a J-hook the force vector is further foreward, so
that it tends to have an intrusive force to the
maxillary incisors and may have an indirect
Figure 10.4: Head strap

Figure 10.5: Combination pull headgear
extrusive force to the maxillary molars as a
result of tipping of the occlusal plane.
Combination Headgear (Fig. 10.5)
If the forces are equal for each attachment
the resulting force vector is usually above
the occlusal plane, but inferior to the vector
created with the occipital attachment alone.
Figures 10.6 and 10.7 show the cervical
pull headgear and occipital pull headgear
respectively.
Advantage
It is a case with which force vector can be
modified and improved comfort afforded by
the increased force distribution.
Figure 10.6: Cervical pull headgear
Dentofacial Orthopedics 387
Figure 10.7: Occipital pull headgear
Disadvantage
It increases the number of parts that the patient
has to wear, manage and possibly lose.
Selection of Headgear
A high pull headgear will place a superior and
distal force on the teeth and maxilla.
A cervical neck strap will place an inferior
and distal force on the teeth and skeletal
structure.
When the headcap and neckcap is com­
bined the force direction can be varied by
altering the proportion of the total force
provided by each component. If each delivers
equal forces the resultant forces is slightly
upward and distal for both teeth and maxilla.
Selection of Headgear Attachment
to the Dentition
Usual arrangement is a face bow to tubes and
permanent first molars.
A removable appliance can be fitted to the
maxillary teeth and the face bow attachment
to this appliance can be fitted to the maxillary
teeth and the face bow attached to this appli­
ance.
This appliance can take a form of:
• A maxillary splint
• A functional appliance.
388 Essentials of Orthodontics
Selection of Required Movement
Teeth: Since the center of resistance for a molar
estimated to be in the midroot region, force
vectors above this point should result in distal
root movement.
Jaws: Control of the line of the force relative
to maxilla is easier when a splint covering all
the teeth is used to apply the headgear force.
The face bow is usually attached to the splint
in the premolar region so that the force can be
directed through the center of resistance of the
maxilla that is estimated to be located above the
premolar roots. Distal tipping of the maxillary
incisors is likely to occur, because of the distal
component of the force delivered to the tooth.
Selection of Magnitude of
Extraoral Force
Extraoral force must be of greater magnitude,
in the range of 400 to 600 gm per side to
maximize the potential for skeletal change and
to minimize the dental change.
Selection of Duration
In contrast to orthodontic tooth movement,
intermittent forces of 12 to 16 hours duration
appear to be effective for facial orthopedic
changes.
The headgear is tooth-borne; however an
intermittent force minimizes tooth movement,
while still providing for skeletal changes.
The intermittent use of headgear is another
practical benefit to treatment of skeletal
problems because few children are willing to
wear a headgear full time.
Selection of Direction
The extraoral attachment can be cervical or
occipital to establish a determined force vector.
Outer bow of the face bow can be short or
long; placed above or below the occlusal table
to produce different force vector.
Selection of Timing
It is basic principle of facial orthopedic
treatment that the greatest amount of skeletal
improvement can be obtained while wearing
the appliance during the most active period
of facial growth.
Advantage
Skeletal changes achieved with class II
treatment are much more resistant to relapse,
probably because of minimal maxillary growth
and residual mandibular growth that often
remain at this stage.
Disadvantage
The renewed expression of the original growth
pattern following treatment may negatate part
of no correction with no permanent long-term
effect on original skeletal growth pattern.
Facial pubertal growth spurt does not occur
in all patients and is not accurately predictable
regarding its magnitude, duration, direction,
and timing.
Limitations
In spite of using heavy, intermittent forces, it
is inevitable that significant tooth movement
will occur.
The dependence on patient compliance to
wear and care for the headgear for successful
treatment progress.
The dependence on an adequate amount
and direction of mandibular growth on
treatment.
PROTRACTION FACE MASK
THERAPY (FIG. 10.8)
Indications
1. The face mask is most effective in the
treatment of mild to moderate skeletal class

Figure 10.8: Reverse pull headgear
III malocclusion with a retrusive maxilla
and a hypodivergent growth pattern.
2. Patient presenting initially with some
degree of anterior mandibular shift and a
moderate overbite have a more favorable
prognosis.
3. Cleft palate cases.
Types
• Protraction headgear by Hickham
• Face mask of Debáire
• Tubinger model
• Petit type of face mask.
Clinical Response to Maxillary
Protraction
Anterior cross bites can be corrected with 3 to 4
months of maxillary expansion and protraction
depending on severity of malocclusion.
Improvement in overbite and molar rela­
tion­ship can be expected with an additional 4
to 6 months of maxillary protraction.
Overbite result was found to be the result
of forward maxillary movement, backward
movement of mandible, labial movement of
maxillary incisors and lingual movement of
mandibular incisors.
Anchorage loss was observed during
maxillary protraction with mesial movement
of mandibular incisors.
Dentofacial Orthopedics 389
In patient with Class III malocclusion,
treat­m ent with maxillary expansion and
protraction can straighten the skeletal and soft
tissue facial profile and improve posture of lip.
In patients with 8 month protraction,
maxilla comes 2.1 mm forward.
FACTORS GOVERNING VARIABILITY
IN CLINICAL RESPONSE
Clinically, the maxilla can be advanced 2
to 4 mm over an 8 to 12 months period of
protraction.
Age of the Patient
The optimal time to intervene in a patient
with early class III malocclusion is at the time
of initial eruption of upper central incisors
(6–8 yrs).
Better skeletal and dental response can be
obtained in primary and early mixed dentition.
Design of Anchorage System
The design for anchorage system for maxillary
protraction varies from palatal arches to rapid
maxillary expansion (RME), occlusal splint.
Patient treated with a protraction face mask
can be divided into two groups with or without
RME.
Force Level, Direction and
Point of Application
Orthopedic effects require greater forces
than do orthodontic movements. Successful
maxillary protraction has been reported using
300 to 500 gm of force per side in primary and
mixed dentition.
An effective forward displacement of the
maxilla can be obtained clinically from a force
applied on a hook placed between the first
and second molar placed about 5 mm above
390 Essentials of Orthodontics
the palatal plane. 15º to 20º downward pull to
the occlusal plane is used to produce a pure
forward translatory motion of the maxilla.
CHIN CUP THERAPY (FIG. 10.9)
Objective
The objective of early treatment with the use
of a chin cup is to provide growth inhibition
or redirection and posterior positioning of
the mandible.
Indication
1. Skeletal class III malocclusion with a
relatively normal maxilla and a moderately
protrusive mandible can be treated.
2. Correction of reverse overbite.
3. Retention appliance following therapy.
Types
Occipital pull chin cup: It derives anchorage
from occipital region of head. Most commonly
used types of chin cup. Used in class III
malocclusion and in patients with protrusive
lower incisors.
Vertical pull chin cup: It derives anchorage
from parietal region of head. Used in patients
Figure 10.9: Chin cup
with steep mandibular plane angle and
excessive anterior facial height.
Force Magnitude and Direction
16 to 24 oz (200-250 gm)/side is advised.
In occipital pull chin cup the force is
directed through the condyle.
In vertical pull chin cup the force is directed
below the condyle.
Treatment Timing and Duration
Patients with mandibular excess can usually be
recognized in the primary dentition despite the
fact that the mandible appears retrognathic in
early years of children.
Evidence exist that treatment to reduce
mandibular protrusion is more successful
when it is started in the primary or early mixed
dentition. The treatment time varies from 1
year to as long as 4 years depending on severity
of malocclusion.
FUNCTIONAL APPLIANCES
Functional appliances or myofunctional app­
liances as they are sometimes referred to are
appliances that depend upon the orofacial
musculature for their action. In contrast to active
removable appliances that make use of active
components like springs, elastics and screws,
the force component of functional appliance
are derived from the orofacial musculature.
These appliances transmit, eliminate or guide
the natural forces of the musculature.
Functional appliances are used for growth
modification procedures that are aimed at
intercepting and treating jaw discrepancies.
They can bring about the following changes:
i. Increase or decrease in jaw size
ii. A change in spatial relationship of the
jaws
iii. Change in direction of growth of the jaws
iv. Acceleration of desirable growth.

DEFINITION
Functional appliances are defined as loose
fitting or passive appliances which harness
natural forces of the orofacial musculature
that are trans­mitted to the teeth and alveolar
bone through the medium of appliance in a
predetermined direction.
Theoretical basis of functional treatment in
general is the principle that a new pattern of
function dictated by the appliance, leads to the
development of corresponding new morph­
ological pattern. The new pattern of function
can refer to different functional components of
the orofacial system, for example, the tongue,
the lips, the facial and masticatory muscles, the
ligaments, and the periosteum. Depending on
the type of appliance, its proponent puts more
emphasis on one of these different functional
components. The new morphological pattern
includes a different arrangement of the teeth
within the jaws, an improvement of the
occlusion, and an altered relation of the jaws.
It also includes changes in the amount and
direction of growth of the jaws and differences
in the facial size and proportions.
CLASSIFICATION OF
FUNCTIONAL APPLIANCES
Functional appliances can be classified in a
number of ways:
I. Tooth borne active appliances
Tooth borne passive appliances
Tissue borne passive appliance.
II. Myotonic appliances
Myodynamic appliances.
III. Removable functional appliances
Fixed functional appliances.
IV. Group I appliances: Directly acting on
tooth
Dentofacial Orthopedics 391
Group II appliances: Acting on tooth and
muscles.
Group III appliances: Acting on muscles.
Tooth borne passive appliance:They are tooth
borne appliances that have no intrinsic force
generating components such as springs or
screws. They depend on the soft tissue stretch
and muscular activity to produce the desired
treatment results. For example, activator,
bionator and herbst appliance.
Tooth borne active appliance: They include
modifications of activator and bionator that
include expansion screws or other active
components like springs to provide intrinsic
force for transverse or anteroposterior chan­
ges.
Tissue borne passive appliances: Tissue borne
appliances are mostly located in the vestibule
and have little or no contact with the dentition.
Example of such an appliance includes the
functional regulator of Frankel.
Myotonic appliances: They are functional
appliances that depend on the muscle mass
for their action.
Myodynamic appliances: They are functional
appliances that depend on the muscle activity
for their function.
Removable functional appliances: They are
myofunctional appliances that can be removed
and inserted into the mouth by the patient.
Examples include activator and bionator.
Fixed functional appliances: They are functional
appliances that are fitted on the teeth by the
operator and cannot be removed by the patient
at will.
Group I appliances: They consist of appliances
that transmit the muscle force directly to the
teeth for the purpose of correction of the
malocclusion. Examples include Oral screen
and inclined plane.
Group II appliances: These appliances repo­
sition the mandible and the resultant force is
392 Essentials of Orthodontics
transmitted to the teeth and other structures.
Examples include activator and bionator.
Group III appliances: These appliances also
reposition the mandible but their area of
operation is the vestibule, outside the dental
arch. Examples include Frankel appliance and
vestibular screen.
Treatment principles: Functional appliances
work on two broad principles:
Force application: Compressive stress and
strain act on the structures involved and result
in a primary alteration in form with a secondary
adaptation in function. Most of the fixed and
removable functional appliances work on this
principle.
Force elimination: This principle involves
the elimination of abnormal and restrictive
environmental influences on the dentition
thereby allowing optimal development. Thus
function is rehabilitized with a secondary
change in form.
All functional appliances are assemblies of a
few simple components. Each component has a
desired function and is generally incorporated
for a specific purpose. The currently used
appliances are made or combinations from
three basic functional components. They are
bite planes, shilds or screens and construction
or working bite. These components produce
skeletal and dentoalveolar changes by acting
on the following.
Bite Planes
Bite planes may be flat or inclined, and anterior
or posterior, which contact single or multiple
teeth. Although they are usually thought of
as blocks of acrylic resin, they may in fact be
made of wire or any other suitable material.
Recent research indicates that relatively
low forces, it applied either continuously or
intermittently, are capable of impeding the
eruption of teeth. Apically directed forces
may therefore by expect to impede or arrest
eruption; other forces may produce tipping
or eruptive deflection from the starting axial
inclination.
A flat anterior bite plane of sufficient
dimensions to disclude the posterior teeth
may be expected to have several effects.
These effects may comprise some or all of the
following:
i. Different eruption of posterior teeth.
ii. Noneruption, relative or absolute
intrusion of incisors.
iii. Incisor overbite reduction.
iv. Distoclusion with removal of inter-
cuspation may well responsible for any
additional increments of mandibular
growth.
v. Unimpeded posterior tooth eruption
may also result in a downward and
backward mandibular rotation that
tends to increase anterior vertical
lower facial height and reduces the
prognathism of the mandible.
Inclined planes may be designed to provide
guide planes for the labiolingual mechanical
eruptive displacement of incisors or the
buccolingual deflection of erupting posterior
teeth.
It should be remembered that as upper
posterior teeth erupt, they migrate not only
in a vertical but also in an anterior direction.
Therefore, impeding or selectively arresting the
eruption of maxillary molars not only permit the
relative increase of mandibular dentoalveolar
height, but also results in a relatively greater
mesial or anterior movement of the lower
buccal segments, both through eruption and
also by their forward translation, which is
produced by normal mandi­bular growth. With
the diminished or arrested eruption of the
maxillary molars, this combination of effects
can be expected to result in the improve­ment

of a Class II molar relationship. Conversely, if
the lower posterior teeth are restrained from
erupting while the uppers do so unimpeded,
the expected result would be an improvement
in a Class III molar relationship.
Shields or Screens
There is little doubt that the growing dento­
alveolar structures are plastic and responsive
to linguo-facial muscle pressures. The so-
called equilibrium theory of tooth position
predicts that overtime tooth movement
occurs in response to any perturbation of
the homeostatic relationship between the
radially directed forces of the tongue and the
opposing forces exerted by the circumoral
muscles of the lips and cheeks. Vestibular
shields or oral screens and lip pads have
been used to shield the muscles away thereby
allowing unrestricted growth of the jaws and
dentoalveolar structures. They are also used to
transmit muscle forces on to the dentoalveolar
structures.
Construction or Working Bite
All of the functional appliances are constructed
to a construction or working bite registration.
Such registrational of maxillomandibular
relationships are based on the assumptions
that by displacing the mandible from its rest
position, and thus stretching the muscles
attached to it, reflex activity tends to restore
the mandible to a postural position that was
originally determined by the unstretched
muscles. Hence, most construction bites are
taken at a vertical dimension that is beyond
the freeway space or interocclusal clearance.
In addition to this increase in the vertical
dimension, the construction bite may also
displace the mandible in the sagittal and
transverse planes.
Dentofacial Orthopedics 393
ADVANTAGES OF FUNCTIONAL
APPLIANCES
The myofunctional appliances offer a number
of advantages, they include:
1. It enables elimination of abnormal muscle
function thereby aiding in normal develop­
ment.
2. Treatment can be initiated at an early age. It
is most often started in the mixed dentition
period.
3. As the treatment is started at an early age,
psychological disturbances associated with
malocclusion can be avoided.
4. These appliances are mostly fabricated at
the dental laboratory. Thus, less chair side
time is spent which enables more patients
to be treated.
5. Frequency of the patients visit to the
orthodontist is less than in case of fixed or
removable appliances.
6. They do not interfere with oral hygiene
maintenance.
7. Most functional appliances are worn
during the night. Thus, patient acceptance
is good.
LIMITATIONS OF FUNCTIONAL
APPLIANCES
They following are the limitations of functional
appliances:
1. They cannot be used in adult patients in
whom growth has ceased.
2. They cannot be used to bring about
individual tooth movement.
3. Most functional appliances are dependent
on the patient for timely wear. Thus, patient
cooperation is essential for the success of
the treatment.
394 Essentials of Orthodontics
4. They may require prefunctional orthodontic
tooth movement for correction of minor
local irregularities that may interfere with
the functional therapy.
5. Fixed appliance therapy may be required
at the termination of treatment for final
detailing of the occlusion.
ACTION OF FUNCTIONAL
APPLIANCES
Functional appliances are capable of producing
the following changes:
Orthopedic changes: Myofunctional appliances
are capable of accelerating the growth in
the condylar region. They can bring about
remodeling of the glenoid fossa. They can be
designed to have a restrictive influence on the
growth of the jaws.
They can change the direction of growth of
the jaws.
Dentoalveolar changes: They can bring
about dentoalveolar changes in the sagittal,
transverse and the vertical directions. Most
functional appliances allow the upper anteriors
to tip palatally and lower anteriors to tip
labially. In the transverse direction, they can
bring about expansion of the dental arches by
incorporating screws in them or by shielding
the buccal muscles away from the dental arch.
In the vertical plane, they can be designed to
allow selective eruption of teeth.
Muscular changes: Functional appliances can
improve the tonicity of the orofacial muscles.
Case selection: The traditional view that
functional appliances are only suited in
treating Class II division 1 malocclusion with
uncrowded lower arches is largely discarded
in recent years. A wider range of cases is
being treated in recent years using functional
appliances as most of the cases may require
some form of finishing with fixed appliances.
Age: The growth modification therapy using
functional appliances is possible only in
a growing patient. The optimum time for
myofunctional therapy according to most
authors is between 10 years of age and pubertal
growth phase.
Social considerations: As stated by Andersen,
functional appliances achieve their results
with minimum supervision and unlike fixed
appliances can be worn safely for long periods
without supervision. Unfortunately all cases
cannot be treated with functional appliances
alone. Patients who live far away from the
clinic or those attending boarding school
may benefit from these appliances provided
they fulfill all other criterias for case selection.
However, such patient’s should exhibit high
degree of motivation if the functional therapy
is to be successful.
Dental considerations: An ideal case for
functional appliance therapy is one that is
devoid of gross local irregularities like rotations
and crowding. Only in uncrowded cases is
it likely that a malocclusion can be treated
satisfactorily by functional appliance alone.
The local irregularities are treated prior to or
after functional therapy with fixed appliances.
Skeletal considerations: Moderate to severe
skeletal Class II malocclusions are ideally
suited for functional appliance treatment.
Class II division 1 malocclusion exhibiting a
Class II skeletal tendency due to a short or
retrognathic mandible can be considered for
functional therapy.
Low angle cases respond well as most
functional appliances encourage vertical
development of posterior teeth. High angle
Class II cases usually fall into two categories—
those with increased overbite and those with
some degree of open bite. The deep overbite
type of high angle cases are successfully treated

using functional appliances while the open
bite type of cases pose a special problem.
Most functional appliances allow vertical
development of the posterior dentoalveolar
structures which may induce unwanted
backward rotation of the mandible.
Class II division 2 type of malocclusions
may be treated with functional appliances
after correcting the axial inclinations of the
maxillary anteriors.
Mild Class III malocclusions, which present
with a reverse overjet and an average overbite,
can be regarded as potentially treatable with
functional appliances. There is as yet no strong
clinical evidence of beneficial skeletal effect in
the use of Class III functional appliances and
most reported cases have demonstrated only
dentoalveolar changes.
VISUAL TREATMENT OBJECTIVE
Visual treatment objective (VTO) is an impor­
tant diagnostic test undertaken before making
a decision to use a functional appliance. This
test enables us to visualize how the patient’s
profile would be after functional appliance
therapy. It is performed by asking the patient to
bring the mandible forward. An improvement
in profile is considered a positive indication
for the use of a functional appliance. In case
the profile worsens, then other treatment
modalities have to be considered. Photographs
of the patient taken with forward mandibular
posture are a valuable aid in motivating the
patient and parents.
VESTIBULAR SCREEN
(ORAL SCREEN)
The vestibular screen is a simple functional
appliance that takes the form of a curved shield
Dentofacial Orthopedics 395
of acrylic placed in the labial vestibule. This
myofunctional appliance was first introduced
by Newell in the year 1912.
Principle
The vestibular screen can be used either to
apply the forces of the circumoral musculature
to certain teeth or to relieve those forces from
the teeth thereby allowing them to move due
to forces exerted by the tongue. Thus, the
vestibular screen works on the principles
of both force application as well as force
elimination.
Indications
The following are the indications for the use of
vestibular screen:
1. These appliances have been used mostly
to intercept mouth breathing habit. They
can also be used for interception of habits
such as thumb sucking, tongue thrusting,
lip biting and cheek biting.
2. Mild distoclusion can be treated using the
vestibular screen.
3. They can be used to perform muscle
exercise to help in correction of hypotonic
lip and cheek muscles.
4. The vestibular screen can be used to correct
mild anterior proclination.
Fabrication: Upper and lower impressions
are made and the working models poured.
The casts should reproduce the depths of the
vestibular sulcus. The upper and lower casts
are occluded in normal intercuspation and
the models sealed together using plaster. In
case the appliance is being used for correction
of distoclusion, a construction bite should be
taken to advance the mandible.
The vestibular screen should extend into
the sulcus to the point where the mucosal
tissue reflects outwards. Care should be taken
not to impinge on the frenum and the muscle
396 Essentials of Orthodontics
attachments. Posteriorly the appliance should
extend upto the distal margin of the last
erupted molar. The models are covered with
2 to 3 mm of wax over the labial surface of
the teeth and the alveolar process. In case of
proclined teeth which needs to be retracted the
wax relief is removed to expose the incisal one-
third of the teeth. The appliance is fabricated
using either self-cure of heat cure acrylic resin.
The appliance is smoothed using sand paper
and polished.
Clinical Management of the
Appliance
The patient should be asked to wear the
appliance at night and 2 to 3 hours during the
day time. The patient is instructed to maintain
lip seal. During the first few days the patient
may show certain areas of irritation in the
sulcular and the frenal areas. Such areas of
the appliance should be carefully trimmed to
avoid tissue irritation.
Modifications of the vestibular screen: A
number of modifications of the vestibular
screen are possible. The following are some
of them.
Hotz modification: The oral screen can
be fabricated with a metal ring projecting
between the upper and the lower lips. This
ring can be used to carry out various muscle
exercises.
In patients having tongue thrust habit an
additional screen is placed in lingual aspect of
the teeth. This additional screen is attached to
the vestibular screen by means of a thick wire
that runs through the bite in the lateral incisor
region.
In case of mouth breathers the vestibular
screen should be fabricated with a number
of holes that are gradually closed in a phased
manner.
Figure 10.10: Lip bumper
Lip Bumper (Lip Plumber) (Fig. 10.10)
The lip bumper or lip plumber as it is
sometimes called is a combined removable
or fixed appliance. The lip bumper can be
called a modified vestibular screen that is
used for muscular force application or force
elimination. The appliance can be used in both
the maxilla and the mandible to shield the lip
away from the teeth.
Uses of Lip Bumper
1. They are used in patients exhibiting lower
lip habits such as lip sucking. The lip
bumper shields the lower lip away.
2. They are also used in patients exhibiting
hyperactive mentalis muscle activity that
causes flattening or crowding of the lower
anteriors. Thus lip bumpers are mostly
used in the mandibular arch and rarely in
the maxillary arch. By removing the soft
tissue forces from the labial aspect of the
lower anteriors it may produce forward
tilting of these teeth under the influence of
the tongue pressure. Thus they increase the
arch length, reduce crowding and decrease
the excessive overjet.

3. Lip bumpers can be used to augment
anchorage. The muscular force transmitted
on to the molars in a distal direction would
discourage the forward movement of the
molars.
4. Distalization of the first molars can be
achieved by use of lip bumpers. The degree
of distal movement can be very limited,
especially where the second molars are
erupted.
5. The lip bumpers can be used as space
regainers if the lower molars have drifted
mesially due to early loss of deciduous
molars.
Appliance Design
The appliance is made of thick stainless steel
wire extending from one molar to the opposite
molar. The wire is made to lie away from the
anterior teeth so theat the lips are kept away
from the teeth. The lip bumper is inserted
into round molar tubes of 0.93 mm diameter
soldered to bands on the first molars. The
anterior portion of the wire from canine to
canine can be reinforced with acrylic.
Although lip bumpers are mostly used in
the mandibular arches, they can also be used in
the maxillary arch. Such an appliance is similar
in design and is called Denholtz appliance.
The lip bumper can be custom made using
0.9 mm hard round stainless steel wire or are
readily available in various sizes.
ACTIVATOR
Knigsley in 1879 devised a vulcanite palatal
plate to be used in patients having retruded
mandible. This vulcanite plate consisted of an
anterior incline that guided the mandible to a
forward position when the patient closed on it.
Hotz devised a ‘Vorbissplatte’ which
was modified form of Kingsley’s plate. This
Dentofacial Orthopedics 397
was used to treat retrognathism associated
with deep bite. It was also used to treat
retrognathism associated with lingually
inclined lower incisors.
Pierre Robin devised an appliance called
Monoblock made up of a single block of
vulcanite. He used it to position the mandible
forward in patients with glossoptosis and
severe mandibular retrognathism. By
positioning the mandible forward it reduced
the risk of airway obstruction.
Viggo Andresen, in 1908, in Denmark
developed a loose fitting appliance which he
first used on his daughter. He made a modified
Hawley type of retainer on the maxillary arch
to which he added a lower lingual horseshoe-
shaped flange which helped in positioning the
mandible forward. He made this appliance
on his daughter who was going on a 3 months
vacation. On her returen 3 months later,
he found a marker sagittal correction and
improvement of the facial profile. Andresen
called it Biomechanical working retainer. Later
Andresen moved over to Norway and teamed
up with Karl Haupl and brought about lot of
changes in his device. They called it Functional
jaw orthopedics.
As Andresen and Haupl were in Norway
while developing the appliance, it became
known as Norwegian appliance. They later
called it the activator due to its ability to
activate muscle forces.
Indications
It is primarily used in actively growing indivi­
duals with favorable growth pattern. The
maxill­ary and mandibular teeth should be
well-aligned. The mandibular incisors should
be upright over the basal bone. The following
are some of the indications for the use of
activator:
1. Class II division 1 malocclusion
2. Class II division 2 malocclusion
398 Essentials of Orthodontics
3. Class III malocclusion
4. Class I open bite malocclusion
5. Class I deep bite malocclusion
6. As a preliminary treatment before major
fixed appliance therapy to improve skeletal
jaw relations
7. For post-treatment retention
8. Children with lack of vertical development
in lower facial height.
Contraindications
1. The appliance is not used in correction of
Class I problems of crowded teeth caused
by disharmony between tooth size and jaw
size.
2. The appliance is contraindicated in
children with excess lower facial height
and extreme vertical mandibular growth.
3. The appliance is not used in children whose
lower incisors are severely procumbent.
4. The appliance cannot be used in children
with nasal stenosis caused by structural
problems within the nose or chronic
untreated allergy.
5. The appliance has limited application in
non-growing individuals.
Advantages
1. It uses existing growth of the jaws.
2. During treatment the patient experiences
minimal oral hygiene problems.
3. The intervals between appointments are
long.
4. The appointments are usually short due to
need for minimal adjustments.
5. Due to above reasons they are more econo­
mical.
Disadvantages
1. Requires very good patient cooperation.
2. The activator cannot produce a precise
detailing and finishing of the occlusion.
Thus posttreatment fixed appliance
therapy may be needed for detailing of
the occlusion.
3. It may produce moderate mandibular
rotation. Thus activators are not used in
cases of excessive lower face height.
Mode of Action of Activator
According to Andersen and Haupl, the activator
induces musculoskeletal adaptation by
introducing a new pattern of mandibular closure.
The appliance loosely fits into the mouth. The
patient has to move the mandible forwards to
engage the appliance. This results in stretching of
the elevator muscles of mastication which starts
contracting thereby setting up a myotactic reflex.
This generates kinetic energy which causes:
i. Prevention of further forward growth of
the maxillary dentoalveolar process.
ii. Movement of the maxillary dentoalveolar
process distally.
iii. A reciprocal forward force on the
mandible.
In addition to this myotactic reflex, a
condylar adaptation by backward and upward
growth occurs.
A third factor is the force generated while
swallowing and during sleeping.
According to Harvold, Woodside and
Herren passive tension caused by stretching
of muscles, soft tissue, tendinous tissue, etc.
are responsible for the action. They called it
the ‘viscoelastic property’.
Construction Bite
The construction bite is an intermaxillary
wax record used to relate the mandible to the
maxilla in the three dimensions of space. They
are used to reposition the mandible in order
to improve the skeletal interjaw relationship.
The bite registration involves repositioning of
the mandible in a forward direction as well as

opening the bite vertically. In most cases, the
mandible is advanced by 4 to 5 mm and the
bite opened to the extent of 2 to 3 mm beyond
the freeway space. The general considerations
for construction bite includes:
i. In case the overjet is too large, the
forward positioning is done step-wise
in 2 or 3 phases.
ii. In case of forward positioning of the
mandible by 7 to 8 mm, the vertical
opening should be slight to moderate,
i.e. 2 to 4 mm.
iii. If the forward positioning is not more
than 3 to 5 mm, then the vertical opening
can be 4 to 6 mm.
Low construction bite with marked
mandi­bular forward positioning: This kind
of cons­t ruction bite is characterized by
marked forward positioning of the mandible
but minimal vertical opening. As a rule of
thumb the anterior advancement should not
exceed more than 3 mm posterior to the most
protrusive position. Vertically the opening
is minimal and is within the limits of the
interocclusal clearance. This kind of activator
constructed with marked sagittal advancement
but minimal vertical opening is called an
‘H’ activator. The H activator is indicated in
patients with Class II division 1 malocclusion
having a horizontal growth pattern.
High construction bite with slight
mandibular forward positioning: The mandible
is positioned anteriorly by 3 to 5 mm only and
the bite is opened vertically by 4 to 6 mm
or a maximum of 4 mm beyond the resting
position. This kind of activator constructed
with minimal sagittal advancement but marked
vertical opening is called a ‘V’ activator. The V
activator is indicated in a Class II division 1
malocclusion having a vertical growth pattern.
Construction bite without mandibular
forward positioning: Sometimes a construction
Dentofacial Orthopedics 399
bite without forward positioning of the
mandible is made in cases such as deep bite
and open bite.
Construction bite with opening and posterior
positioning of the mandible: In a Class III
malocclusion, the bite is taken after retruding
the mandible to a more posterior position. In
addition, the bite is opened sufficiently to clear
the bite. In general a vertical opening of 5 mm
and a posterior positioning of about 2 mm is
required.
Fabrication of Activator
Impression: Impressions of the upper and
lower arches are made to construct 2 pairs of
models, study models and working models.
Bite Registration
i. The amount of sagittal and vertical
advancement of the mandible is
planned.
ii. A horseshoe-shaped wax block is
prepared for insertion between the
upper and lower teeth. It should be 2 to
3 mm thicker than the planned vertical
opening.
iii. The patient is made to sit in an upright
relaxed and nonstrained position.
iv. The mandible is guided to the desired
sagittal position. The operator should
merely guide the mandible using the
thumb and forefinger. He should not
use pressure or force.
v. The patient is asked to practice
placement of mandible at the desired
sagittal position a few times before
registration of the bite.
vi. The horseshoe-shaped wax block is
placed over the occlusal surface of the
lower cast and is gently pressed so as
to form the indentations of the lower
buccal teeth.
400 Essentials of Orthodontics
vii. The wax block is placed on the lower
jaw and the patient is asked to bite at
the desired sagittal position.
viii. It is then removed and placed on the
models and checked.
ix. If found all right, it is chilled and once
again tried on the cast. The excess wax
is trimmed off.
x. The hardened wax block is again tried
in the patient’s mouth.
Articulation of the models: The wax bite
registration is placed on the occlusal surface
between the upper and lower models. The
models are then articulated in a reverse
direction so that the anterior teeth face the
hinges. This kind of articulation ensures
sufficient access to the palatal surface of the
upper and lingual surface of the lower models
during the fabrication of the appliance.
Preparation of the wire elements: The usual
design requires an upper labial bow. The labial
bow is made with 0.8 or 0.9 mm stainless steel
wire and consists of a horizontal section with
2 vertical loops. The ends of the vertical loops
enter the acrylic body between the canine and
deciduous first molar (or first premolar). The
labial bow can be active or passive.
Fabrication of acrylic portion: The appliance
consists of three parts, maxillary part,
mandibular part and an interocclusal part.
The appliance can be fabricated by using either
heat cure of cold cure resin. In case of heat cure
resin the models are first waxed and then they
are flasked.
MANAGEMENT OF THE APPLIANCE
The patient should be sufficiently convinced
about the benefits of the appliance. In this
respect a good patient-doctor relation is
essential. The dentist can make use of video
tapes, booklets, etc. to motivate the patient.
The patient is also taught how to use, place and
remove the appliance by himself. Usually the
patient is asked to wear the appliance for 2 to
3 hours a day during the day time for the first
week. During the second week the patient is
asked to wear it for 3 hours during the day as
well as while sleeping. In case the patient has
difficulty in using it the whole night, more day
time wear is prescribed until the patient can
use it for the entire night.
A trimming plan should be developed
based on the individual needs of the patient.
Some orthodontists prefer the appliance to be
worn for a week without any grinding so that
the patient can get used to it.
Trimming of Activator
After fabrication of the activator it is usually
found to fit tightly as acrylic is interposed
between the upper and lower occlusal
surfaces. Planned trimming of the appliance
in tooth contact area is carried out to bring
about dentoalveolar changes so as to guide
the teeth into good relation in all the 3 planes
of space. Selective trimming of acrylic is
done in the direction of tooth movement. The
acrylic surfaces that transmit the desired force
by contact with the teeth are called guiding
planes. The areas of acrylic that contact the
teeth become polished.
Approximate trimming can be done on the
plaster casts. However, final trimming should
be done at the chair side.
Trimming of activator for vertical control:
Selective trimming of the activator can be done
to intrude or extrude the teeth.
Intrusion of teeth: Intrusion of the incisors is
achieved by loading the incisal edge of these
teeth with acrylic. In case labial bows are
used, they should be placed below the area
of greatest convexity, i.e. incisally to aid in the

intrusion. In case of intrusion of posteriors
is needed then only the cusp tips are loaded
with acrylic. The fosses and fissures are free of
acrylic. This applies a vertical intrusive force
on the molars.
Extrusion of teeth: In case of extrusion of the
incisors, the lingual surface is loaded above
the area of greatest convexity in the maxilla
and below the area of greatest convexity in
the mandible. The extrusive movement can
be enhanced by placing a labial bow above the
area of greatest convexity in the gingival 1/3rd
of the labial surface.
In case of molars, extrusion brought about
by loading the lingual surface above the area
of greatest convexity in maxilla and below the
area of greatest convexity in mandible.
Trimming of the activator for sagittal control:
Selective trimming of the activator can be
done to protrude or retrude the anterior teeth
and also to improve the molar relation of the
buccal teeth.
Protrusion of incisors: In case the incisors
should be protruded, lingual surface of the
teeth is loaded with acrylic and a passive labial
bow is given that is kept away from teeth to
prevent perioral soft tissues contacting the
teeth. This acrylic loading of the lingual surface
can be of two types:
i. Entire lingual surface is loaded. Since
the area of contact is more the force for
proclination is also low.
ii. Only the incisal portion of the lingual
surface is loaded. As acrylic is small
greater degree of force is generated to
tip the incisors labially.
Retrusion of incisors: The acrylic is trimmed
away from the lingual surface and an active
labial bow is used to bring about retrusion of
the incisors.
Movement of posterior teeth in sagittal plane:
The teeth in the buccal segment can be
Dentofacial Orthopedics 401
moved mesially and distally to help in treating
Class II and Class III malocclusion. In Class
II malocclusion, the maxillary molars are
allowed to move distally while the mandibular
molars are allowed to move mesially by
loading the maxillary mesiolingual surface and
mandibular distolingual surface.
Trimming of the Activator for
Transverse Control
It is possible to trim the activator to stimulate
expansion of the buccal segment. This is
done by allowing the contact of the acrylic on
the lingual surfaces of the teeth to be moved
transversely. But better expansion is possible
by placing a jack screw in the activator.
Modifications of activator: Over the years
a number of modifications of the classical
activator have been described.
The bow activator of AM Schwarz: The bow
activator is a horizontally split activator having
a maxillary portion and a mandibular portion
connected together by an elastic bow. These
kinds of modifications allow step-wise sagittal
advancement of the mandible by adjustment
of the bow. In addition this design allows
certain amount of transverse mobility of the
mandible. The independent maxillary and
the mandibular portions can have a screw
incorporated to allow arch expansions.
WUNDERER’S MODIFICATION
This is an activator modification that is mostly
used in treatment of Class III malocclusion.
This type of activator is characterized by
maxillary and mandibular portions connected
by an anterior screw. By opening the screw the
maxillary portion is moved anteriorly, with a
reciprocal backward thrust on the mandibular
portion.
402 Essentials of Orthodontics
THE REDUCED ACTIVATOR OR
CYBERNATOR OF SCHMUTH
This modification of the activator is proposed
by Professor GPF Schmuth. This appliance
resembles a bionator with the acrylic portion
of the activator reduced from the maxillary
anterior area leaving a small flange of acrylic
on the palatal slopes. The two halves may be
connected by an omega-shaped palatal wire
similar to bionator.
PROPULSOR
This is an activator modification conceived
by Muhleman and refined by Hotz. This
appliance can be said to be a hybrid that
combines the features of both the monoblock
and the oral screen. The propulsor is devoid
of any wire components and consist of acrylic
that covers the maxillary buccal portion like
an oral screen. This acrylic portion extends
into the interocclusal area and also as a lin­
gual flange that helps position the mandible
forward.
Cutout or Palate-Free Activator
This is a modification proposed by Metzelder
to combine the advantages of bionator and the
Andresen’s activator. The mandibular portion
of the appliance resembles an activator while
the maxillary portion has acrylic covering only
the palatal aspect of the buccal teeth and a
small part of the adjoining gingival. The palate
thus remains free of acrylic thereby making
the appliance more convenient for patients to
wear the appliance for longer periods. Due to
the greater amount of wearing time, success
should be greater with the palate free activator.
According to Dr Klaws Metzelder the appliance
is excellent in mandibular positioning in TMJ
dysfunction cases.
KARWETZKY MODIFICATION
This consists of maxillary and mandibular
plates joined by a ‘U’ bow in the region of
the first permanent molar. The maxillary and
mandibular plates not only cover the lingual
tissues and lingual aspect of teeth, it also
extends over the occlusal aspect of all teeth.
This type of activator allows step-wise
advancement of the mandible by adjustment
of the U loop.
The U loop has a larger and a shorter arm.
Based on their placement pattern we can have
three types of Karwetzky’s activators.
Type I: This is used in the treatment of Class II
division 1. In this modification, the larger lower
leg is placed posteriorly. Thus, when the two
arms of the U bow are sqeezed the lower plate
moves sagittally forwards.
Type II: This is used for the treatment of Class
III malocclusion. In this appliance the larger
lower leg is placed anteriorly. Thus when the U
bow is squeezed the mandibular plate moves
distally.
Type III: They are used in bringing about
asymmetric advancements of the mandible.
The ‘U’ bow is attached anteriorly on one
side and posteriorly on the other side to allow
asymmetric sagittal movement of the mandible.
This activator allows mobility of the
mandible and therefore, makes the activator
more comfortable to wear. The appliance
allows gradual and sequential forward positi­
oning of the lower jaws.
HERREN’S MODIFICATION OF THE
ACTIVATOR
Herren modified the activator in two ways:
i. By overcompensating the ventral posi­
tion of the mandible in the construction
bite.

ii. By seating the appliance firmly against
the maxillary dental arch by means of
clasps.
The construction bite is taken in a strong
mandibular protrusion. Herren recommends
maximum forward positioning of the mandible
reaching sometimes the feasible maximum.
This advanced position of the mandible
causes the retractor muscles to try to bring the
mandible back to original position. This causes
a backwardly directed force on the upper teeth
and a mesial directed force on the lower teeth.
According to Herren, with every 1 mm increase
of forward position of the mandible, the sagittal
force on the jaws will increase by 100 gm. The
amount of forward positioning of the mandible
is 3 to 4 mm beyond the neutral occlusion, i.e.
in case of Class II molar relation the mandible
is brought forward to Class I molar plus an
additional 3 to 4 mm forward. A vertical opening
of 2 to 4 mm is recommended.
Triangular or Jacksons clasps are used
to firmly seat the appliance to the maxillary
dentition. Expansion screws can be used
for expansion. Mobility of the mandible is
restricted by extending the lingual flange of the
activator as far as possible towards the floor of
the mouth.
FUNCTION REGULATOR
(FRANKEL APPLIANCE)
The function corrector or function regulator
is a myofunctional appliance developed by
Professor Rolf Frankel of Germany. This appli­
ance is also called Frankel appliance, vesti­
bular appliance and oral gymnastic appli­ance.
The Frankel appliance has two main
treatment effects. First, it serves as a template
against which the craniofacial muscles
function. The framework of the appliance pro­
vides an artificial balancing of the environment
Dentofacial Orthopedics 403
thereby promoting more normal pattern
of muscle activity. Secondly, the appliance
removes the muscle forces in the labial and
buccal areas that restrict skeletal growth
thereby providing an environment which
enables skeletal growth.
Frankel Philosophy
Frankel has based his appliance on the
following principles:
Vestibular arena of operation: According to
Frankel, the dentition is influenced by perioral
muscle function. Abnormal perioral muscle
function creates a barrier for the optimal
growth of the dentoalveolar complex. Thus the
Frankel appliance is designed to hold away the
muscles (buccal and labial) from the dentition,
so that the dentoalveolar structures are free
to develop. In addition, the Frankel appliance
acts as an exercise device or an oral gymnastic
device that aids in correction of the abnormal
perioral muscle function.
Sagittal correction via tooth borne maxillary
anchorage: The Frankel appliance is anchored
firmly in the maxillary arch by means of grooves
in the molar and canine regions. The mandible
is positioned anteriorly by means of an acrylic
pad that contacts the alveolar bone behind
the lower anterior segment. This lower lingual
pad acts more as a proprioceptive trigger for
postural maintenance of the mandible.
Differential eruption guidance: The Frankel
appliance is free of the mandibular teeth.
This allows selective eruption of the lower
posterior teeth which aids in correction of
the discrepancy in the vertical dimension
and also helps in sagittal correction of Class II
malocclusion by allowing upward and forward
movement of only the mandi­bular teeth.
Minimal maxillary basal effect: It has been
noted that in most Class II malocclusion, the
maxillary position I close to normal while the
mandible is retruded. The Frankel appliance
404 Essentials of Orthodontics
has relatively little retrusive sagittal effect
on the maxilla in contrast to the marked
protrusive change in mandible.
Periosteal pull by buccal shields and lip pads:
The buccal shields and lip pads are extended to
bring about outward periosteal pull. This aids
in bone formation at the apical base.
Mode of Action of Frankel Appliance
The following are the effects of the Frankel
appliance on the dentoalveolar structures:
Increase in transverse and sagittal intraoral
space: The buccal shields and lip pads play an
important role in eliminating the abnormal
forces acting on the dentoalveolar structures
from the periosteal region and at the same
time favor forces acting from within the oral
cavity. In addition, the buccal shields and
lip pads exert a constant outward pull on
the connective tissue and muscles which is
transmitted to the underlying bone by means
of fibers inserted into the periosteum of the
bone. This tissue pull on the periosteum
causes bone formation and also aids in lateral
movement of the dentoalveolar shell.
Increase in vertical space: An increase in
vertical intraoral space is possible as the
Frankel appliance is kept free from the
posterior teeth. The posterior teeth are free
to erupt.
Mandibular protraction: The lingual pad
guides the mandible to a more mesial position.
Thus the position of the mandible is changed
in due course of time by gradually training the
protractor or retractor muscles and by condylar
adaptation. Whenever the mandible is brought
back, the lingual pads apply pressure on the
lingual alveolar process. This immediately
causes the protractor muscles to position the
mandible mesially.
Muscle function adaptation: The Frankel
appliance helps in overcoming the abnormal
perioral muscle activity and rehabilitates the
muscles that are causing the problem. The
lip pads and shields cause periosteal muscle
pull leading to bone formation. The pads and
shields massage the soft tissues and improve
blood circulation. The shields loosen up the
tight muscles and improve muscle tone. The
lip pads prevent hyperactivity of the mentalis
muscles, eliminate lip trap and help in
establishing proper lip seal.
Frankel has recommended certain oral
exercise called oral gymnastics. Some of the
exercises recommended are:
i. To keep the lip closed at all times. This
can be aided by asking the patient to
keep a piece of paper between the lips.
ii. Swallowing, speaking, etc. become more
or less an exercise when the appliance is
used.
Types of Function Regulators
Frankel I (FR I): They are used for treatment
of Class I and Class II division 1 malocclusion.
The FRI is divided into the following three
types:
FR Ia: Used for Class I malocclusion where
there is mild to moderate crowding or arrested
development of basal arches. It is also used for
Class I deep bite cases.
FR Ib: Used for Class II division 1 malocclusion
where overjet does not exceed 5 mm.
FR Ic: Used for Class II division 1 malocclusion
in which the overjet is more than 7 mm.
Frankel II (FR II): Used for treatment of Class II
division 1 and division 2. In these cases prior to
functional appliance therapy a short period of
mechanotherapy is given in order to produce
the optimal tooth alignment.
Frankel III (FR III): They are used for treatment
of Class III malocclusion. Here the lip pads are
situated in the maxillary arch instead of the
mandibular arch.

Frankel IV (FR IV): They are used for treatment
of open bite and bimaxillary protrusion. Its use
is almost exclusively confined to the mixed
dentition.
Frankel V (FRV): They are functional regulators
that incorporate headgear. They are indicated
in long face patients having a high mandibular
plane angle and vertical maxillary excess.
Components of Frankel Appliance
(Fig. 10.11)
Frankel appliance consists of both acrylic and
wire components.
Lip pads: The lower lip pads are also called
pellots. The lip pads help in elimination
of abnormal perioral muscle activity, i.e.
hyperactive mentalix muscle activity. It helps
in eliminating lower lip trap which causes or
accentuated the proclination of upper incisors.
In addition, the lip pads cause periosteal pull
which results in bone growth. In case of FR
III, the lip pads are placed in the maxillary
vestibular region.
Buccal shields: The buccal shields are also
called the vestibular shields. The buccal
shields are made to extend as deeply into the
vestibule as possible within the confines of
patient comfort and tissue attachment. The
shields stand away from the dentition and
basal alveolar bone. This helps in unrestricted
Figure 10.11: Frankel appliance
Dentofacial Orthopedics 405
dentoalveolar development. In addition they
also cause periosteal bone deposition.
Palatal bow: The palatal bow has its convexity
facing distally. The palatal bow should stand
clear of the palatal tissue. The lateral extension
of the bow crosses the occlusal surface in
the embrasure mesial to the first permanent
molar and enters the acrylic buccal shield. The
recurved ends of the palatal bow terminate as
occlusal rests on the occlusal surface of the first
permanent molars between the mesiobuccal
and distobuccal cusps. These occlusal rests
prevent the appliance from being dislodged
superiorly and also prevent supraeruption of
the first permanent molars.
Canine loops: The canine loops act as extention
of the vestibular shields and are kept 2 to 3 mm
away from the buccal surface of the canines.
They are also called canine guards. They help in
elimination of the restrictive muscle function
thereby helping in transverse development in
the canine region.
Labial bow: The upper labial bow originates
from the vestibular shields. The wire runs
in the middle-third of the labial surface of
the maxillary incisors. It turns gingivally at
right angles at the distal margin of the lateral
incisors. The labial bow should be bent in
an ideal contour and not in the contour of
malposed teeth. This bow is passive in nature.
In case of FR III the labial bow is adapted on
the labial surface of the lower anteriors.
Lingual stabilizing bow: This wire is also
called upper lingual wire or protrusion bow.
It originates from the vestibular shields and
passes between the upper canines and first
deciduous molars and curves along the lingual
surface of the upper incisors at the level of
the cingulum. This wire prevents the lingual
tipping of the incisors during treatment.
Lower lingual springs: These wire components
rest against the lingual surface of the lower
anteriors. The main uses of the lingual springs
406 Essentials of Orthodontics
are to prevent eruption of the lower incisors, to
screen the tongue pressure from lower incisors
and to procline the lower incisors actively. This
is done when they are retroclined. The springs
get embodied in the lingual pad.
Lingual crossover: This is made of 1.25 mm
stainless steel wire. It follows the contour
of the lingual mucosa 3 to 4 mm below the
lingual gingival margin of the lower incisors.
It is placed 1 to 2 mm away from the mucosa.
This wire crosses the occlusal surface between
the deciduous molars and gets embedded in
the buccal shields.
Labial support wires: This is made of 0.9 mm
wire. They offer support for the lip pads. This
wire should be at least 7 mm below the gingival
margin. The central wire is inverted ‘V’ shaped
to accommodate the lower labial frenum.
Another wire emerges from the lip pad and
gets embedded in the buccal shields.
Construction Bite
It varies from type-to-type. It is recommended
to move the mandible forward by 4 to 6 mm
and to bring about an edge-to-edge contact of
incisors so that there is at least 2.5 to 3.5 mm
clearance in the buccal segments to allow the
crossover wires to pass through.
According to Petrovich and associates,
correcting the sagittal discrepancy in two or
three stages may be more effective and it also
makes it easier for the patient to adjust to the
forward positioning.
Clinical Handling of the Frankel
Appliance and Potential Management
Notching of the distal surface of the upper
deciduous second molar and mesial surface of
upper furst deciduous molar is done. Margins
of the appliance are checked before trying in
patient’s mouth. Appliance is seated in maxilla
and checked for stabilization of the wires, and
then it is seated in lower arch. Patient is asked
to bite on the appliance and tissues are checked
for blanching of the tissues, position of buccal
shields, lip pads and extension of the shields.
Initially patient should be advised to wear the
appliance for 2 to 4 for the first weeks. Later
period is extended to 4 to 6 hours of day time.
Wear for the next 3 weeks. Once the patient
had adapted to the appliance advice night time
wear. This usually takes about 2 months time.
Treatment Timing
Optimum time to start the treatment is around
7½ to 8½ years or when the lower incisors
have erupted. It is not advisable to start in
deciduous dentition period because the child
is not mature enough to cooperate with all
aspects of treatment. Active treatment lasts
for about 1½ to 2 years in the mixed dentition
phase followed by retention phase of 2 years. In
open bite cases the appliance is given as soon
as the first permanent molars have erupted.
Preconditions for successful treatment:
1. Proper appliance construction
2. Right indication for the treatment
3. Cooperation of the patient
4. Right psychological introduction of the
appliance.
The functional matrix concept of functional
appliance:
According to this theory the functional
oral space is the capsular matrix in which
the mandible is embedded. The expansion in
volume of this space will lower the mandible
and induce compensatory articulation with
articular eminence. It would seem at first
glance that passive translation of mandible
thus described could be reproduced by the
construction bite for functional appliances.
However the corres-ponding growth of con­
dylar process presumed by activator theories
has not been clearly substantiated.

BIONATOR (FIG. 10.12)
The bionator was developed by Balters during
the early 1950s. It had much in common with
the activator. However, it differed from the
conven­tional activator in that it was less bulky
and more elastic.
There are three types of bionator:
Standard appliance: This is used for the
treatment of Class II division 1 and Class I
malocclusions having narrow dental arches.
The standard appliance consists of a relatively
slender acrylic body fitted to the lingual
aspects of the mandibular arch and part of
the maxillary arch. The acrylic extends upto
the distal of the first permanent molars. The
maxillary plate covers only the molars and
the premolars with anterior region remaining
uncovered. The acrylic extends 2 mm below
the gingival margin. The intero­cclusal space of
some of the buccal teeth is filled with acrylic
extending over half of the occlusal surface of
the teeth to stabilize the appliance.
The wire components of the bionator
are the palatal arch and the vestibular wire.
The palatal arch is made of 1.2 mm diameter
wire. It emerges opposite the middle of the
first premolars and follows the contour of the
palate forming a curve that reaches the distal
surface of first permanent molars. The palatal
arch is kept 1 mm away from the mucosa. The
Figure 10.12: Bionator
Dentofacial Orthopedics 407
vestibular wire is made up of 0.9 mm stainless
steel wire. It emerges from the acrylic below
the contact point between the upper canines
and premolars. It rises vertically and is bent
at right angles to go distally along the middle
of the upper premolar crowns. Mesial to the
molar, a rounded bend is made so that the wire
runs at the level of the lower papilla upto the
mandibular canine where it is bent to reach the
upper canines. It forms a mirror image on the
opposite side. The vestibular were is kept away
from the surface of incisors by the thickness
of a sheet of paper. The lateral portions of the
wire are sufficiently away form the teeth allow
expan­sion of the arch.
Class III Appliance (Reverse Bionator)
This is used in mandibular prognathism.
The acrylic parts are similar to the standard
appliance. The palatal arch is placed in the
opposite direc­tion so that the rounded arch is
placed anteriorly.
The vestibular wire runs over the lower
inci­sors instead of terminating at the lower
canines.
The open bite appliance: This is used in open
bite cases. The palatal arch and the vestibular
wires are same as the standard appliance. The
maxillary acrylic portion is modified so that
even the anterior area is covered. Its purpose is
to prevent the tongue from thrusting between
the teeth as the tongue is responsible in most
cases for the open bite.
Bite Registration
Bite registration is done in the same way as for
the activator. In most cases an edge-to-edge
bite is desirable. If the overjet is too much a
step-wise advancement is preferred.
Indications
1. In Class II division 1 malocclusion having
well-aligned dental arches, retruded man­
408 Essentials of Orthodontics
dible, not very severe skeletal discrepancy
and labial tipping of upper incisors.
2. Class III malocclusion where reverse
bionator can be used.
3. Open bite cases where open bite bionator
can be used.
TWIN BLOCK APPLIANCE
(FIGS 10.13A TO C)
The twin block technique effectively combines
inclined planes with intermaxillary and
extraoral traction. The appliance consists of
an upper and a lower plate having occlusally
inclined bite planes that induce favorably
directed occlusal forces by causing a functional
mandibular displacement.
The upper plate is retained by modified
arrowhead clasps. The clasp can incorporate
a tube for attachment of a face bow. The
upper plate can also have a jack screw in
case maxillary arch expansion is required.
The upper appliance consists of a bite block
that contacts the lingual cusps of the upper
posterior teeth, extending anteriorly till the
mesial ridge of the upper second premolar.
The lower plate is retained by inter­dental
ball end clasps. The lower bite block extends
distally up to the distal marginal ridge of the
second premolar. The lower molars are kept
free to help in their eruption if needed. The
upper and lower bite blocks interlock at a
70o.
A B
Figures 10.13A to C: Twin block appliance
Bite Registration
The twin block appliance is constructed after
a bite registration procedure as described for
activator. The mandible is sagittally advanced
by 5 to 7 mm. Vertically the bite is opened by
3 to 5 mm in the premolar region.
Orthopedic Traction
In cases with severe skeletal discrepancy
extraoral traction is used. The twin block appli­
ance uses a Concorde face bow that combines
the extraoral traction with intermaxillary
traction. The face bow is unique as it has a
curved labial hook. The face bow is attached
to the maxillary molar. Intermaxillary elastics
can be used from the curved labial hooks of
the face bow to the mandible. Extraoral traction
of 200 gm each side for 8 to 10 hours a day is
prescribed. Intermaxillary force of 150 gm is
applied from lower appliance to the labial hook
of the concord face bow.
Fixed Twin Blocks
The twin block appliance may be designed
for direct fixation to the teeth by bonding.
It resembles a Herbst appliance, substuting
occlusal inclined planes for telescopic tubes, to
guide the mandible into a protrusive position.
Patient Acceptance
This appliance has very good patient acce­
ptance due to the following reasons:
i. The bite planes offer greater freedom
of move­ment in anterior and lateral
C

excursion than other functional app­
liances.
ii. They offer less inference with normal
function.
iii. Significant changes in patients appear­
ance is seen in 2 to 3 months.
HERBST APPLIANCE (FIG. 10.14)
Herbst is a fixed functional appliance that was
developed by Emil Herbst in the early 1900.
It was introduced to the dental profession at
the International Dental Congress in Berlin in
1905. This appliance was soon forgotten and
it was reintroduced in 1979 by Hans Panchers.
Indications
1. The Herbst appliance is indicated in correc­
tion of Class II malocclusion due to retro­
gnathic mandible.
2. They can be used as an anterior repositi­
oning splint in patients having temporo­
mandibular joint disorders.
3. Treatment with Herbst may be completed
within 6 to 8 months and can be used in
postadolescent patients.
4. Herbst appliance can be used in mouth
breathers unlike other removable functi­
onal appliances.
5. It is fixed appliance and is worn 24 hours a
day, thus it can be used in uncooperative
patients.
Figure 10.14: Herbst appliance
Dentofacial Orthopedics 409
Description
The appliance can be compared to an artificial
joint working between the maxilla and
mandible. A bilateral telescopic mechanism
keeps the mandible mechanically in continuous
anterior position. The devise consists of a tube
into which the plunger (that resembles a rod)
fits. The tube is fixed to the distal end of the
maxillary molars while the rods are fixed to the
lower first premolars.
Types of Herbst Appliance
Broadly the Herbst appliance can be classified
into two types:
Banded Herbst: Upper and lower first premolars
and first molars are banded. The tubes are fixed
to pivots soldered to the distobuccal aspect of
the upper first molar bands. The shafts or rods
are fixed to pivots soldered to the lower first
premolar bands.
Bonded Herbst: The bonded type of Herbst
appliance is a wire reinforced acrylic splint
that covers the occlusal and part of the buccal
and lingual surfaced of all teeth except the
anteriors. The pivots are fixed to the wire
framework at the distobuccal aspect of the
upper first molars and the mesial aspect of the
lower first premolars. The tube is fitted onto
the pivots in the maxillary molar area while
the shaft is fixed to pivots in the mandibular
premolar region.
Treatment Effects
The following effects are seen when the Herbst
appliance is used for the treatment of a Class
II malocclusion:
i. Class I molar relation or over corrected
Class I molar relation.
ii. An increase in mandibular growth.
iii. A certain amount of distal driving of
the maxillary molars that helps in the
correction of molar relation.
410 Essentials of Orthodontics
iv. Overjet reduction by increase in man­
di­bular length and proclination of man­
dibular incisors.
v. It has an inhibitory influence on the
sagittal maxillary growth.
vi. Weislander suggests double contour
of the glenoid fossa indicating anterior
trans­formation of the glenoid fossa.
vii. Increase in SNB angle and decrease in
SNA angle.
Advantages
The following are the advantages of the Herbst
appliance:
1. As it is a fixed functional appliance that is
not removed by the patient the action it
produces is continuous.
2. The treatment duration is short due to the
continuous nature of action.
3. Less patient cooperation is needed as it is
a fixed appliance.
4. It can be used successfully in patients who
are at the end of their growth.
5. Herbst appliance can be used in patients
who have mouth breathing habit due to
nasal airway obstruction.
Disadvantages
1. Like any other functional appliance it
requires patient cooperation, as initial
discomfort is usually present.
2. It can cause minor functional disturbances
in the masticatory system which are
temporary and gradually disappear.
3. There is an increased risk for the develop­
ment of a dual bite, with dysfunction sym­p­
toms of the TMJ as a possible con­sequence.
4. Repeated breakage and loosening of the
appliance occurs, especially in the lower
premolar area.
5. Plaque accumulation and enamel decalcifi­
cation occur, especially in the splint type of
appliance.
6. Tendency for posterior open bite at the
termination of therapy.
Jasper Jumper (Fig. 10.15)
The Jasper jumper is a relatively new type
of flexible, fixed, tooth borne functional
appliance that was introduced by JJ Jasper in
the year 1980. Their action is similar to Herbst
appliance, but lacks the rigidity.
Appliance Design
The appliance uses a modular system comm­
only known as Jasper Jumper, which can be
attached to fixed appliances that are placed
on the upper and lower arches. This Jasper
module is analogus to the tube and plunger
of Herbst appliance but is more flexible. The
Jasper jumper is constructed of stainless
steel coil that is attached at both the ends to
stainless steel end caps. The module is given
opaque polyurethane covering for purpose of
hygiene and comfort. The Jasper modules are
available in seven sizes ranging from 26 mm to
38 mm in length.
The end caps are attached to the fixed
appliance at the maxillary posterior and
mandibular anterior region. The force module
is attached posteriorly to the maxillary arch
by a ball pin that passes through the face bow
tube of the maxillary first molar. Anteriorly
the module is anchored to the lower arch wire
Figure 10.15: Jasper jumper

distal to the mandibular canine by way of a
small bayonet bend and lexan bead.
Since the force module is attached to pre­­
viously placed fixed appliances, care should
be taken to have adequately thick arch wires.
Indications
They are basically indicated in skeletal Class
II malocclusion with maxillary excess and
mandibular deficiency.
Mechanism of Action
The force is selected by measuring the distance
between the mesial aspect of the upper face
bow tube and the distal aspect of the lexan ball
distal to the mandibular canine. To this length,
12 mm is added to get the required length of
the force module.
Thus when the teeth come into occlusion,
the force module being longer tends to curve
thereby producing a mesial force on the
mandibular arch and a distal force on the
maxillary arch.
Effects of Jasper Jumper
According to Rankin, Parker and Blackwood
the Jasper Jumper brings about both skeletal
and dentoalveolar changes in ratio of 40:60.
Dentofacial Orthopedics 411
The skeletal effects include the holding
and minimal displacement of maxilla distally.
A small shift of point A distally, clockwise
rotation of mandible and a forward movement
of condyle.
The dental changes include, posterior
tip­ping and intrusion of upper molars, back­
ward tipping of maxillary incisors, anterior
translation and tipping of mandibular teeth,
and intrusion of mandibular incisors.
Jasper states that Class II correction with
this appliance is brought about by:
• 20% maxillary skeletal restraining
• 20% backward dentoalveolar movement of
maxilla
• 20% forward dentoalveolar movement of
mandible
• 20% condylar stimulation
• 20% downward and forward remodeling of
glenoid fossa.
Advantages:
1. Produces continuous forces.
2. Does not require patient compliance by
way of timely wear.
3. Allows greater degree of mandibular
freedom than Herbst appliance.
4. Oral hygiene is easier to maintain.
412 Essentials of Orthodontics
CHAPTER
Retention and
11 Relapse
RETENTION
Graber defined Retention as “Holding of teeth
in ideal esthetic and functional position.”
Retention has been defined by Moyers as
“Maintaining newly moved teeth in position
long enough to aid in stabilizing their corr­
ection.”
SCHOOLS OF RETENTION
Different philosophies or schools of thought
had developed:
I. The occlusion school: Kingsley stated,
“The occlusion of the teeth is the most
potent factor in determining the stability
in the new position.” Many early writers
considered that proper occlusion was of
importance in retention.
II. The apical base school: Axel Lundstrom
suggested that apical base was one of the
most important factors in the correction
of malocclusion and maintenance of
correct occlusion.
McCauley suggested that intercanine
width and intermolar width should be
maintained as originally presented to
minimize retention problems.
Nance and Arnold also noted that arch
length may be permanently increased
only to a limited extent.
III. The mandibular incisor school: Tweed
suggested that incisors should be
kept upright and over basal bone.Gri­­
eves also suggested that post-treat­
ment stability increased when lower
incisors were placed upright or slightly
retroclined.
IV. The musculature school: Rogers intro­
duced consideration of the necessity of
establishing proper functi­onal muscle
balance which has been corroborated
by others.
THEOREMS OF RETENTION
Riedel has summarized the different concepts
and philosophies existing into nine theories.
To this list of nine theories Moyers has added
another theory that is mentioned here as the
tenth theorem:

Theorem 1: Teeth that have been moved tend
to return to their former position.
There now seems to be a general agreement
that teeth tend to go back to their original
position after orthodontic tooth movement.
The causes for this relapse are many and a
single etiology cannot be highlighted.
Theorem 2: Elimination of the cause of
malocclusion will prevent relapse
The cause for the malocclusion should be
identified at the time of diagnosis and adequate
steps should be formulated in the treatment
plan to eliminate it. Failure to remove the cause
increases the relapse potential. This theorem
can only be applied in cases of malocclusion
where the cause is obvious such as thumb-
sucking, tongue thrusting, etc. and not in any
malocclusion where the cause is elusive.
Theorem 3: Malocclusion should be over
corrected as a safety factor.
Many orthodontists recommend over
correction so as to give Leeway for a certain
amount of relapse. This has been practiced in
treating certain conditions such as rotations,
treatment of Class II, Class III malocclusions.
There is, however, no available data to validate
this theorem.
Theorem 4: Proper occlusion is a potent factor
in holding teeth in their corrected positions.
Post-treatment stability is increased by
good occlusion. The orthodontist should
not restrict treatment to achieving a good
intercuspation when the jaws are closed
but should aim further at a good functional
occlusion, i.e. harmonious occlusal contacts
during functional movements of the jaw.
Theorem 5: Bone and adjacent tissue must
be allowed time to reorganize around newly
positioned teeth.
When teeth are moved orthodontically,
numerous changes occur in the bone and
surrounding tissues. It takes considerable
Retention and Relapse 413
time for the reorganization to be completed.
The new osteoid bone formed around recently
moved teeth offers inadequate retention.
Similarly the periodontal as well as the gingival
fibers take time to reorganize.
Theorem 6: If the lower incisors are placed
upright over basal bone they are more likely
to remain in good alignment.
Most stable results are obtained by placing
the mandibular incisor upright over the basal
bone. The mandibular or occlusal plane is
used as the reference plane. The Orthodontist
should aim at positioning the lower incisors
perpendicular to the mandibular plane or even
retroclined.
Theorem 7: Corrections carried out during
periods of growth are less likely to relapse:
Orthodontic therapy should be initiated
at the earliest possible age. Early treatment
procedures involving growth modulation,
aimed at intercepting skeletal malrelations,
prevent full fledged malocclusions and
compensation (both skeletal and dental) from
occurring.
Such treatment modalities carried out
during the active growth period allow the
tissue system to adapt well and therefore
reduce the relapse tendency.
Theorem 8: The farther the teeth have been
moved the lesser is the risk of relapse.
The farther a tooth has been moved
the lesser is the risk of it returning to its
original position. Although this sounds
logical, it is desirable to guide the erupting
teeth to intercept future malocclusion. Such
teeth require lesser tooth movement by
comprehensive fixed mecha-notherapy and
also a reduced retention period and hence
have a lesser risk of relapse.
Theorem 9: Arch form, particularly the
mandibular arch cannot be permanently
altered by appliance therapy.
414 Essentials of Orthodontics

Alteration of existing arch forms results

in increased risk of relapse. According to
McCauley, the mandibular intercanine and
intermolar widths are uncompromising. Thus
they should be considered as fixed landmarks
and the rest of the arch built around them.
Theorem 10: Many treated malocclusions
require permanent retaining devices. A
This theorem was subsequently added by
Moyers. Certain malocclusion might require
the patient to be fitted with a permanent
retaining device. This is true in cases that have
not been treated to achieve occlusal goals that
stand for stability.

RALEIGH WILLIAMS SIX KEYS B

FOR RETENTION

Key 1: Incisal edges of the lower incisors

should be placed on the A-P line or 1mm in
front of it.
Key 2: Lower incisors apices should spread
distally to the crowns (Figs 11.1A to C).
Key 3: Apex of lower cuspid should be
positioned distal of the crown.
Key 4: All four lower incisor apices must be in
the same labiolingual plane.
Key 5: Lower cuspid root apex must be posi­
tioned slightly buccal to the crown apex.
Key 6: The lower incisors should be slen­­d­erized
and contact points made even.
THEORIES OF RETENTION
C
Figures 11.1A to C: Raleigh Williams keys for
retention
Retention can be grouped under the follo­
wing headings:
Group I: No retention, cases which do not
require retention.
Group II: Standard or limited retention.
Group III: Prolonged retention.
Group IV: Permanent retention.

1. Discrepancy theory: Wherein retainers are Group I: No Retention

necessary
2. Equilibrium theory: Where there is no need
for retainers.
3. Partial assistance theory: Part time wearing
of retainers is required as there is semi-
equilibrium position at debanding stage.
Following are some of the conditions which do
not require retention:
i. Anterior and posterior cross bite, in the
corrected cases where the occlusion
ensures the stability of tooth movement,
no retention is required.

ii. Dentition treated by serial extraction.
iii. Highly placed canines.
iv. Canine impactions.
Group II: Standard or Limited
Retention
In majority of cases where the teeth have been
moved to positions of soft tissue and occlusal
balance, the teeth have to be retained until the
alveolar bone and periodontal ligament have
been fully remodeled. This takes between 3 to 6
months. It is adviced to wear full time retention
for 3 months; followed by wear only at nights
for a further 3 months of a passive retention
appliance. Part time wear during the latter half
of the retention period is adequate and has
the advantage that, if the teeth are not stable
positions, they will become more mobile and
so some warning of potential relapse is given.
Following are some of the examples:
i. Majority of orthodontic cases fall under
this group.
ii. Class I proclination and spacing.
iii. Class I, II, and III extraction cases.
iv. Corrected deep bite cases.
v. Class II division 2 cases.
Group III: Prolonged Retention
Certain tooth movements, rotations in parti­
cular have a strong tendency to relapse, even
though the teeth are in soft tissue and occl­usal
balance. The reason is that supra-alve­olar
connective tissue, i.e. free gingival fibers have
residual tension in them; they take a very
long time of about 232 days or above for their
reorganization. Hence, these tooth move­ments
require prolonged retention. On the otherhand
pericision following derotation of teeth reduces
their relapse tendency. This should be followed
by a standard period of retention. Example:
i. Rotation correction.
Retention and Relapse 415
Group IV: Permanent Retention
There are patients whose natural retentive
factors are so inadequate that an unacceptable
degree of relapse can be anticipated. The
only alternative is indefinite or permanent
retention. Following are some of the examples:
i. Severe rotations
ii. Midline diastema
iii. Cleft lip and palate cases
iv. Generalized spacing
v. Expansion of lower arch
vi. Patients with abnormal muscle habits.
METHODS OF RETENTION:
RETAINERS
Retainers are passive orthodontic appliances
that help in maintaining and stabilizing
the position of teeth long enough to permit
reorganization of the supporting structures
after the active phase of orthodontic therapy.
The type of retainers to be used depends on
various factors such as the type of malocclusion
treated, the esthetic needs, patients’ oral
hygiene, patients’ cooperation the duration of
retention, etc.
Graber has put forward certain criteria that
a good retainer should possess:
1. Retainer should retain all teeth that have
been moved into desired positions.
2. The retainer should permit normal
functional forces to act freely on the denti­
tion.
3. It should be self-cleansing and should
permit oral hygiene maintenance.
4. It should be as inconspicuous as possible.
5. Strong enough to bear the day-to-day use.
Classification of Retainers
Retainers can be classified into:
416 Essentials of Orthodontics

Removable Retainers Removable Retainers

1. Hawley’s retainer Removable retainers are simple removable
2. Begg’s retainer orthodontic appliances which does not have
3. Wrap around (Clip on) retainer any active component.
4. Canine-to-canine clip on retainer Any active removable appliance can be
5. Tooth positioner used as a retainer without activating the active
6. Invisible retainer components in it.
7. Barrer spring retainer
8. Removable partial denture. Indications
1. Proclinations correction
Fixed Retainers 2. Deep bite and open bite.
1. Fixed appliances
2. Fixed lingual bonded retainers with spiral Advantages
wires 1. Easy to fabricate and adjust
3. Band and spur appliance 2. Less chair side time
4. Banded canine-to-canine retainer 3. Less expensive.
5. Cast retainers
6. Lower lingual bar. Disadvantages
1. Patient cooperation is required
Active Retainers 2. Not very esthetic
1. Hawley’s appliance 3. May cause tissue irritation
2. Spring retainer 4. May affect speech
3. Modified functional appliances 5. Frequent visits are required.
i. Activator
ii. Bionator Hawley’s Retainer (Figs 11.2A and B)
iii. Frankel appliance. The Hawley’s appliance was designed in 1920 by
Charles Hawley. It is the most frequently used
Morton A Levyn classified retainers as: retainer. The classic Hawley’s retainer consists
1. Temporary of clasps on the molars and a short labial bow
A. Fixed extending from canine-to-canine having
• Intracoronal adjustment loops.
• Extracoronal.
B. Removable
• Extracoronal.
2. Permanent
A. Fixed
• Intracoronal
• Extracoronal.
B. Removable A B
• Extracoronal. Figures 11.2A and B: Hawley’s retainer

The simple design can be modified in
several ways to suit specific requirements. The
labial bow can be made to extend from one
first premolar to the opposite first premolar.
This design helps in closing spaces distal to
canine. Another modification is to solder the
bow to the bridge of the Adam’s clasp. Another
modification is to solder the bow to the bridge
of the Adam’s clasp. This design avoids the risk
of space opening up between the canine and
premolar due to the cross over wires. Fitted
labial bow (Fig. 11.3) can also be used to offer
excellent retention. Anterior bite planes can
be incorporated to retain or correct deep bite
cases. The advantages of this appliance include
ease of fabrication due to simple design and
minimal patient discomfort due to reduced
bulk. In addition it is acceptable to most
patients as it is relatively inconspicuous.
Hawley’s Appliance with Fitted Labial Bow
Hawley’s appliance with fitted labial bows
can be effectively used as retention appliance
(Fig. 11.3).
van der Linden’s Retainer
(Figs 11.4A and B)
A Hawley-type retainer introduced by FPGM
van der Linden, with a modified labial bow
made of stainless steel wire 0.028 inch (0.70
Figure 11.3: Fitted labial bow
Retention and Relapse 417
A
B
Figures 11.4A and B: van der Linden’s retainers
mm) in diameter. This labial bow contacts the
labial surfaces of the six anterior teeth and
is bent back upon itself at the distal aspect
of the canines, embracing them in a C-clasp
fashion at their cervical regions. When there
is inadequate clearance for the labial bow to
cross the occlusion mesial to the canines, the
crossover wire can be placed distal to them
and the recurved C-clasp can be made on the
first premolars. These canine clasps provide
adequate retention and do not deform by
repetitive removal and replacement of the
appliance by the patient. Additional C-clasps
coming from the distal of the terminal molars
are used to enhance retention. The acrylic
is relieved from the palatal aspect of the
posterior teeth, allowing them to settle in
their natural position, as determined by the
occlusion. Only the mandibular anterior teeth
are contacting the acrylic of the appliance
in habitual occlusion. This retainer does not
allow adjustment of the anterior tooth position
during the retention period due to the design
of the labial bow.
418 Essentials of Orthodontics
Figure 11.5: Begg’s retainer
Begg’s Retainer (Fig. 11.5)
This retainer was popularized by PR Begg, it
consists of a labial wire that extends till the
last erupted molar and curves around it to get
embedded in acrylic that spans the palate.
The advantage of this retainer is that there is
no cross over wire between the canine and
premolar thereby eliminating the risk of space
opening up.
Clip on Retainer (Spring Aligner)
This appliance is made of a wire framework
that runs labially over the incisors and then
passes between the canine and premolar and
is recurved to lie over the lingual surface. Both
the labial as well as the lingual wire segments
are embedded in a strip of clear acrylic. The
retainer can be used to bring about correction
of rotations commonly seen in the lower
anterior region. In such cases where it is used
as an active retainer, it is fabricated on a cast
wherein the teeth are placed in ideal positions
by wax setup.
Wrap Around Retainer
This is an extended version of the spring
aligner that covers all the teeth. It consists
of wire that passes along the labial as well as
lingual surfaces of all erupted teeth which is
embedded in a strip of acrylic. This type of
retainer is not routinely used in orthodontic
practice. It finds application in stabilizing a
periodontally weak dentition.
Kesling Tooth Positioner (Fig. 11.6)
The tooth positioner was described by HD
Kesling in 1945. It is made of a thermoplastic
rubber-like material that spans the interocclusal
space and covers the clinical crowns of the
upper and lower teeth and a small portion of
the gingival. The tooth positioner needs no
activation at regular intervals and is durable.
The drawbacks include difficulty in speech and
risk of TMJ problems.
Invisible Retainers (Figs 11.7A and B)
They are retainers that fully cover the clinical
crowns and a part of the gingival tissue. They
are made of ultra thin transparent thermo­
plastic sheets using a Biostar machine. They
are esthetic and often go unnoticed.
Fixed Retainers
Fixed retainers are usually cemented or bonded
directly to the teeth. They are commonly used
for prolonged retention or permanent reten­tion.
Indications
1. Midline diastema closure
2. Lower anterior crowding
Figure 11.6: Tooth positioners
 Retention and Relapse 419

Band and Spur Retainer

This type of retainer is used in cases where a
single tooth has been orthodontically treated for
rotation correction or labiolingual displacement.
The tooth that has been moved is banded and
spurs are soldered on to the bands so as to
overlap the adjacent teeth. In case it is side to
retain a tooth that has been blocked palatally,
the spurs are made on the labial aspect so that
A
the tooth does not once again get displaced
palatally. In derotation cases one spur is
placed labially (on the side tooth tends to
rotate palatally) and the other lingually to
avoid relapse.

B Banded Canine-to-Canine Retainer

Figures 11.7A and B: Invisible retainers
This type of retainer is commonly used in the
lower anterior region. The canines are banded
3. Compromised periodontal conditions and a thick wire is contoured over the lingual
4. Prevention of rotation relapses aspects and soldered to the canine bands. The
5. Extraction spaces. bands predispose to poor oral hygiene and are
unesthetic.
Advantages
1. No patient cooperation required Bonded Lingual Retainers
2. They are more esthetic (Figs 11.8A and B)
3. Can be used for permanent and semi-per­ They are retainers that are bonded on the
ma­nent retention lingual aspect. Stailness steel or blue Elgiloy
4. Well-tolerated by patients wire is adapted lingually to follow the anterior
5. No tissue irritation and jiggling tooth cur­v­ature. The ends are curved over the can­
move­ments ines where it is bonded.
6. Recall visits are reduced. Various prefabricated lingual retainers
are available that can be bonded on to the
Disadvantages teeth. An alternative to the use of wires is to
1. Placement is difficult use etched or perforated metal cast bars that
2. More expensive
3. Increased chair side time
4. More prone to breakage.

Fixed Appliance Retainers

The fixed appliance that was used for orthod­
ontic correction can be left in place to serve A B
as a retainer. Figures 11.8A and B: Bonded lingual retainers
420 Essentials of Orthodontics
can be bonded on the lingual side of the teeth.
Recently some wor­kers have recommended
the use of a spiral wire that can be bonded
individually to each tooth in a segment.
Flexible spiral wires can also be used as the
bonded retainers.
Essix Retainer
A removable vacuum-formed clear retainer
made of thermoplastic copolyester, covering
the teeth of one or both arches, from canine-
to-canine. According to JJ Sheridan, who
introduced the appliance, a sheet of the
material 0.030 inch (0.75 mm) thick is
preferred, for a good combination of flexibility
and strength. During the thermoforming
process the thickness of the material is reduced
from 0.030 inch (0.75 mm) to 0.015 inch (0.38
mm). Despite its limited thickness, the Essix
retainer may not be recommended for patients
with an open bite tendency, as it only covers
the anterior teeth. The risk of swallowing
or aspirating the appliance also should be
considered.
Spring Retainer (Barrer Retainer)
(Figs 11.9A and B)
A maxillary or mandibular removable appli­
ance, introduced by HG Barrer in 1975. The
mandi­bular appliance is mainly used today. It
consists of a single piece of stainless steel wire
0.022 inch (0.56 mm) to 0.029 inch (0.72 mm)
in diameter, bent around the six anterior teeth.
The wire lies parallel to the incisal edges on the
A B
Figures 11.9A and B: Spring retainers
labial side and crosses the occlusion between
the canines and premolars, bilaterally. It is bent
downward on the labial and lingual surfaces
of the canines in the form of U loops, so that it
follows the curvature of the gingiva on these
teeth, but without actually contacting it. The
ends of the wire overlap in the midline at the
lingual aspect of the incisors. The wire does not
touch the surfaces of the teeth and is covered
by acrylic on the labial and lingual sides. This
forms two bands approximately 4 mm wide,
engaging the incisors across the middle third
of their crowns. The wire surrounding the
canine is free of acrylic and functions as a
spring, which can be appro­priately adjusted
to activate the appliance.
The greatest disadvantage of the Barrer
retainer is its small size. Various modifications
to increase its size have been reported, to
avoid accidental swallowing or aspiration.
The most common modification includes
bilateral extensions of the lingual acrylic,
terminating with two occlusal rests on the
mandibular first molars.
Adjuvants to Retention
They are the procedures carried out along with
or before retention.
1. Reproximation: Reproximation is required
in some cases of crowding and rotations.
Reproximation will provide good contact
points and thereby prevent relapse. They
are commonly done in lower anterior
region.
2. Pericision or circumferential supracrestal
fiberotomy (CSF procedure): A simple
surgical method of severing all supracrestal
fibrous attachment to a rotated tooth
has been demonstrated to significantly
alleviate relapse following rotation, with
no apparent damage to the supporting
structures of the teeth (Fig. 11.10).
 Retention and Relapse 421

to provide an interlocking pattern to resist

rotational relapse. “Keystoning” is done
by obli­que interproximal strip­ping, so that
rotati­onal tendency of one tooth would be
coun­teracted by the reverse rotational relapse
tendency of its adjacent tooth (Figs 11.11A
and B).
7. Extractions: Extractions of impacted third
molars are often indicated after ortho­
dontic treatment to prevent the relapse of
lower anterior crowding.
8. Prosthesis: Replacement of missing tooth
is one of the essential adjuvants that will
prevent relapse of the malocclusion.

Figure 11.10: Pericision RELAPSE

Relapse is the tendency of the teeth to revert

3. Frenectomy and associated procedures: to their original position after orthodontic
Frenectomy is done to prevent relapse corre­ction.
following midline diastema closure due
to high labial frenum. Frenectomy is Causes of Relapse
a minor surgical procedure involving Numerous are the causes attributed to relapse.
removal of fibrous bands of the frenum. No single factor can be said to be the sole cause
Buccal or lingual frenectomy may be rarely
performed if they are found to be causing
the diastema.
4. Occlusal equilibration: Occlusal equili­
bration is the removal of high points
and occlusal interferences in the centric
occlusion. They are commonly done in
premolars and molars following fixed
A
appliance therapy for proper settling and
finishing.
5. Myofunctional therapy: Myofunctional
therapy of muscular exercises may be
used following functional correction of
malocclusions. Exercises for tongue, cheek
muscles and lips are common.
6. “Keystoning” is the reshaping of the inter­­­ B
proximal aspects of the mandibular incisors Figures 11.11A and B: Reproximation
422 Essentials of Orthodontics
of relapse. In most cases relapse occurs due to
a combination of causes.
Periodontal Ligament Traction
Whenever teeth are moved orthodontically the
periodontal principal fibers and the gingival
fibers that encircle the teeth are stretched.
These stretched fibers can contract and are
thus a potent cause of relapse. The principal
fibers of the periodontal ligament rearrange
themselves quite rapidly to the new position.
Studies have shown that the principal fibers
reorganize in about 4 weeks time. The supra-
alveolar gingival fibers on the other hand take
as much as 40 weeks to rearrange around the
new position, and thus predispose to relapse.
After comprehensive orthodontic treatment,
teeth require 4 to 5 months of full time
retention so as to allow the reorganization of
periodontal ligament fibers. After this period,
retention should be continued on a reduced
basis for a further 7 to 8 months so as to allow
the more sluggish gingival fibers to readapt to
the new tooth positions.
Relapse due to Growth Related
Changes
Patients with skeletal problems associated
with Class II, Class III, open bite or deep bite
malo­c clusion may exhibit relapse due to
continuation of the abnormal growth pattern
after orthodontic therapy. Studies have shown
that the original growth pattern resurfaces
or dominates if the orthodontic treatment is
completed prior to the completion of growth.
Hence, prolonged retention is indicated until
active growth is completed.
Bone Adaptation
Teeth that have been moved recently are
surrounded by lightly calcified osteoid bone.
Thus, the teeth are not adequately stabilized
and have a tendency to move to their original
position. The bony trabeculae are normally
arranged perpendicular to the long axis of the
teeth. However, during orthodontic treatment,
they get aligned paralleled to the direction of
force. During the retention phase, they revert
back to their normal arrangement.
Muscular Forces
Teeth are encapsulated in all directions by a
blanket of muscles. Muscle imbalance at the
end of the orthodontic therapy can result in
reapp­earance of the malocclusion. The ortho­
dontist should aim at harmonizing the muscles
at the conclusion of the orthodontic treatment
so as to increase the stability of the treatment
results achi­eved.
Failure to Eliminate the
Original Cause
The cause of the malocclusion should be
determined at the time of diagnosis and
adequate treatment steps should be planned
to eliminate the same or reduce its severity.
Failure to remove the etiology can result in
relapse.
Role of Third Molars
The third molars erupt very late in the
development of dentition. They erupt in most
cases between the ages of 18 to 21 years. By this
time most patients would have completed their
orthodontic treatment. The pressure exerted by
the erupting third molars is believed to cause
late anterior crowding, predisposing to relapse.
Role of Occlusion
Good intercuspation of the upper and the lower
teeth is an important factor in maintaining the
stability of treated cases. The centric relation
and centric occlusion should coincide or the
slide from centric should be not more than 1.5

to 2 mm in order to have greater stability of the
treatment results. Presence of certain occlusal
mannerisms such as clenching, grinding, nail
biting, lip biting, etc. is important causes of
relapse.
Other causes of relapse include:
1. Forces produced by lips, tongue and cheek
during resting.
2. Persistence of abnormal habits.
3. Inadequate wear of retention appliances.
4. Failure to upright roots in extraction
spaces.
5. Presence of excess tooth material to arch
size.
6. Poor patient cooperation.
FAILURES IN ORTHODONTICS
In orthodontics, as in any area of endeavor,
failure is caused by errors of omission as
well as errors of commission. Preparation,
formulation, and exec­u tion of a plan of
treatment, set the format for success in
treatment, once a goal has been set that is
within the realm of practical clinical reality.
Most failure in orthodontic treatment are,
therefore, based on the lack of:
1. Knowledge
2. Perception
3. Technique
4. Procedure
5. Judgment.
Unfortunately, in any biologic are or science
there are variables so numerous that exclusive
parameters for one variable cannot be made
without recognized or evaluating the effect upon
other variables.
In orthodontics, most biomechanical
techniques and procedures have been
evaluated and examined with some degree
of precision. The physics concerning the
mechanical principles involved in levers,
Retention and Relapse 423
springs, and fulcrums can be delineated with
greater ease than can the individual response
of tissues to the physical forces applied during
treatment.
In orthodontics, as in other disciplines in
dentistry, the mechanistic factors often are
more easily understood that are the biologic
or psy­chologic factors.
Orthodontic Goals
To prevent failure and to anticipate the
outcome of treatment certain empirical criteria
must be established to form the philosophic
framework within which to operate.
The following goals have been deemed
desi­rable and fundamental to prevent failure:
1. There must be a full complement of teeth
and each tooth must be made to occupy its
normal position.
2. There must be normal cusp, fossa and
inclined plane relationship of opposing
teeth.
3. There must be normal relationship of teeth
to their respective jaw bones.
4. There must be normal axial inclinations of
all the teeth.
5. There must be normal relationship of the
jaw to each other and to the skull.
6. There must be normal function of all
associated parts and structures.
The goals enumerated are obviously
ideal and not readily attainable in most
malocclusions because of the nature of the
malocclusion. It is nece­ssary to recognize the
limitations of ortho­dontic therapy within the
limits set by the malo­cclusion, the investing
tissues, the treatment goals, the appliance
therapy and the cooperation of the patient.
The compromises most readily available
are surgical procedures:
i. Extraction of teeth to create arch length,
to gain interdigitation of teeth and to
reduce procumbency of the dentition.
424 Essentials of Orthodontics
ii. Surgical resection of the maxilla or
mandible, for enmasse movement of
teeth and jaws and to correct bony
anteroposterior and vertical deficiencies.
iii. Implants of bone, cartilage or plastic to
enhance facial esthetics.
iv. Rhinoplasty to recontour the midface.
Limitations of Treatment
The limitations of orthodontic treatment are of
a biologic, psychologic and mechanical nature.
The biologic limitations are the most
difficult to overcome and pose the problems
inherent in growth, muscle, bone, tooth
proprioception, respiration, function, etc.
The psychologic limitations are those
imposed by the patient, either upon the
orthodontist or on the goals of treatment
through acts of cooperation of disinterest.
The mechanical limitations are usually
those of appliance design and appliance
manipulation. It is better in most cases to select
an appliance which will control and move teeth
toward a selected goal with predictable results
than to use an appliance which moves teeth in
an unpredictable fashion with uncontrollable
results.
Growth
Since, most orthodontic treatment requires
lengthy supervision and observation, in
children and young adults, it is required
that growth, not present in adult patients, be
considered as a limiting factor in the successful
orthodontic outcome.
An orthodontic diagnosis must be made
today for the treated individual 24 to 36 months
hence, so that treatment and growth coincide
at some moment in the future. Furthermore,
growth does not cease with termination of
treatment but continues for some variable time
afterward. Future growth, after treatment and
during or after retention, may well unto the
best treatment results and often does.
Growth Patterns
The significance of growth types and growth
rates of facial structures is fundamental to
diagnosis and to treatment outcome.
Three types of skeletal growth, for purposes
of classification, have been delineated—Class
I growth, in which both the maxilla and
mandible grow at a proportionately even
rate; Class II growth in which the maxilla
proportionately outgrows the mandible
and Class III growth in which the mandible
proportionately outgrows the maxilla. The
skeletal growth types can be recognized by
serial cephalometric radiographs taken over
a period of years.
It is well to recognize that growth can both
help and limit orthodontic treatment and that
growth is a highly individual variable guided
by genetic, endocrine and nutritional factors.
Anteroposterior Discrepancies
The anteroposterior discrepancy is a measure
of the relative discrepancy between the basal
bone of the maxilla and mandible.
The anteroposterior difference is a measure­
ment taken as an angular discrepancy between
the most retruded portion of the maxillary
bone and the most retruded portion of the
mandibular symphysis as related to nasion.
The interrelationship of the angle ANB and
the angle of the mandibular plane to cranial
base are important in defining the severity
of the malocclusion, establishing a goal of
treatment, and limiting the eventual stability
of the treated case. The worse the skeletal
discrepancy in an anteroposterior direction
and in a vertical direction the less pleasing will

be the facial esthetics, the dental occlusion and
the dental stability, and the greater will be the
chances of failure.
Vertical Dimension
The vertical dimension is a measure of face
height. Face height is a changeable factor
which can be measured in several ways. The
vertical dimension is influenced by treatment,
growth and the eruption of teeth.
Among the variables measured in the
vertical dimension are: vertical growth of
the maxilla; vertical growth of the maxillary
alveolus; eruption of the maxillary teeth;
eruption of the mandibular teeth; vertical
growth of the mandibular alveolus, and vertical
growth of the mandible.
It is acknowledged that low mandibular
plane angles tend to denote somewhat
favorable growth patterns and that steep
mandibular planes denote unfavorable growth
patterns.
Posterior Facial Height
A second factor in the vertical dimension is the
posterior facial height. Posterior facial height
is the relative ratio of the ascending ramus as
compared to the anterior facial height.
It has been observed that many cases with
large ramus lengths will have skeletally closed
bites, low alveolar bone heights, and flatter
occlusal planes. If the bite is mechanically
opened in these cases it will have a tendency
to close again as growth proceeds.
The orthodontist or dentist cannot readily
determine the subtle distinction between
vertical dental dysplasias and vertical skeletal
dysplasias by clinical inspection of by dental
casts alone. Determinations of growth patterns,
skeletal patterns, and muscular patterns, as
well as observation of the drape of the facial
soft tissue around the dentition during rest
Retention and Relapse 425
and function must be made. A requirement
for the determination of vertical skeletal
dysplasias and anteroposterior dysplasias is
the inspection and analysis of well-oriented
cephalometric radiographs.
Bite Opening
Failures often arise and create an unfortunate
circumstance when bite plate therapy to open
the bite of the anterior teeth is combined with
vertical traction to the first permanent molars.
Molar Displacement
The effects of the molar teeth on the changes
in occlusion, bite opening, occlusal plane,
mandibular plane, vertical height and antero­
posterior dimension cannot be over­stressed.
Molars have a troublesome say of extruding
during all types of orthodontic therapy. Molars,
because of root volume, root area, location,
eruption pattern; occlusal stress and crown
morphology possess a profound influence on
the success or failure of treatment.
Extrusion and forward tipping of the
molars occurs with ease, whereas uprighting of
the molars is more difficult and intrusion of the
molars is exceedingly difficult if not impossible
without the use of heavy orthopedic forces.
The position of the molar therefore
not only permits the classification of
dental malocclusions but forms the basis
for diagnosis and sets the objectives of
treatment. Management of the first molar in
an anteroposterior direction and in vertical
direction precludes success or failure in most
orthodontic treatment.
Freeway Space
Caution must be exercised when opening the
bite not to exceed the natural freeway space
presented at the beginning of the treatment.
Freeway space in the buccal segments is
426 Essentials of Orthodontics
more variable in developing dentitions and
tends to become more fixed as a gradient of
increasing age, decreasing growth rate, and
decreasing tooth eruption rate. The eruption
rate of teeth and the freeway space seem to be
in equilibrium with the skeletal development
and the masticatory and facial musculature.
There is usually a tendency for some closure
of the mandibular plane after treatment and a
tendency for the overbite to increase and
deepen after treatment. Some of the increase in
overbite and overjet is due to growth, forward
rotation of the mandible, increases in the curve
of Spee and further eruption of the anterior
teeth.
In extraction cases there is a tendency
for an increase in overbite, probably caused
by adjustments in occlusal stress and axial
inclin­ation of teeth after treatment and forward
displacement of the molars.
Tooth-to-Bone Discrepancies
The tooth to bone discrepancy most commonly
noted is an irregularity of the teeth in one or
both jaws. In many instances of malocclusion
irregularities are first noted in the anterior
teeth, although notable irregularities do occur
in the buccal quadrants as well.
It is recognized that with most biome­
chanical procedures on teeth, changes and
remodeling of bone occur, depending on the
direction, duration, magnitude and mode
of force application. Bone changes of the
alveolar structure, resorption, deposition and
remodeling occurs as a response to mechanical
stimulation and stress on the bone tooth socket
through the periodontal membrane. Changes
in the alveolar bones and the alterations in
tooth alignment brought about by mechanical
forces, though imitative of the growth process,
cannot be considered “growth” in the strict
scientific sense. To hope that adaptive changes
(growth) will occur in the basal bone and
musculature as a result of gross anterior and
lateral expansions of the dental arch is to deny
the known physiologic response of muscle
versus bone.
Tooth Size Discrepancies
Of the many problems causing failure in
treatment, or after retention, tooth size
discrepancies (variations in tooth size, shape,
and contour) are perhaps the most easily
overlooked. In as many as 70% of malocclusions
tooth size problems may be contributing factor.
Moderate-to-severe discrepancies may occur
bilaterally or may be confined to individual
quadrants or teeth.
Obvious tooth size discrepancies such as
peg-shaped laterals are the cause of spacing
in the anterior quadrant. Should an attempt be
made to close spaces in the anterior segment,
treatment would result in anterior spaces distal
to the laterals, an end-to-end relationship
an anterior cross bite of the anterior teeth or
collapse of the mandibular anterior segment.
Mismatched tooth sized in arch qua­drants
may cause the return of spacing, rotations,
tipping, traumatic occlusion and pro­prio­ceptive
changes in function. Many problems during
treatment in the matching of midlines, arch
form and problems in occlusal interference
occur because of unequal sizes of teeth and
because of tooth morphology incompatible
with adjacent or opposing teeth.
Nature unfortunately does not issue a per­
fect set of well-balanced and occluded teeth
with proper cusp heights, ideal morphology
and precise inclined plane angulations. The
teeth that the orthodontist attempts to occlude
may exhibit various states of wear and trauma
existing with the original malocclusion but
incompatible with the function of the treated
malo­cclusion.

Dental Drift
In the developmental pattern during the loss,
eruption and occlusion of teeth there are
possibly three periods of rapid dental drift.
In order to prevent tooth drift or to mask
the effects of teeth drift “preventive overtreat­
ment” has often been recommended. The
overtreatment allows for the passive relapse of
teeth into a normal occlusion and counters the
residual effects of growth. The overcorrection
of rotated and displaced teeth appears to be
necessary to prevent relapse and recurrence
of the malocclusion.
Third Molars
Third molars have been implicated as offending
the integrity and equilibrium of the dental
arch. It is true that these teeth in function
may act though functional stress and add to
the anterior component of force in the dental
mechanism.
In late tens and early twenties many cases
which have been stable and functional for
some years suddenly begin to drift and relapse.
It apparently makes little diference whether the
third molars have been extracted.
Musculature
The importance of the oral and facial mus­
culature in the stability of occlusion cannot be
overstressed. Any dental treatment which does
not consider the effects of muscular equilibrium
is doomed to failure.
The buccinator and the associated
masticatory and facial muscles form an
anteroposterior and lateral sling around the
tooth, which when balanced by the pressures
of the tongue, forms a muscular trough around
the dental arch and preserves the stability of
the occlusion.
The recognition of persistent neuro­
muscular habits and patterns and their
Retention and Relapse 427
treatment or modification are necessary to
prevent orthodontic failure.
Iatrogenic Problems
In all orthodontic treatment something is
compromised or sacrificed to obtain a chosen
goal. There is not one orthodontic appliance
which does not have an untoward effect on the
teeth or surrounding oral tissues.
Regardless of the occlusion obtained at
the end of orthodontic treatment, gross loss
of bone, loss of root apices, loss of interdental
papilla and excessive damage to tooth viability
do not constitute successful treatment.
Hawley, Bimler, Crozat or Andresen-Haupl
appliances as well as fixed appliances cause
soft tissue damage cause decalcification pitting
and eroding of enamel tear and disturb the
periodontal membrane and effect changes in
the pulp.
The greatest failure occurs when the iatro­
genic problems outweigh the orthodontic
results and the malocclusion is unresolved or
unstable. The purpose in orthodontics, as in
all dental discip­lines, is to do the most good
and the least harm within the limitations of
the problems, the treat­ment objective and the
appliance of choice.
SUMMARY
There are several dogmatic rules for the preven­
tion of orthodontic failure and to aid in the
philosophical approach to orthodontic problems:
i. No occlusion is so stable as a maloc­
clusion once established and in equili­
brium.
ii. Stability of the anterior teeth can more
easily be maintained when upright
overbasal bone and closest to the
position of the original malocclusion.
428 Essentials of Orthodontics
iii. The intercuspal widths and intermolar
widths of the mandibular teeth are
most stable when contained within the
arch form and muscular balance of the
original malocclusion.
iv. Growth of the jaws is largely a product of
genetics, endocrine balance and nutri­
tion.
v. Proper skeletal relationships may be
more important than dental relation­
ships in evaluating the severity of a
maloc­clusion.
vi. Relapse is more likely to occur in the
mandibular arch first that in the maxill­
ary arch.
vii. Most well-treated malocclusions will
lose about 10 to 15% of the treatment
results after retention.
Disregard of the following factors, singly
or in combination, probably leads to the most
failures in orthodontic treatment:
1. Tooth-to-bone discrepancies
2. Bone-to-bone discrepancies
3. Tooth-to-tooth discrepancies
4. Aberrant neuromuscular patterns
5. Changing growth patterns
6. The limitations of treatment goals
7. The limitations of appliance therapy
8. The effects of orthodontic therapy on the
psyche of the patient, his self-image, his
goals and his cooperation.
Today, it is natïve to anticipate that a good
dental cusp fossa relationship, a good centric
occlusion and centric relation, proper contact
points, and reasonable alignment of the
anterior teeth with good cuspid rise and other
mechanistic parameters, will suffice as the sole
criteria for tissue health, dental stability and
facial esthetics.
Most orthodontic failures cannot be laid
to one single factor. Failures usually are the
cumulative effect of several factors, one leading
to another like a series of fallen dominoes.
The important factors in successful treat­
ment can be linked to a chain of events with
each link having importance and the omission
of a kink causing a break in the successful
outcome of treatment.
The orthodontist strives, along with his
dental colleagues, for perfection in occlusion,
stability, function and dental and facial
esthetics, but is simpler to move a tooth into a
given position with known mechanical forces
that to maintain the tooth in a new position
subject to the unknown forces of occlusal stress
and a new muscular environment.
Fortunately, the oral mechanism is forgiving
of ignorance and abuse, will tolerate many
minor errors and will adjust and compensate
to establish harmony and homeostasis within
its functional limits.

CHAPTER
Surgical
12 Orthodontics
MINOR SURGICAL
PROCEDURES
Surgical orthodontics is a term that refers to
surgical procedures carried out as an adjunct to
or in conjunction with orthodontic treatment.
These surgical procedures are usually carried
out to eliminate an etiologic factor or to correct
severe dentofacial abnormalities that cannot
be satisfactorily treated by growth modification
procedures or orthodontic camouflage.
Surgical orthodontic procedures are
broadly classified as minor surgical procedures
and major surgical procedures. While most
minor procedures are an integral part of
orthodontic therapy, the major procedures
are aimed at treatment of severe skeletal
malocclusion or dentofacial deformities.
Minor surgical procedures include:
1. Extractions
i. Therapeutic extractions
ii. Serial extraction
iii. Extraction of carious teeth
iv. Extraction of supernumerary teeth
v. Extraction of impacted teeth.
2. Surgical exposure of impacted teeth
3. Frenectomy
4. Pericision
Surgical Orthodontics 429
5. Transplantation of teeth
6. Corticotomy
7. Implants for orthodontic purpose.
EXTRACTIONS
Extractions are the most commonly undertaken
minor surgical procedure in conjunction with
orthodontic therapy. Extractions performed
as a part of orthodontic therapy include
therapeutic extraction, serial extraction
and extraction of supernumerary carious or
malformed teeth.
Therapeutic Extractions
Therapeutic extractions are undertaken
as a part of comprehensive orthodontic
treatment mainly to gain space. Prior to
therapeutic extraction a thorough diagnostic
exercise is essential. Extr­action should be as
atraumatic as possible. During the extraction
care should be taken to preserve the integrity
of the alveolus. Any break or loss of either
the buccal or the lingual bony plates may
prevent ideal positioning of the teeth during
orthodontic therapy. Preoperative radio­graphs
430 Essentials of Orthodontics
are a valuable aid in planning and execu­tion
of extractions.
Serial Extractions
Serial extraction involves removal of some
deciduous teeth followed by specific
permanent teeth in an orderly sequence to
guide the rest of the permanent teeth into
a more favorable position. Serial extraction
is usually carried out when an arch length
deficiency exists which prevents normal
alignment of the whole comple­ment of teeth.
Extraction of Supernumerary
Impacted and Ankylosed Teeth
The presence of supernumerary, impacted
and ankylosed teeth are important local
causes of malocclusion. The most commonly
seen super­numerary teeth are the mesiodens.
Super­n um­e rary teeth can also occur in
the incisor, premolar and molar region.
Impactions in the maxilla generally occur in
the canine region.
Prior to the removal of these teeth their
exact location and their relationship is
ascertained by radiographs. During the
extraction procedure, care should be taken
not to damage the adjacent teeth or roots.
The tooth is approached by a buccal or
palatal flap depending upon its location. After
careful elevation of the flap, adequate amount
of bone is removed using rotary cutting
instruments. The impacted or supernumerary
tooth is removed and the extraction socket
inspected for any pathological tissue. The flap
is repositioned and sutures placed for a week.
SURGICAL EXPOSURE OF
IMPACTED TEETH
The presence of impacted teeth in the dental
arch can cause minor dental irregularities due
to deflection of adjacent teeth. Impaction of
teeth usually occurs as a result of arch length
discre­p ancy or presence of mucosal and
bony barriers that prevent their eruption.
The most commonly impacted tooth is the
maxillary permanent canine. In many cases
it is possible for the orthodontist to guide the
impacted canine into its normal location in the
dental arch after adequate surgical exposure.
The following steps are undertaken in the
management of impacted tooth:
Location of the Tooth
The exact location of the impacted tooth
is deter­m ined using the Clark’s tube shift
technique or the right angle technique. Most
impacted teeth present a bulge corresponding
to their location which should be examined
clinically by inspec­tion and palpation.
Evaluation of Favorability
In many cases the orientation of the impacted
teeth may be such that surgical orthodontic
guidance of the tooth into the arch may not be
possible. The favorability should be examined
prior to undertaking of the procedure. It is
consi­dered favorable whenever the apex of the
canine is close to its normal position.
Evaluation of Space Adequacy
When the impacted tooth is guided into
the dental arch, adequate space should be
present for its normal alignment. In many
cases involving the impaction of permanent
canines the deciduous canines are over
retained. These teeth may have to be extracted
to accommodate the permanent canines. In
certain patients, the space intended for the
permanent canine may be lost by migration of
the adjacent teeth. In such cases space for the
permanent canine is created by consolidating
the rest of the teeth and possibly extracting a
premolar.

Surgical Excision and Bone Removal
The crown of the impacted tooth is exposed
by excision of the overlying soft tissue and
removal of bony covering. The bone should be
removed up to the maximum height of contour.
Fixing Orthodontic Attachments
In most cases of favorably impacted canines,
once the soft tissue and bony tissues are
removed, the canine erupts on its own. In some
cases, orthodontic guidance for eruption of the
teeth into the arch may be required.
Attachments are placed on the impacted
tooth to guide the erupting tooth into the arch.
Some of the attachments that can be placed on
the impacted crowns are:
i. Metal crown with a hook.
ii. Celluloid crown with an attachment
bonded to it.
iii. Bondable orthodontic brackets or
buttons.
A ligature wire is wound around the
attachment and the other end tied to a
removable or fixed orthodontic appliance. The
wire is gradually tightened at regular intervals
to guide the erupting tooth.
FRENECTOMY
Many cases of midline diastema are believed
to be caused and maintained by abnormalities
of the maxillary labial frenum. The presence
of a thick, fleshy and fibrous frenum prevents
the two maxillary central incisors from
approximating each other. In these patients the
frenal tissue may crossover and get attached in
the intermaxillary suture area on the palatal
aspect.
Frenectomy is a surgical procedure
performed to excise the frenum and remove the
deeply embedded fibrous tissue. Controversy
exists regarding the timing of the surgical
Surgical Orthodontics 431
procedure. According to some, frenectomy
should be performed prior to orthodontic
closure of the midline diastema. According
to another school of thought, frenectomy
should be performed after space closure as it
reduces the risk of scar tissue formation that
can prevent closure of the midline space.
Regardless of the timing when the
procedure is performed the following points
should be remembered:
i. Frenum should not merely be clipped;
it should be totally excised to the bony
level.
ii. Any palatally attached fibrous tissue
should be removed.
iii. Fibrous tissue attached to the inter­
maxillar y suture area should be
removed.
iv. The mucosa of the lip is undermined
to prevent reattachment of the fibrous
tissue.
PERICISION (CIRCUMFERENTIAL
SUPRACRESTAL FIBROTOMY OR
CSF PROCEDURE)
Pericision or circumferential supracrestal
fibro­t omy, as it is often called is a minor
surgical pro­c edure that is undertaken to
counter the relapse tendency of the stretched
gingival fibers. The transseptal and alveolar
crestal groups of gingival fibers remain
stretched and do not readily readopt to the new
tooth position following correction of rotations
hence causing relapse.
Pericision involves surgical sectioning of
these fibers by passing a sharp narrow scalpel
through the gingival sulcus around the tooth
to a depth of 2 mm apical to the alveolar
crest. Pericision is generally undertaken
as an adjunctive retention procedure after
correction of rotations.
432 Essentials of Orthodontics
CORTICOTOMY
Corticotomy is a surgical procedure usually
undertaken in patients having dental procli­
nation with spacing. This technique involves
the sectioning of the dentoalveolar region into
multiple small units to hasten orthodontic
tooth movement. Labial flaps are raised and
interdental bony cuts are made parallel to the
long axes of the teeth. These cuts may be joined
together by a horizontal bony cut above the
apices of the roots. Care should be taken not to
totally separate the individual units. Following
the surgery orthodontic tooth movement is
initiated using fixed appliance.
ORTHODONTIC IMPLANTS
Implants made of titanium have been widely
used by several orthodontists as they offer
‘Absolute anchorage.’
Classification of Implants
Implants can be broadly classified under the
following headings:
Based on the Location
1. Subperiosteal implants: Implant body lies
over the bony ridge. The subperiosteal
design currently in use for orthodontic
purpose is the ‘Onplant.’
2. Transosseous implants: The implant body
penetrates the mandible completely, this
type is not used in orthodontics.
3. Endosseous implants: These are partially
submerged and anchored within the bone.
These have been the most popular and
widely used.
Based on the Configuration Design
1. Root form implants: These are the screw
type endosseous implants and the name
has been derived due to their cylindrical
structure.
2. Blade or plate implants: These have blade
or plate shape.
Based on the Composition of Implant
1. Stainless steel
2. Cobalt-Chromium-Molybdenum (Cr-Co-
Mo)
3. Titanium
4. Ceramic implants
5. Miscellaneous such as vitreous carbon and
composites.
Based on the Surface Structure
1. Threaded or nonthreaded: The root form
implants are generally threaded as this pro­
vides for a greater surface area and stability
of the implants.
2. Porous or nonporous: The screw type impl­
ants, whereas the plate or blade implants
(non­threaded) have vents in the implant
body to aid in growth of bone and thus
a better interlocking between the metal
structure and the surrounding bone.
Application of Implants in
Orthodontics
Implants are used mainly as anchorage sources
in orthodontics,
1. As source of anchorage alone (indirect
ancho­rage).
a. Orthopedic anchorage
i. Maxillary expansion
ii. Headgear like effects.
b. Dental anchorage
i. Space closure
ii. Intrusion of anterior teeth or post­
erior teeth
iii. Distalization of molars.
2. In conjunction with prosthetic rehabili­
tation (direct anchorage).
 Surgical Orthodontics 433

Recent advances include modified implant ORTHOGNATHIC SURGERY

designs which are specifically meant for orth­
odontic usage like:
1. Screw design
i. Mini-implant
ii. Impacted titanium post
iii. Skeletal anchorage system
iv. The microimplant
v. The Aarhus implant
vi. The orthosystem implant systems
vii. Newer systems (Spider screw, OMAS
system, Leone implant, Imtec screws,
etc.).
2. Implant disks:
i. Onplants
3. Plate designs:
i. Skeletal anchorage system (SAS)
ii. Graz implant supported system
iii. Zygoma anchorage system.
Method of Placement
The implant is placed by a surgeon through a
specialized procedure known as tunneling. After
making an incision in the posterior region of the
palate, a subperiosteal tunnel flap is created
extending till the desired location, using an
elevator. The implant is placed and is not distur­
bed for a period of 3 to 4 days allow biohealing.
Implants for the purpose of conserving
ancho­rage are welcome additions to the arma­
mentarium of a clinician. They help the orthod­
ontist to overcome the challenge of unwanted
reciprocal tooth movement. The presently
available implant systems are bound to change
and evolve into more patient-friendly and
operator-convenient desigs. Usage of implants
to achieve orthopedic changes in growing
children has also been documented. Long-
term clinical trials are awaited to establish
clinical guidelines in using implants for both
orthodontic and orthopedic anchorage.
Orthognathic surgeries are surgical procedures
carried out along with orthodontic treatment
which provide an opportunity for the ortho­
dontist and the oral surgeon to treat in collabor­
ation, severe dentofacial malformations that
cannot be satisfactorily treated by ortho­
dontic treatment alone. The major surgical
procedures are mainly aimed at treating den­
tofacial defor­mities.
ETIOLOGY OF
DENTOFACIAL DEFORMITIES
Dentofacial deformities can be congenital,
developmental or acquired in nature and can
affect the maxilla, the mandible or both in
combination.
The classification of etiologic factors in
den­tofacial deformities are:
Specific Causes
A. Prenatal causes:
1. Fetal alcohol syndrome
2. Retinoic and thalidomide therapy
3. Hemifacial microsomy
4. Goldenhar’s syndrome
5. Mandibulofacial dysostosis
6. Facial clefting syndrome
7. Achondroplasia
8. Craniosynostosis syndrome
9. Pierre Robin syndrome.
B. Postnatal causes:
1. Injury to nasal septum
2. Injury to condyle
3. Injury to ramus
4. Injury to alveolar bone and teeth
5. Missing muscles
6. Condylar hyperplasia.
434 Essentials of Orthodontics
Hereditary
1. Mandibular prognathism
2. Interracial mixing.
Environmental
1. Effect of posture
2. Respiratory influence
3. Effect of biting force.
ORTHOGNATHIC SURGERY
Orthognathic surgeries are major surgical pro­
cedures carried out along with orthodontic
the­rapy to correct dentofacial deformities or
severe orofacial disproportions involving the
maxilla, the mandible or both in combination.
Ortho­g nathic surgery basically involves
planned fracturing of the facial skeletal parts
and repo­s itioning them as desired. They
should be performed as a team with the oral
surgeon and the orthodontist being important
members of the team.
Orthognathic surgeries can be performed
in the maxilla as well as the mandible or in
com­bination to correct jaw discrepancies in
all the three planes of space.
The various orthognathic procedures
include:
I. Sagittal procedures:
Maxillary Prognathism
1. Subapical osteotomy
2. LeFort I osteotomy
3. Anterior maxillary osteotomy (AMO).
Maxillary Retrognathism
1. LeFort I osteotomy
2. LeFort II and III osteotomy.
Mandibular Prognathism
1. Bilateral sagittal split osteotomy (BSSO)
(Figs 12.1A and B).
2. Extraoral vertical osteotomy
A B
Figures 12.1A and B: BSSO advancement
3. Ramus vertical osteotomy
4. Reduction genioplasty.
Mandibular Retrognathism
1. Bilateral sagittal split osteotomy
2. Intraoral vertical osteotomy
3. Augmentation genioplasty.
II. Transverse procedures:
1. Midpalatal osteotomy
2. Surgically assisted rapid palatal
expansion.
III. Vertical procedures:
1. Sagittal split osteotomy
2. LeFort I
3. Subapical osteotomy
4. Combination of sagittal split and LeFort
I osteotomy
5. Genioplasty.
The planning and execution of orthognathic
surgery are done in a methodical manner. The
following are steps involved in orthognathic
surgery.
Diagnosis (Preoperative Evaluation)
Preoperative diagnosis is very important
for the success of orthognathic surgery. The
diagnosis is aimed at determining the nature,
severity and the possible etiology of the
dentofacial deformity.
General medical evaluation: The patient’s
general medical history should be recorded

to rule out medical disorders. The patient’s
overall dental health should be evaluated.
Pulpoperiodontal problems should be relived
prior to the surgical intervention.
Sociopsychological evaluation: The patient is
assessed to determine whether they are aware
of the existing dentofacial deformity and what
they expect out of the surgical therapy. This
helps in determining the patient’s motivation.
The patient’s social status should also be
evaluated.
Envelope of Discrepancy
(Figs 12.2A and B)
A diagram devised by WR Proffit and JL Acker­
man to illustrate graphically the amount of
change that can be produced by orthodontic
tooth movement alone (inner envelope),
orthodontic tooth movement combined with
growth modifi­cation (middle envelope) and
orthognathic surgery (outer envelope) in the
sagittal and vertical planes of space, based on
the authors’ clinical judgment.
Cephalometric evaluation: Cephalometric
evaluation is an important tool in determining
the nature and severity of the skeletal
A
B
Figures 12.2A and B: Envelope of discrepancy
Surgical Orthodontics 435
problems. The commonly used cephalometric
analyses are the Burstone’s Cephalometrics
for Orthognathic Surgery (COGS) analysis and
Quadrilateral analysis. Frontal cephalometric
evaluation helps in determining the facial
asymmetry.
Radiographic examination: Prior to the
surgical intervention the following radiographs
are mandatory.
1. Intraoral periapical radiographs: These
radiographs help in determining the
condition of the teeth and alveolar bone.
Presence of pathology around the tooth
can also be determined using these
radiographs.
2. Panoramic radiographs : Panoramic
radio­g raphs offer a wide view of the
entire dento­facial region including
the temporomandibular joint. These
radiographs are useful in evaluation
of bony pathologies, evaluation of the
temporo­m andibular joints and the
maxillary sinuses.
3. Digital cephalometric radiographs: Lateral
and Frontal (in transverse problems)
are essential for proper diagnosis and
treatment planning. Cephalometric
prediction tracings are highly useful in
treatment planning.
Softwares like Dolphin imaging can predict
the surgical outcome of the patients.
4. Submentovertex view : A radiograph
routinely used is the submentovertex view
to determine the buccolingual thickness of
the mandible as well as degree of deformity
of the face.
5. CT scan and MRI scans: CT and MRI
scans may be useful in cases where three
dimensional assessment are required.
Study model evaluation: Study models are
helpful in the evaluation of occlusion from all
directions. They are used to assess interarch
436 Essentials of Orthodontics
and intra-arch discrepancies. Study models
are also used in mock surgery and Splint
preparation.
Photographic evaluation: Extraoral photo­gra­
phs are particularly used to evaluate the facial
changes that may occur after orth­o­gnathic
surgery may be visualized by photographic
mock surgery.
TMJ evaluation: The temporomandibular
joint is evaluated by inspection, palpation,
auscultation and by radiographic examination
to evaluate joint movements and any pathology.
PRESURGICAL ORTHODONTICS
The objective of presurgical orthodontics
is to prepare the patient for the intended
orthognathic surgery and not to make the
occlusal relationship as ideal as possible.
The following procedures are undertaken
as a part of presurgical orthodontics:
i. Alignment of the arch.
ii. Space closure, unless it is to be utilized
during surgery.
iii. Coordination of the arches.
iv. Intrusion of teeth.
Most severe skeletal jaw discrepancies
are partly compensated by change in axial
inclin­ation of the anterior teeth. For example,
mandi­bular retrognathism is associated with
proclined lower anteriors to partially offset the
skeletal discrepancy. Class III patients with
prognathic mandible usually exhibit lingually
tipped lower incisors to compensate for the
skeletal relation. Presurgical orthodontics
should correct these positions of compensation
to position the teeth correctly over their
supporting bone. This procedure is called
decompensation.
Since most patients require postsurgical
orthodontic treatment, it is unnecessary
to carry out extensive presurgical tooth
movement that can be accomplished more
easily and quickly during or after the surgery.
Presurgical ortho­dontic preparation should
never extend more than one year (Fig. 12.3).
Mock Surgery
Soon after the completion of presurgical ortho­
dontic treatment a mock surgery is perfor­med
on the upper and lower models mounted on a
semiadjustable or fully adjustable arti­culator.
The models are cut and repositioned in the
desirable position. The segments are secured
in their new position using sticky wax. The
mock surgery they help in evaluation and
possible modification of the surgical treatment
plan. It also helps in the preparation of an
occlusal splint to be used during surgery.
Orthognathic Surgery and
Stabilization
The next step involves the surgical fracturing
and repositioning of the bony segments.
The teeth of the upper and lower arches are
wired in occlusion to splints. The orthodontic
arch wire and brackets can be used for the
intermaxillary fixation. Intermaxillary fixation
usually spans for 6 to 8 weeks following which
the splint is removed.
Figure 12.3: Decompensation

MAXILLARY
Surgeries
Anterior Maxillary Segmental
(Subapical) Osteotomy
Osteotomy of the anterior maxillary seg­
ment, usually from canine-to-canine, with
displacement in a posterior, inferior, superior
or rotational manner. Most commonly a
combin­ation of posterior and inferior repositi­
oning of the anterior segment is performed,
into the space created by simultaneous
extraction of the max­illary first premolars.
Anterior repositioning of the segment is
almost impossible because of diffi­culties in
stabilization and fixation, even with bone
grafting and because the soft tissue pedicles
often are insufficient to cover the surgical
defects. The most popular techniques for this
type of osteo­tomy are the Wassmund and
Wunderer tech­niques (Fig. 12.4).
Wassmund Technique
An approach to anterior maxillary segmental
osteotomy described by M Wassmund (1927),
which relies on maintaining both the labial
and palatal pedicles for vascular supply to the
anterior maxillary segment. The osteotomies
are carried out through mucosal tunnels
created on the vestibular side by vertical
incisions at the midline and at the level of the
first premolar and through palatal tunnels
created by connecting the extraction sockets
of the first premolars to a midpalatal incision.
Wunderer Technique
An alternative approach to anterior maxillary
segmental osteotomy described by S Wunderer
(1963). The technique relies on the vestibular
pedicle for vascular supply to the anterior
maxillary segment, together with some blood
Surgical Orthodontics 437
supply from the incisive canal. Bilateral vertical
incisions are performed on the vestibular
side at the level of the first premolars. These
are connected by a transpalatal horizontal
incision, allowing reflection of the palatal flap
posteriorly.
Complete Maxillary Osteotomy
Maxillary osteotomies traditionally are
described in comparison with the common
fracture patterns of the midfacial skeleton,
named after the work of R LeFort (1900).
The LeFort I, II and III fractures indicate the
general levels at which the maxilla may be
sectioned selectively from the rest of the
skull, although the osteotomies are tailored to
the individual patients and may deviate from
the known fracture patterns (Fig. 12.5).
LeFort I Osteotomy
The most frequently performed of all midfacial
osteotomies. It sections the midface through
the walls of the maxillary sinuses, the lateral
nasal walls and the nasal septum, at a level
just superior to the apices of the maxillary
teeth. Starting at the inferiorlateral margin
of the pyriform aperture of the nose, the
osteotomy line traverses the lateral walls of
the maxillary sinus approximately 3 to 4 mm
above the apices of the canine, premolars and
molars. It passes across the canine fossa to
the base of the zygomatic buttress and curves
around and above the maxillary tuberosity
to the lowest part of the pterygomaxillary
fissure, where it crosses the posterior wall
of the sinus at the same level. It then turns
anteriorly through the lateral wall of the nose
below the inferior turbinate to join the point
of origin. The cut is made bilaterally. Following
this, the pterygomaxillary plates are separated
from the posterior aspects of the maxillary
tuberosities, and the nasal septum is detached
438 Essentials of Orthodontics

Figure 12.4: Maxillary surgeries


Figure 12.5: LeFort osteotomy
from the superior aspect of the hard palate by
dividing it along its length with a chisel, so that
the maxillary segment is freed. The LeFort I
osteotomy offers a great number of options
as the freed maxilla can be reoriented in all
spatial planes. Further segmentation of the
maxilla can be performed to correct transverse,
anteroposterior and vertical discrepancies
between the maxilla and the mandible.
LeFort II Osteotomy
A pyramid-shaped osteotomy that is identical
to the Le Fort I procedure from the pterygoid
column to the zygomatic buttress. From that
point, instead of continuing anteriorly to the
pyriform aperture of the nose, the cut is directed
superiorly, towards the orbit. The cut is kept
anteromedial to the infraorbital foramen and
crosses the inferior orbital margin at a point
halfway between the lacrimal duct medially
and the infraorbital canal laterally. It then is
continued posteriorly along the floor of the
orbit and at right angles to the orbital rim until
past the lacrimal groove and its contained
lacrimal sac. The cut then is turned medially
and anteriorly across the apex of the lacrimal
groove and emerges medially to the orbit,
just below the midpoint of the medial canthal
attachment. The frontal process of the maxilla
then is crossed and the cut becomes continuous
with the osteotomy of the other side across the
nasal bones. The nasal septum is divided at a
higher level than during the LeFort I osteotomy,
Surgical Orthodontics 439
passing from the nasal bones anteriorly in
a downward and backward direction to the
posterior part of the septum just above the
posterior nasal spine. The lateral nasal walls are
fractured during mobilization of the maxilla at
levels corresponding to the septal cut.
LeFort III Osteotomy
The basic LeFort III osteotomy, as originally
described by P Tessier (1971), was designed
to achieve anteroposterior movement of
the whole facial mass, establishing normal
dental occlusion and increasing orbital
capacity, enlarging both the height and the
depth of the orbits. The aim is to separate the
facial mass from the cranial base along the
interfrontofacial and the interpterygomaxillary
planes. To do this, the osteotomy traverses, on
each side, the medial orbital wall, the orbital
floor and the lateral orbital wall to reach
the region of the frontozygomatic suture.
The frontal process of the zygomatic bone
then is split sagittally (effectively splitting
the lateral wall of the orbit) and the cut is
continued inferiorly to complete division
of the zygoma. The two sides are connected
centrally through the frontonasal area, as in
the LeFort II osteotomy. Pterygomaxillary and
septal separation then are completed as in
the LeFort II operation and the central facial
block is mobilized. Many variants of LeFort
III procedures exist that can be applied in the
treatment of a variety of craniofacial problems
and can be combined with surgery of the
cranial vault.
Küfner Osteotomy
A modification of the LeFort II osteotomy
originally described by J Küfner (1971). It is
intended for patients with good nasal bridge
and projection, but exhibiting retrusion of the
infraorbital region and maxillary dentoalveolar
440 Essentials of Orthodontics

area, with zygomatic flatness. The difference is

that the osteotomy does not involve the nasal
bridge, but is extended laterally to include the
infraorbital rim and zygomatic process.

Multiple-piece Maxillary Osteotomy

(Fig. 12.6)
When a severe transverse discrepancy between
the maxillary and mandibular arches exists, a
two- or a three- and sometimes even a four-piece
maxillary procedure is performed, following a
LeFort I osteotomy, to reposition each segment
separately to an ideal relationship with the
mandibular arch. Due to the increased risks
entailed in the segmental procedures, most
Figure 12.7: Bilateral sagittal split osteotomy
clinicians prefer to limit the number of
segments into which they divide the maxilla.

MANDIBULAR SURGERIES

Bilateral Sagittal Split Osteotomy

(BSSO) (Figs 12.1, 12.7 and 12.8)
A mandibular orthognathic surgical procedure
first reported in the English literature by
R Trauner and HL Obwegeser (1957) and
subsequently modified by others. In this Figure 12.8: Bsso setback

procedure the rami of the mandible are

Figure 12.6: Multiple-piece maxillary osteotomy
split parallel with the sagittal plane to allow
repositioning of the mandibular body into a
more favorable relationship with the maxilla
and the face. The procedure currently is
routinely performed through an intraoral
approach and can be used for advancement,
setback and rotation of the distal (mandibular)
segment.
When the distal segment is advanced, a
gap is created in the buccal plate. When it is set
back, a section of the buccal plate is removed to
allow good approximation of the buccal cortex
of the proximal segment against the lingual
cortex of the distal segment on each side. The
osteotomy design spares the mandibular nerve
 Surgical Orthodontics 441

and provides a broad interface of the bony

segments to aid with fixation and healing.
Fixation is achieved by bone screws or bone
plates, or through circumosseous fixation wires
in combination with IMF.

Transoral Vertical Ramus Osteotomy

(TOVRO), Intraoral Vertical Ramus
Osteotomy (IVRO)
A vertical osteotomy of the mandibular
ramus performed via a transoral approach
for correction of mandibular prognathism. It
commonly is carried out in conjunction with
a coronoidectomy. The coronoid fragment
with attached temporalis tendon is allowed to
retract. The line of the osteo­tomy extends from
an area in front of the condyle to a point at or
near the angle of the mandible.
This osteotomy is reserved for patients who
require a mandibular setback, as it necessitates
full-thickness overlap between the mandibular
segments. After the setback the condylar
segment lies laterally to the distal mandibular
segment. Stabilization can be provided by a
circumramus suture or wire, by rigid fixation
screws, or alternatively no stabilization is
used. In the latter case, patients are left in
intermaxillary fixation for 4 to 6 weeks. The
TOVRO is advocated to be less likely than the
BSSO to produce neuro­sen­sory changes.
Genioplasty (Fig. 12.9)
An orthognathic surgical procedure designed
to reshape the contour of the chin, giving it a
more esthetic appearance. The procedure is
performed intraorally by a vestibular incision
and depen­ding on the situation, can augment
or reduce the prominence of the chin in
the anteroposterior, vertical or transverse
plane of space. This can be performed by
various approaches, such as by sliding the
distal (genial) segment on the proximal
Figure 12.9: Genioplasty
(mandibular) segment and/or by removal of a
wedge of bone. Alloplastic grafts to increase the
prominence of the chin are no longer widely
performed, due to their side effects.
Postsurgical Orthodontics
Soon after the surgery, a phase of postsurgical
orthodontic treatment is initiated. During
this phase, the final settling and detailing of
the occlusion and esthetic root paralleling
is carried out. Most cases of postsurgical
orthodontics are completed by 4 to 6 months.
Cosmetic Surgeries
They are surgical procedures carried out
to improve the esthetic appearance of the
patient. These surgeries can involve the nose
and the chin. Cosmetic surgery of the nose
is called rhino­plasty. They are undertaken to
correct abnormal configuration of the nose.
Cosmetic surgery of the chin is referred to as
genioplasty. Cosmetic surgeries of the lips are
called cheiloplasty.
442 Essentials of Orthodontics
DISTRACTION OSTEOGENESIS
DEFINITION
“Distraction osteogenesis is the process of new
bone formation between the surfaces of bone
segments gradually separated by mechanical
traction.”
Specifically this process is initiated when
intermental traction is applied to the reparative
callus that joins the divided bone segments
and continues as long as the tissue is stretched.
This technique was pioneered in the 1950s by
Garvil Illizarov, a Russian orthopedic surgeon
who began using techniques that combined
compression, tension and then repeat bone
compression to heal fractured long bones
with segmental defects. Illizarov, based on his
research on canine and human long bones put
forward the Law of tension stress according
to which gradual traction of living tissues
created stress that stimulate and maintain the
regeneration and active growth of certain tissue
structures. He concluded that bone generation
could be initiated by the piezoelectric effect of
tension. Moreover, distraction forces applied
to bone also create tensional stresses in the
surrounding soft tissues leading to active
histogenesis in different tissues like skin, fascia,
blood vessels, nerves, muscles, ligaments,
cartilage and periosteum. This procedure,
known as Distraction histogenesis generally
accompanies distraction osteogenesis.
Successful use of this technique on
endochon­dral bones led to its application on
the membranous bones of the craniofacial
region in the 1970’s. Though initially used
on the mandible, in recent years the maxilla,
entire midface, orbits as well as cranial bones
have been successfully distracted. Distraction
osteogenesis is fast ganing widespread
acceptance as a popular alternative to ortho­
gnathic surgery in the treatment of various
craniofacial anomalies.
The most common technique in distraction
osteogenesis is mechanical stretching of
the reparative bone tissue by a distraction
osteogenesis is through a suture, wherein
new bone is generated in distracted suture.
The most popular example is rapid palatal
expansion, where in the hard palate is
distracted transversely through the midpalatal
suture. Midfacial sutures have also been
successfully distracted in growing animals.
Current research is also focused on the
possibility of applying this technique to
achieve rapid orthodontic tooth movement.
HISTORICAL PERSPECTIVE
Codvilla in 1905 performed the first bone
distraction for lengthening a shortened femur.
In 1927, Abbott applied this same concept
for lengthening a tibia.
According to Wassmund, Rosenthal
in 1927 performed the first mandibular
osteodistraction procedure by using an
intraoral tooth borne appliance that was
gradually activated over a period of one month.
In 1937, Kazanjian also performed mandi­
bular osteodistraction by using gradual incre­
mental traction instead of acute advancement.
It was Illizarov, who was responsible for
popularizing this technique and laying down
the protocols of distraction osteogenesis for
limb lengthening. In the 1950s he used the
concept of distraction osteogenesis to treat
fractured long bones with segmental defects
and then pioneered the radical concept of
generating bone by the piezoelectric effect of
tension (Law of tension stress).
Snyder in 1972 resected a 15 mm bone
segment unilaterally from a canine mandible

and showed that it was possible in craniofacial
region.
In 1976, Michieli and Miotti demonstrated
the feasibility of mandibular lengthening using
an intraoral device and a distraction protocol
similar to Snyder’s.
Karp in the early 90s published a detailed
histological analysis of the ossification process
after mandibular distraction osteogenesis in
the canine model.
McCarthy et al performed the first mandi­
bular distraction in humans in 1989, a small
series of which was reported in 1992.
INDICATIONS
Some of the common indications of distraction
in craniofacial region include:
1. Craniofacial microsomia­­—unilateral or
bilateral
2. Nager’s syndrome
3. Treacher Collins syndrome
4. Pierre Robin syndrome
5. TMJ ankylosis
6. Posttraumatic growth disturbances
7. Developmental micrognathia
8. Midface hypoplasia (craniofacial
synostosis syndromes)
9. Condylar regeneration
10. Correction of Class II skeletal discre­
pancies with underdeveloped mandi­
bles due to other cause
11. Expansion of mandibular symphysis in
Brodie’s syndrome
12. Maxillary development in cleft lip and
palate.
ADVANTAGES
The process of distraction osteogenesis has a
number of advantages over the conventional
Surgical Orthodontics 443
orthognathic surgery procedures in the
treatment of maxillomandibular deformities
or discrepancies.
1. Length of hospitalization and operating
time is drastically reduced. It can even be
performed on an outpatient basis.
2. Blood transfusions are generally not
required during the placement or removal
of the devices.
3. There is no need for autogenous bone
grafting.
4. It can be applied to correct deformities in the
very young child as early as 2 years of age.
5. Compared to the significant relapse in
tra­d­i­t i­­o nal orthognathic surgery pro­
ced­­u­r es, there is minimal relapse in
distra­ction osteogenesis. This is because,
during distraction osteo­genesis there is
gradual distraction and lengthening of
the soft tissue and the functional matrix
surrounding the bony skeleton along with
the bony lengthening. Gradual lengthening
also allows the soft tissue matrix to adapt
and hence leads to extremely stable
results after distraction osteogenesis. Con­
trarily, orthognathic surgery aims at acute
repositioning of the bony segments without
any adaptation of the soft tissue and muscle
envelope.
6. Orthognathic surgeries only permit acute
changes in the position of bone with
limited possibilities of new bone growth.
In contrast the bony regenerate formed by
distraction osteogenesis is continuously
molded by the neuromuscular envelope.
DISADVANTAGES
The limitations of distraction osteogenesis
include:
444 Essentials of Orthodontics
1. Distraction osteogenesis cannot be useful
in dysplasias due to excessive growth.
It is a treatment modality for deficiency
problems only.
2. It is highly dependent on patient compli­
ance.
3. The use of bulky extraoral appliances is
psychosocially not very well-accepted.
4. Scarring can occur if extraoral approach is
used.
5. Risk of infection.
PREOPERATIVE CLINICAL
EXAMINATION
This is similar to the examination carried out
for orthognathic or craniofacial surgeries.
The patient is examined with the head
in upright position. The bird’s eye view and
submental vertex position observation is
also important. In the general extraoral and
intraoral examination special care should
be taken to document asymmetries and
deformities in detail.
The function of the TMJ before distraction
and the motor (muscles of mastication and
facial expression) and the sensory (inferior
alveolar, infraorbital nerve functions of the
patient are recorded.
A transient limitation to opening can
occur after distraction. Thus it is important to
document mandibular excursion and original
interincisal opening for use as an objective goal
during postdistraction physical therapy.
Diagnostic records to be taken include,
study models, photographs, lateral and
posteroanterior cephalograms and orthopan­
tograms. Specialized investigations like
three dimensional cephalo­grams and three
dimensional CT scan can be taken if available
for additional information.
Vectors of Distraction Osteogenesis
The muscular and soft tissue forces plays an
important role in the deciding the final shape of
the distracted bone. Thus the various biological
and mechanical factors that influence the final
result of distraction are:
1. Articulation of distraction device to skeletal
anatomy.
2. Type of distraction device.
3. Orthodontic intervention during the distr­
action and consolidation.
4. Moulding effect of the surrounding neuro­
muscular envelope.
The vector of distraction is decided
by orien­tation of the distraction device to
skeletal anatomy. The devices are oriented
to the occlusal plane. If there are significant
irregularities in the occlusal plane, the long
exis of the mandibular body is used to describe
the orientation of the distraction device into
the following three cate­gories:
i. Vertical: This increases the vertical
dimension of the mandibular ramus.
ii. Horizontal: Placing the distraction
device in the horizontal orientation to
the mandibular body is the most efficient
approach for sagittal advancement of
the mandible.
iii. Oblique: This results in increase in both
the vertical and horizontal dimensions
of ramus and body. Overjet and both
ramus and body size deficiency may be
addressed.
In growing patients the discrepancy should
be overcorrected by several millimeters.
Distraction Device Characteristics
Distraction devices can be of two types:
I. Extraoral (Fig. 12.10)
II. Intraoral (Fig. 12.11).
Intraoral devices offer the advantage of
being more esthetic more psychosocially

Figure 12.10: Extraoral distraction appliance
Figure 12.11: Intraoral distraction appliance
accepted and avoid an external cutaneous scar.
Though their use is rapidly increasing extraoral
devices are still preferred in certain situations.
Intraoral devices can be easily by used if
there is sufficient bone stock and unilateral
or bilateral lengthening is required using
horizontal vector. However, if there is severe
ramal deficiency and a vertical vector is
required the extraoral device is preferred.
The distraction devices may be uniplanar
or multiplanar. Uniplanar devices have a
straight screw that elongates in a linear fasion
when activated. However, the changes in bony
anatomy may not be uniplanar due to the
Surgical Orthodontics 445
complex pull of the neuromuscular envelope
and orthodontic intervention.
Multiplanar devices have the potential for
controlling distraction in three planes. They
can be used for increasing mandibular sagittal
thrust while at the same time, altering the
angular relationship between body and ramus.
However, angular activation should commence
after some regerate has been formed.
Orthodontic Management
The orthodontist has an extremely important
role to play right from diagnosis and treatment
planning till the end of the treatment of the
patient.
Orthodontic management can be divided
into three stages:
Predistraction Orthodontics
This begins with careful appraisal of the denti­
tion and how it relates to the projected skeletal
changes. Orthodontic appliances are selected
and treatment initiated that is consistent with the
overall goals of the distr­action treatment plan.
This involves the following procedures:
i. Removal of dental compensations
ii. Preliminary alignment
iii. Coordination of arch widths
iv. Fabrication and use of distraction
stabili­zation appliance
v. Fabrication of surgical hooks.
Orthodontics during Distraction
and Consolidation
Active orthodontics or orthopedics continues
throughout the distraction and consolidation
phases and may include the use of bands,
brackets, distraction stabilization appliances,
maxillary expansion appliances, functional
appliances are to direct the tooth bearing
446 Essentials of Orthodontics
segment towards its planned postdistraction
position.
During distraction the following four
factors determine the final outcome of the
treatment:
i. Orientation of the device: Vertical
horizontal or oblique. The orientation
is done based on the occlusal plane to
obtain predictable changes.
In patients in whom deficiency is
bilateral or symmetrical it is necessary
to place the distraction device in a
bilaterally symmetrical position to
prevent asymmetrical results.
ii. Type of device: Distraction devices with
multidirectional capabilities are able to
alter the observed vector as it deviates
from the planned vector. They also allow
for differential vertical, horizontal or
transverse vector components to be
added or deleted as the distraction
progresses. These alter­ations may be
part of the original treatment plan or
introduced by the orthodontist during
distraction to redirect the tooth bearing
segment.
iii. Neuromuscular influence: The bones on
either side of the regenerate have the
capability to rotate around the skeletal
fixation pins. This allows for moulding
of the shape of the regenerate. Complex
pull of the surrounding muscles and
soft tissues alter the direction of the
devices.
iv. Application of external influences: This
is applied by the clinician by adjusting
the multi­planar devices as discussed
pre­viously by orthodontic or orthopedic
means. Large changes can be affected
by orthodontic means die to increased
metabolic response to the surgical insult
or manipulation of the regenerate.
Orthodontics after Distraction
and Consolidation
After consolidation and removal of the device
orthodontics, aims to accomplish the original
treatment goals.
In bilateral distraction to correct sagittal
discrepancies in growing individuals patients,
overcorrection with creation of an anterior
cross bite is a temporary treatment objective.
Eruption guidance and dental alignment over
basal bone is done. If the patient may require
further distraction or surgery after growth,
orthodontic treatment at this time aims to
ready the occlusion for the future procedures.
In adults minimal correction is done during
dis­­tr­­action and orthodontic finishing is accom­
plished after consolidation.
GROWTH AND STABILITY
AFTER DISTRACTION
One of the most significant advantages of
distr­action osteogenesis overorthognathic
procedures is the minimal relapse and
excellent stability of results after distraction.
This is due to the fact that along with the bones,
the surrounding soft tissues and muscles also
get distracted and adapt to the new bone
position.
The growth of the mandible after distraction
returns to the original growth pattern of the
patient and hence, significant overcorrection
is needed during distraction in the growing
patients.
Dental Distraction (Fig. 12.12)
Liou and Huang in 1998 stated that the process
of osteogenesis in the periodontal ligament
during orthodontic tooth movement is similar
to the osteogenesis in the midpalatal suture
during rapid palatal expansion. They proposed

Figure 12.12: Dental distraction device
a new concept of distracting the periodontal
ligament to elicit rapid canine retraction
in 3 weeks. They coined the term “Dental
distraction” for this procedure.
Future Directions
The future development of osteodistraction
in craniofacial applications will probably
establish more complete understanding of
the biology of new bone formation under the
influence of gradual traction, major trends
may include:
i. Refinement of distraction protocols
ii. Modification of osteotomy procedures
Surgical Orthodontics 447
iii. Further improvement of distraction
devices
iv. Enhancement of regenerate maturation
with pharmacologic agents, such as gro­
wth factors and cytokines
v. Development of new techniques to
moni­tor distraction regenerate form­
ation and remodeling.
CONCLUSION
Osteodistraction procides a means whereby
bone may be molded different shapes to more
ade­q uately address the nature of skeletal
deformities and asymmetries. In addition, the
phenomenon of distraction histogenesis may
allow larger skeletal movements without the
inherent risk of relapse. Furthermore, many
of the congenital deformities that require
extensive musculo­skeletal movements may
be addresses with fewer procedures eventually
achieving the same structural, functional, and
esthetic results comm­only seen with modern
orthognathic procedures. The new millennium
may also witness the use of the concepts of
distraction osteogenesis to achieve better,
faster and more efficient tooth movement.
448 Essentials of Orthodontics
CHAPTER
Multidisciplinary
13 Orthodontics
ADULT ORTHODONTICS
In the last few years there has been considerable
interest in orthodontic treatment for the adult
patient. There is no definite age when the male
or the female reaches physical maturity and
it is therefore impractical to try to determine
exactly when adulthood begins. Since an adult
is defined as one who is fully grown, most
males of 18 to 19 years and most females of
16 to 17 years can be considered as adults.
According to Ackerman adult orthodontics
is concerned with striking a balance between
achieving optimal proximal and occlusal contact
of the teeth, acceptable dentofacial esthetics,
normal function and reasonable stability.
REASONS FOR INCREASE IN
ADULT PATIENTS
The percentage of adult patients who have
received orthodontic treatment has increased
significantly in the last decade. From 1970 to
1990, an 800% increase in adult patients was
observed.
An increase in the number of adult patients
in the past few years has undoubtedly been due
to decreased numbers of child patients with
the recent explosion of activity in the field of
preventive dentistry. Harvey G Barrer observed
that the child population is decreasing and
that the number of orthodontists is increasing.
At the same time, we find an increase in the
number of adult consultations. The reservoir
of adult orthodontics is large because of many
who could not avail themselves of treatment
two or three decades ago.
The increasing number of adults requiring
or requesting orthodontic treatment can also
be ascribed to:
1. Innovations in appliances, especially the
advent of direct bonding, ceramic brackets
and tooth colored wires, have caught the
attention of many adults who would not
otherwise seek orthodontic treatment.
2. Improved appliance placement techni­
ques. The latest development is lingual
orthodontics, or invisible orthodontics,
which may shortly be a proven technique.
3. Increased experience with adult orthodontic
treatment and the achievements of good
results.
4. Increased public awareness of the possibili­
ties of adult treatment.

5. Increased desire of patients and restorative
dentists for treatment of dental mutilation
problems, using tooth movement and
fixed restorations rather than removable
prosthesis.
6. More sophisticated and successful mana­
gement of the symptoms associated with
joint dysfunction.
7. More effective management of jaw dyspla­
sias, using advanced orthognathic surgical
techniques.
With the ever changing times, the adult
has awakened to the benefits of orthodontics.
His increased social and business activity
has made him aware of visible esthetic short
comings; growing personal affluences and
access to third party participation have put
him in reach of treatment previously difficult
to obtain but now readily available. With this
the orthodontist has a now responsibility of
developing esoteric procedures for treating
adult patients.
The increased demand for adult ortho­
dontics today can also be ascribed to the
following factors:
1. Media: Numerous articles in magazines
and newspapers, as well as advertising by
dentists increase public awarness.
2. Insurance: Third party payment for patients
of other phases of dental care can make
funds available for adult orthodontics
which is only occasionally covered by
insurance.
3. Affluence: Total dental treatment is more
acceptable in today’s adults because they
can afford it.
4. Family dentist awareness: The family
dentist is more aware of the problems of
occlusion and the role of proper tooth
alignment in enhancing restorative
dentistry. Paralleling abutment teeth
simplifies tooth preparation for crowns,
Multidisciplinary Orthodontics 449
bridges, partial dentures, resin bonded
retainers and other restorations.
5. Esthetics: Today there is greater awareness
of health and appearance. To achieve better
facial esthetics, the teeth must be properly
aligned, with all missing teeth replaced.
Orthodontic treatment for adults has been
the fastest growing area in orthodontics in
recent years. There appear to be two reasons for
this, and therefore two groups of adult patients.
The first groups, comprising of young adults
who desired but did not receive comprehensive
orthodontic treatment as youths, now seek it
as they become financially independent, and
are more aware of the benefits of orthodontic
treatment.
The second group consisting of adults
(often older than those in the first group)
who recognized as candidates for adjunctive
orthodontic treatment to make control of dental
disease and restoration of missing teeth easier
and more effective.
Difference between Adult and
Adolescent Patients
What are the differences between adult and
child orthodontics? The basic difference is
that in children we must concern ourselves
with tooth movement plus growth, whereas
in adults we are dealing strictly with tooth
movement. We cannot count upon growth to
help us in achieving our treatment objectives.
In a way, then, adult orthodontics is simpler,
for we have one less (and often unpredictable)
factor with which to contend.
The need for orthodontic treatment in the
adult is often symptom related which can be
detected by the patients, while that in child
is based more often by signs detected by the
parents or the practitioner. There are, however,
several other differences between adult and
child orthodontics.
450 Essentials of Orthodontics
Indications for Adult Orthodontic
Treatment
Ravins clearly outlined the reasons for adult
orthodontic therapy:
1. To improve tooth-periodontal tissue
relationship.
2. To establish an improved plane of occlusion
in order to distribute forces through the
broadest area possible.
3. To balance the existing space between
teeth for better prosthetic replacement.
4. To improve spaces to provide normal tooth-
to-tooth contact.
5. To improve occlusion and coordination
with the masticatory muscles and the TMJ.
6. To satisfy the esthetic desires of the patient.
Contraindications for
Adult Orthodontics
Barrer discussed several contraindications
relating to adult orthodontic therapy. They are:
1. Severe skeletal discrepancies.
2. Advanced local or systemic diseases.
3. Excessive alveolar bone loss.
4. Inability to obtain a result that the patient
or doctor will perceive as satisfactory.
5. Poor stability prognosis.
6. Lack of patient motivation.
BIOMECHANICAL
CONSIDERATIONS
Since adult patients who need orthodontic
treatment often have periodontal problems,
the amount of bone support of each tooth is an
important consideration. When bone has been
lost, the periodontal ligament area decreases,
and the same force against the crown produces
greater pressure in the periodontal ligament
of a periodontically compromised tooth
than a normally supported one. The absolute
magnitude of force used to move teeth must be
reduced when periodontal support has been
lost, to prevent damage to the periodontal
ligament, bone, cementum and root.
The greater the loss of attachment, the
smaller the area of supported root and the further
apical the center of resistance will become. The
center of resistance of a single rooted tooth
lies approximately six tenths of the distance
between the apex of the tooth and crest of the
supporting alveolar bone. Loss of alveolar
bone height or periodontal attachment leads to
apical relocation of the center of resistance. The
magnitude of the tipping moment produced by
a force is equal to the force times the distance
from the point of force application to the center
of resistance.
Orthodontic forces must be applied to
the crown of a tooth, and the further the
point of force application is from the center
of resistance, the grater will be the tipping
moment produced by any given force and
consequently a larger countervailing couple
would be necessary to effect bodily movement.
Mechanics and Treatment
Adult treatment mechanics need not differ
from the standard techniques; they are
modified only to meet specific treatment
requirements. Simplicity with maximum
control is the byword. All dental movements
are considered to be possible. Of these
intrusion is difficult; root resorption is a
frequently seen. Extrusion is the least difficult.
Tipping is not difficult, but septal crest bone
loss may be a serious hazard. Rotation is simple
and rapid but has the highest relapse factor.
With well-designed appliances controlled
dental movement and availability of basic
requirements treatment can be no more
eventful for the adults than for the child,
perhaps less so.

Age-related Changes in the
Periodontal Ligament
The primary tissue to be influenced by
mech­anical forces applied to the teeth is the
periodontal ligament. Collagen is produced by
the fibroblasts, which are the most frequently
occurring cells of the periodontal ligament. The
osteoclasts occurring within a few hours after
orthodontic stimulus are most likely derived
from the local monocyted and or macrophages.
After the initial wave, a second population of
resorbing cells appears that are blood borne.
Some of these cells migrate from the vascular
network at the center towards the bony surface,
serving as progenitor cells for osteoblasts.
A mechanical stimulus, such as a force
applied to a tooth, will result in an increased
proli­feration of the cells in the periodontal liga­
ment. It has been proposed that the insuffi­cient
source of preosteoblasts might account for the
delayed response to mechanical stimulus.
Norton suggested that the decreasing
blood flow and vascularity that occurs with
increasing age may provide an explanation
for the insufficient source of progenitor’s cells
that characterizes the ageing patient. The age-
related changes in visualization may explain
the delayed reaction to orthodontic forces
described in adults.
Age-related Bone Changes
Orthodontic tooth movement as a result of
bone modeling and remodeling also depends
greatly on age-related changes of the skeleton.
Cortical bone becomes denser while the
spongeous bone reduces with age and the
structure changes from that of a honeycomb
to a network.
Local Age Changes
The apical displacement of the marginal
bone level is a local factor that influences the
biological background for tooth movement in
Multidisciplinary Orthodontics 451
adults. The marginal bone loss is age-related
but is also the result of progressive periodontal
disease. With marginal bone loss the center of
resistance of the tooth is displaced apically.
Another factor of importance is occlusal
function. This is highly related to both the
quality and quantity of the lamina dura and
surrounding bone. Teeth that have lost occlusal
contacts because of extraction develop disuse
atrophy in their supporting bone.
Together, these hard and soft tissue changes
dictate a conservative approach to mechanics.
The biological background for orthodontic
tooth movement in adult indicated that:
i. The forces used in adults should at a
lower level than those used in children.
ii. The initial forces should further be kept
low because the immediate pool of cells
available for bone resorption is low.
iii. The moment to force ratio for a particular
tooth movements should be increased
according to the periodontal status of
the individual teeth.
iv. With increasing marginal bone loss light
continuous intrusive forces should be
maintained during tooth displacement.
DIAGNOSIS AND ADULT
ORTHODONTICS
Orthodontic diagnosis deals with recognition of
the various characteristics of the malocclusion.
It involves collection of pertinent data in a
systematic manner to help in identifying the
nature and cause of the problem. Diagnosis
involves development of a comprehensive
data base of pertinent information. The data is
derived from case history, clinical examination
and other diagnostic aids such as study casts,
radiographs and photographs. The standard
diagnostic aids are mandatory. Because of a
greater possibility for dormant pathosis, buried
452 Essentials of Orthodontics
roots, impactions, periodontal breakdown,
and atrophic changes, periapical, occlusal
and TMJ films should be obtained routinely in
addition to the panoragram and cephalogram.
A systematic approach to the examination is
essential to ensure that nothing is overlooked.
The problem oriented diagnostic procedure
as described by Proffit and Ackerman is
recommended to ensure that no aspect of the
patient need is ignored.
Adult patients come to us after years of using
and abusing their dentitions, the teeth have:
i. More wear facets
ii. Shorter cusps
iii. Shallower fossae
iv. Many have had extensive dental work,
amalgams, crowns or inlays
v. Bridges and partial dentures.
For the adult, the clinical examination takes
on special significance in isolating existing of
potential ptosis and the etiological factors of
trauma, mandibular shifts, wear facets, occlusal
disharmonies, and faulty dental restorations.
Additional diagnostic procedures that we
should consider in our adult patients are:
i. A full series of TMJ examination and
X-rays
ii. Muscle examination
iii. Stress evaluation
iv. Diet evaluation.
Periodontal Considerations in
Diagnosis
Most adult patients who seek orthodontic
treat­m ent have some form of periodontal
breakdown. Orthodontic treatment in the
presence of period­ontal disease results in
more septal bone loss, more tooth mobility
during treatment and more residual mobility
posttreatment. Pre-treatment consultation
with the periodontist should be routine and
orthodontic objectives should be altered if
required on his advice.
Re-evaluation and constant periodontal
therapy during orthodontic treatment will
further ensure a more positive prognosis.
They require specific long-term retention
procedures, often of a fixed design.
Multidisciplinary Approach
Most adult patients require a multidisciplinary
team for their comprehensive rehabilitation.
The team may include:
i. General dentist
ii. Orthodontist
iii. Restorative dentist
iv. Prosthodontist
v. Oral and maxillofacial surgeon
vi. Periodontist
viii. Plastic surgeon.
TREATMENT ASPECTS IN
ADULT ORTHODONTICS
Proffit has classified adult orthodontic
procedures into the following three areas:
1. Adjunctive Orthodontic Treatment
Adjunctive orthodontic treatment is by
definition, tooth movement carried out to
facilitate other dental procedures necessary to
control disease and restore function. Although
malocclusion as classically described is not
necessarily an unhealthy condition, some
tooth positions are not conductive to long-
term oral health. The goals of adjunctive
treatment should be to:
i. Facilitate restorative treatment by posi­
tioning the teeth so that more ideal
and conservative techniques can be
used.
ii. Improve the periodontal health by
elimi­nating plaque harboring areas,
improving the alveolar ridge contour
adjacent to the teeth.

iii. Establish favorable crown to root ratios
and position the teeth so that occlusal
forces are transmitted along the long
axes of the teeth.
Adjunctive treatment implies limited ortho­
dontic goals, improving a particular aspect of
the occlusion rather than comprehensively
altering it. Typically, appliances are required in
only a portion of the dental arch and for only a
short time. The adjunctive treatment includes:
i. Uprighting of teeth (Fig. 13.1):
ii. Forced eruption
iii. Alignment of teeth.
2. Comprehensive Treatment for
Adults
Comprehensive orthodontic treatment accor­
ding to Proffit implies orthodontic treatment
which would take more than six months
duration. Comprehensive treatment in adults
is similar to that in adolescents. However, the
following considerations should be kept in
mind while treating adults:
i. Keep in mind the biological limitations:
Adults exhibit decreasing blood
flow and vascularity and insufficient
source of progenitor’s cells at the site
of tooth movement. In addition the
Figure 13.1: Molar uprighting
Multidisciplinary Orthodontics 453
cortical bone becomes denser while
the spongeous bone reduces with age.
These biological limitations dictate a
conservative approach to mechanics in
adult orthodontic treatment.
ii. Lower force levels: The forces used in
adults should be at a lower level than
those used in children. The initial forces
should further be kept low because the
immediate pool of cells available for
bone resorption is low.
iii. Periodontal considerations: Adults
are more likely to be periodontally
compromised. Periodontal care should
be undertaken as frequently as needed
during the orthodontic treatment to keep
a check on periodontal inflammation.
iv. Multidisciplinary approach: Most adult
patients require a multidisciplinary team
for their comprehensive rehabilitation.
The team may include orthodontist,
restorative dentist, prosthodontist, and
oral surgeon.
v. Esthetic requirements: Adults are usually
more concerned of esthetics. They
are likely to be put off by appliances
that are not esthetic. Use of esthetic
tooth colored brackets and lingual
orthodontics can be considered for
adult patients.
vi. Comfort requirements: Adults are usually
less adaptable to the appliance than
young patients. Thus simple comfortable
appliances are preferred in adults.
vii. Biomechanical considerations: Adults
exhibit greater bone loss and loss of
attachment leading to apical shift of the
center of resistance. Thus greater will
be the tipping moment produced for a
given force.
Adult treatment mechanics need not
differ from the standard techniques; they
are modified only to meet specific treatment
454 Essentials of Orthodontics
requirements. Simplicity with maximum con­
trol is the byword. Adults are turned off by:
i. Unesthetic appearance
ii. Fear of pain
iii. Extended treatment time
iv. Personal inconvenience
v. Cost.
The appliances used in adult orthodontics
should fulfill the following requirements:
i. Should be simple in order to maximize
the cooperation.
ii. They should respond to light force for
best physiological response.
iii. They should be fixed to maintain treat­
ment control.
iv. They should be long-acting to decrease
the number of appointments.
v. They should require the shortest overall
treatment period while affording us the
highest potential for a stable correction
with minimum retention requirements.
Invisalign® Technology (Fig. 13.2)
Invisalign® is the invisible way to straighten
teeth without braces. It uses a series of clear
Figure 13.2: Invisalign® system
removable aligners to straighten teeth without
metal wires or brackets. Zia Chishti and
Kelsey Wirth introduced it in 1997, by Align
Technology in Sunnyvale, California.
The treatment procedure is handled by the
computer technicians; process takes 3 weeks to
a month. After approval from the orthodontist,
specifications are transmitted to the manu-
facturing plant.
Patient gets the first aligner 6 weeks after
the 1st visit.
Most treatments require 20 to 60 aligners
worn for 2 weeks each.
Should be taken off only for eating and
brushing.
Indications
Mild-to-moderate crowding and rotations.
Contraindications
1. Patients with severe malocclusions.
2. Cannot be used as a alternative to regular
fixed appliances.
3. All children–growing jaws and erupting
teeth too complicated for the computer to
model.
3. Surgical Orthodontic Treatment
As adults do not grow any longer dentofacial
ortho­g nathic surgeries are major surgical
procedures carried out along with orthodontic
therapy to correct dentofacial deformities or
severe orofacial disproportions involving the
maxilla, the mandible or both in combination.
Orthognathic surgery basically involves
planned fracturing of the facial skeletal parts
and repositioning them as desired. It requires
a team approach with the oral surgeon and
the orthodontist being important members
of the team.
Orthognathic surgeries can be performed
in the maxilla as well as the mandible to correct

jaw discrepancies in all the three planes of
space.
Retention in Adult Orthodontics
Retention mechanics should be part of
the original treatment plan. It may include
removable retainers, operative procedures
and or fixed retention. When the patient has
abnormal lip, tongue, or cheek muscle activities,
it is incumbent on the ortho­dontist to prepare
the patient for long-term use of fixed retainers.
Retention is a critical and challenging aspect
of adult orthodontics. The general principles of
retention hold good for adult patients.
In many cases of adult orthodontics the
need for postorthodontic stabilization will
coincide with the need for both restorations of
mutilated dentition and cross arch stabili­zation.
ORTHODONTICS IN
MULTISPECIALTY APPROACH
MULTISPECIALTY
ORTHO­DONTIC TREATMENT
The aim of multidisciplinary treatment app­
roach is to achieve optimal esthetics and
function, consistent with a physiologically stable
occlusion. Various specialities in den­tistry such
as prosthodontics, conservative dentistry, and
periodontics require adjunctive orthodontic
treatment as a part of comprehen­sive treatment.
Typical problems that require orthodontic
treatment:
Cosmetic dentistry: Closing diastemas, space
management, anterior alignment, elimination
of interproximal ‘black spaces.’
Preprosthetic alignment: Molar uprighting,
abut­ment paralleling, space closure or open­ing.
Forced eruption: Extrusion of endodontically
treated fractured teeth, periodontal defects,
compromises of the ‘biologic width.’
Multidisciplinary Orthodontics 455
Periodontal treatment: Extrusion of teeth to
correct vertical defects, uprighting molars
to eradicate pseudoperiodontal pockets,
extrusion of ‘hopeless’ teeth to generate bone
in preparation for an implant.
Sequence of Treatment in
Orthodontics
I. Disease control:
1. Caries control (Operative dentistry)
2. Endodontics
3. Initial periodontics (no osseous surgery)
4. Initial restorative (no cast restorations).
II. Establishment of occlusion:
1. Orthodontics
2. Orthognathic surgery
3. Periodontal maintenance.
III. Definitive periodontics (including osseous
surgery):
IV. Definitive restorative:
1. Cast restorations
2. Splints, partial dentures
3. Maintenance.
Conservative Management of
Malocclusion
Esthetics is one of the main reasons for
orthodontic treatment, patients with mild
to moderate esthetic problems like mild
midline diastema, irregular shape of incisors
and mild rotations can be managed without
orthodontic treatment. The management in
these conditions includes the restorations and
cosmetic contouring of the midline diastema
or mild rotations and they are made to appear
more esthetically.
Indications
1. Midline diastema of less than 2 mm
2. Mild rotations
3. Irregular shape of incisors
4. Mammelions
456 Essentials of Orthodontics
5. Peg-shaped lateral incisors
6. Talons cusp or cusp of Carabelli
7. Mild incisal tip fractures
8. Adult patients
9. Periodontal problems
10. Patients not willing for orthodontic
treatment.
Management
Management in these cases includes esthetic
restoration with hybrid composite resins
combined with cosmetic contouring of the
occlusal and incisal defects. The procedure
involves the use of fine diamond burs, disks
or proximal stripping kits to provide for the
desired contour and for good esthetic appe­
arance. Finishing and polishing burs are used
with pumice and rubber cups for final finishing
and polishing. Precaution should be taken not
to over trim and expose the dentin or pulp.
In some moderate to severe cases,
orthodontic treatment is carried out along
with these procedures to permanently alter
the tooth positions.
Advantages
1. Treatment time is very short when com­
pared to routine orthodontic treatment
2. Relapse tendency is very less
3. Less expensive.
Disadvantages
1. Thickness of enamel should be kept in
mind not more than 0.5 mm of enamel
should be removed.
2. Sensitivity may occur.
Orthodontic Management of
Ankylosed Teeth
Ankylosis, a localized fusion of alveolar bone
and cementum, is the result of a defective or
discontinuous periodontal membrane and is
apparently caused by mechanical, thermal,
or metabolic trauma to the periodontal mem­
brane during or after tooth eruption. It occurs
most often in the primary dentition, in the
mandibular teeth and in molars.
Ankylosis can sometimes be detected
from radiographic evidence of periodontal
membrane obliteration. The obliterated area,
however, is usually small and therefore may
not be evident on a radiograph. Diagnosis
of ankylosis is usually based on the clinical
finding of a sharp or ringing sound upon
percussion and by lack of tooth mobility or
soreness, even with heavy, continuous orthod­
ontic forces.
Ankylosis during eruption almost always
produces a submerged tooth. Ankylosis after
eruption impedes adaptive and therapeutic
tooth movements. In any event, ankylosis can
have a profound effect both on the occlusion
and on orthodontic treatment.
In the primary dentition, ankylosis is
usually treated by simple neglect, restoration,
or extraction. Ankylosis of a permanent tooth,
however, is more complicated if orthodontic
treatment is planned. Intervention can include
luxation, corticotomy, and/or ostectomy.
Luxation involves a mechanical breakage
of the bony bridge between the alveolar bone
and cementum. This is accomplished much
like tooth extraction, by administering a local
anesthetic, grasping the tooth with a forceps
or sharp-pointed elevator, and cautiously
rocking the tooth either buccolingually or
mesiodistally to free the osseous-cemental
fusions. Orthodontic movement can then be
started immediately.
Corticotomy is a surgical technique in
which the intact ankylosed tooth, with the
surrounding cortical bone and enough soft
tissue to maintain the blood supply, is isolated
as a block in one or two stages. The isolated

tooth can be repositioned during surgery, or
it can be moved orthodontically through less-
dense medullary bone to the intended site.
This technique does not correct the ankylosis,
but it does permit optimal repositioning of the
tooth.
Another conservative approach that
preserves the tooth and restores its mobility
involves localized ostectomy of the fused
bone. After local anesthesia, a periodontal
flap is raised, the affected osseous tissue is
excised, and the flap is sutured back in place.
Unfortunately, this approach works only if
the ankylosis is in the crestal area. Ankylosis
elsewhere on the root surface is not readily
accessible to surgery.
ORTHODONTIC-PERIODONTIC
INTERRELATIONSHIP
The ultimate aim of the dentist is to ensure
that his patient receives the maximum benefit
of therapy with the minimum of deleterious
effects. It has been known for almost half a
century that conventional multiattachment
appliances have been local etiologic factors
in contributing to periodontal problems.
Today, guiding the patient’s individual growth
potential for basal and muscular correction
followed by alignment of the dental arches
requires a sophisticated knowledge of the
periodontium, for as forces are applied to
individual dental units it is the periodontal
structures that exhibit morphologic changes.
Stage I: Diagnosis
Orthodontic services now extend from the
neonates to the adults. This being the situation,
recognition of patients with periodontal
problems and modification of treatment to
suit their needs is the requirement of the day.
Multidisciplinary Orthodontics 457
More important recognition of the orthodontic
appliance as a potential etiologic agent in
periodontal disease and acknowledging
periodontal disease as a serious entity to
contend with, are the basis of a successful
orthodontic therapy.
Recognition of Individual Patient
Response
1. The clinician must be well-acquainted with
clinical disease parameters and the ability
to assess disease activity for all patients.
2. The orthodontist must also be aware of the
disease activity state of the various sites
involved in orthodontic treatment. It is
now accepted that periodontitis is not a
steadily progressive disease, but shows sites
and times of remissions and exacerbations.
Hence, active sites and the limitations they
impose on orthodontic therapy must be
recognized.
3. The high-risk patient must be identified.
Lindhe et al (1974) have shown that tipping
and intrusive forces in the presence of
plaque were capable of shifting the plaque
to sub-gingival position, which resulted in
an apical shift of the epithelial attachment
and in the creation of an infraosseous
defect. Matssen (1978) concluded from his
studies that the adults’ dentition is more
susceptible to plaque than the deciduous
dentition.
Identification of the Susceptible
Patients
Thin Tissue
The labiolingual thicknesses of gingival and
alveolar housing are to be determined. Thin
tissue is more likely to undergo recession
during orthodontic therapy than thick one. If
there is a minimum zone of attached gingival
458 Essentials of Orthodontics
or thin tissue, a free gingival graft changing the
type of tissue around the tooth will help control
inflammation. This should be done before the
orthodontic movement begins.
Frenum Considerations, Gingival
Hyperplasias and Mouth Breathing
The high frenum contributes to movement of
the marginal gingiva, where the keratinized
tissue has been lost or detached. It has been
recommended that a frenectomy procedure be
done in the maxillary midline for yong children
because of the belief that the midline diastema
is caused by the maxillary labial frenum.
Many believe that this frenum prevents mesial
migration of the maxillary central incisors
and that removal should precede orthodontic
therapy. It is postulated that the scar tissue
formed in the healing frenectomy wound
serves to being the two incisors together,
although this is still under dispute.
Generally, surgical removal of maxillary
labial frenum should be delayed until after
ortho­dontic treatment unless the tissue pre­
vents space closure and becomes painful and
traumatized. Frenectomy may be indicated
after orthodontic treatment to change irrever­
sible hyperplastic tissue to normal gingival
form and to enhance post-treatment stability.
Gingival changes associated with ortho­
dontic appliances to the periodontal tissues.
Usually, correction of abnormal gingival form
is done after the appliances are removed.
Gingiva recedes following recessive changes in
periodontal fibers and bone; it does not recede
over bone.
Although the plaque index is not signifi­
cantly higher in mouth breathers it has been
reported that there is an increase in gingival
index. This incrased inflammation should
be reduced to a minimum before bonded
appliances are placed. Gwinnett (1979)
showed that the resin used in bonding brackets
was responsible in causing gingival disease.
They hypothesized that the surface area of
resin, the size of the particles in the resin
and the type of bracket used were important
variables in determining the severity and
extent of periodontal disease.
Ectopically Positioned and
Unerupted Teeth
Many orthodontic patients do not exhibit
teeth that have not penetrated the oral mucosa
nor will not erupt. Complications such as
devitalization, reexposure, ankylosis and
external root resorption, injury to adjacent
teeth, marginal bone loss and gingival
recession have been considered routine in
teeth that must be surgically exposed. On
labially positioned teeth in the maxilla and
mandible and lingually in the mandibular arch,
the surgical procedure should incorporate a
means of prociding attached gingiva. Muco­
gingival problems are avoided, provided that
there is proper marginal tissue replacement
adequate inflammatory control absence of
excessive force, atraumatic surgery, and proper
gingival attachment during tooth movement.
Curettage necessary to eliminate recurring
marginal inflammation, should not be done
over­zelously because this may cause an apical
shift of the epithelial attachment.
Acknowledgment of Psychophysiology
as a Science
Psychosomatic diseases have an important
hand in modifying treatment response. They
may affect the soft and the hard tissues. As far as
the soft tissues lesions are concerned they alter
patient acceptance of a potentially irritating
device in an already hyperesthetic mouth.
Psychosomatic diseases cause parafunctions
like bruxism, clenching, etc. which have

profound effects on the alveolar housing of
the tooth and so modify treatment procedures.
Stage II: Treatment Planning
The overall treatment plan for a patient with
periodontal disease often involves orthodontic
realignment of the teeth.
Indications for orthodontic treatment in
periodontics are:
1. If a malocclusion exists and further pro­
motes periodontal disease or affects its
course:
a. Mouths with crowded teeth exhibit a
greater degree of periodontal problems
than aligned arches, may be due to:
i. Hygiene is difficult even for the
conscious patient.
ii. Osseous defects are difficult to treat
because of proximity of roots.
iii. When fixed splinting is necessary,
tooth preparation is difficult.
iv. Restorations of adequate bulk may
cause impingement on gingival,
closed contacts harbors plaque and
unesthetic appearance.
b. Deep overbites are often accompanied
by:
i. Trauma to maxillary palatal gingival.
ii. Trauma to mandibular labial
gingival.
iii. Locked bite anteriorly, directing
excessive force on the maxillary
incisors, often with migrations and
mobility as a result.
iv. Excessive wear on the labial surfaces
of mandibular incisors and lingual
surfaces of maxillary incisors.
2. If tooth migrations occur such as flaring
caused by disease, parafunction or because
of tooth extraction, which can increase the
severity of disease. Physical forces can act
on the tooth in a manner similar to that of
Multidisciplinary Orthodontics 459
an appliance. Schwartz postulated factors
such as tongue, lips, cheeks, chewing and
swallowing habits, newly placed fillings
and rocking partial dentures as etiologic
agents in migration. Physiologic tooth
movements occur in most dentitions at old
age.
Although they may influence the migration
of periodontally involved teeth, they are
responsible for drifting of uninvolved teeth as
well.
Preister has listed few changes in the
patient’s metabolism such as pregnancy,
scurvy, altered carbohydrate metabolism,
diabetes, muscular dystrophy, as causes of
tooth mobility.
Muhlemann is of the opinion that in
disorders such as acromegaly, phenytoin
hyperplasia and Paget’s disease, the growth of
tissues can move teeth.
Migration as a cause of Disease
Tooth migration can contribute to periodontal
disease by causing:
i. Alterations in occlusion.
ii. Posterior bite collapse.
iii. Flaring and loosening of anterior teeth.
iv. Open contacts leading to food impaction.
v. Perforation or resorption of buccal and
lingual alveolar walls.
vi. Crater of infrabony defect formation, if
alveolar housing is thick.
vii. Buckling which may change gingival
contour and promote plaque retention.
viii. Alterations in patterns of mastication and
parafunction, leading to traumatism.
Repositioning of such malposed teeth is
indi­cated if periodontal disease can be demon­
strated. Repositioning may also be warranted
in the absence of periodontal disease, if
esthetic needs or reconstructive requirements
dictate or if conditions potentially hazardous to
460 Essentials of Orthodontics
the periodontal health of the patient become
apparent.
Treatment of bony defects: Combined perio­
dontal orthodontic measures are efficacious in
the treatment of the following osseous defects:
i. Mesial infrabony defects and pockets on
tilted teeth.
ii. One or two walled infrabony defects on
a single tooth (Goldman Ingber).
iii. Furcation defects.
iv. Bony defects existing because of stage
of eruption, axial inclination of teeth,
or tooth rotations.
The uprighting of a tilted tooth may elimi­
nate most of the bony defect by remodeling of
the bone. Ostectomy and osteoplasty can then
be used to eliminate the residual defect.
Bear and Peterbaugh (1966) have suggested
that incisal and occlusal surfaces of teeth
be ground to permit eruption. As the tooth
erupts, bone is deposited at the crest and
angular defects are reduced. Orthodontically,
forced eruption can also be used to reduce or
eliminate angular bone defects.
Furcation involvements have been succ­
essfully eliminated and regrowth of bone
induced by the use of eruption preceded by
open subgingival curettage.
It is imperative to check every single tooth
during every recall visits.
Preparation for reconstruction: The need for
orthodontic therapy prior to reconstruction
is frequently encountered in dental practice
because fixed splinting required parallel abut­
ments, pontic spaces of sufficient width, open
embrasures and an esthetic and harmonious
occlusion. To bring about these conditions,
the dentist must upright tilted and protruded
teeth. When teeth are properly positioned,
torque is minimized and forces are transmitted
in the long axis of the tooth.
Stage III: Treatment
The orthodontic appliances are an implement
designed to place pressure against a tooth to
produce movement. A bite plane on a Hawley’s
appliance is one of the oldest and most versatile
devices still used in adjunctive therapy for
periodontal patients. It may be employed in a
number of situations.
1. To free the occlusion and permit repair.
2. To facilitate eruption of a posterior teeth
or teeth and the depression of mandibular
anterior teeth.
3. To facilitate tooth movement in bucco­lin­
gual or mesiodistal directions, to rotate
intrude or facilitate eruption of a tooth or
teeth.
4. As an appliance for attachments to correct
landmark relationships and tooth posi­tions.
i. By facilitating mandibular tooth move­
ments.
ii. By permitting retraction of anterior teeth
and changing crown-root ratio.
iii. To permit testing of changes in vertical
dimension.
iv. To permit repair of bony defects.
a. Changes in crestal form by eruption
of tooth or by changing the axial
inclination of roots.
b. Infrabony defects by uprighting teeth
and by permitting or encouraging
eruption of a tooth.
The fixed appliances have become extre­
mely popular with the dentists and the public
for the range and degree of tooth movements
achieved by them.
These are significant to the periodontist in
the following ways:
1. Forces and direction of forces applied on
the periodontium.
2. Degree of torque affected by the appliance:
All the newer modifications (Roth, Vari-­

sim­plex) of older fixed appliance techni­
ques use the principle of overcorrection to
compensate for relapse. This soft of over­
correction might leave the periodontium
in a state of stress, as the periodontal
mem­­­brane is now thought to be a thixo­
tropic gel that loosens up or liquefies under
stress and firms up again on removal of the
applied force.
3. Plaque retention: The older forms of fixed
appliances incorporating numerous
springs, and loops and ligatures acted as
reservoirs for plaque. Brushing was an
ordeal even if the patient was sufficiently
motivated. Now, with the different intended
tooth movements incorporated into the
bracket itself and with the placement of the
bracket being a critical step in correction
of malocclusions, periodontal health care
procedures have become less complicated.
Periodontal Care during
Orthodontic Therapy
Plaque causes an inflammatory reaction
and orthodontic treatment opens up new
pathways of spread of inflammation. Hence,
plaque control must be practiced assiduously
in order that an effective orthodontic therapy
is possible. As it is popularly said, the tooth
must not only stand in position, it must stay
in position. All periodontal inflammatory
lesions must be controlled before onset
of orthodontic care. The patient must be
sufficiently motivated and use of adjuncts to
plaque control like gingival stimulations, water
jets, etc. must be advocated.
Orthodontic Care for the
Periodontally Involved Patient
The biologic situation in the periodontal
patient is:
a. Absence of growth: Extrusion is avoided
because vertical dimensions increases,
Multidisciplinary Orthodontics 461
sagittal jaws relationship changes and
freeway space are reduced. This cannot be
compensated for by subsequent growth.
Hence, correction is affected solely be
dentoalveolar changes.
b. Loss of periodontal support: Hence, redu­
ced forced forces ought to be used. Also,
moment of forces is affected by marginal
bone loss. Further, the position of center
of resistance is now altered. These changes
limit orthodontic therapy.
c. Biology of adult bone: Amount of minerali­
zing bone is decreased with age and
the lamina dura is fenestrated. Hence,
only gradual movements and prolonged
retention periods are possible.
Stage IV: Post-treatment
Orthodontic appliances are extremely popular
as periodontal splints as they are less traumatic,
more esthetically acceptable and functionally
more stable than the conventional wire
ligatures.
Retention is generally considered to be
a difficult part of orthodontic treatment in
adolescent patients. It is often even more
difficult to maintain the treatment result in
adults. This may be attributable to:
i. Their generally slower tissue turnover
rates.
ii. The face that normal functional adap­
tation occurs more slowly when growth
has been completed.
iii. The fact that reduced height of the
perio­dontium may make teeth more
susceptible to postorthodontic move­
ment in undesirable directions.
A relatively now approach to adult retention
problems is, the use of flexible spiral wire
(FSW). This might be used to:
1. Prevent reopening of median diastema.
2. Prevent reoccurence of multiple spacing of
teeth.
462 Essentials of Orthodontics
3. Use a periodontal splint after migrated
teeth has been realigned.
4. Stabilize excessively mobile teeth.
5. Prevent reopening of extraction sites.
6. Prevent rotational relapse of incisors.
Orthodontic Therapy in Patients with
Juvenile Periodontitis
Juvenile periodontitis (JP) is characterized by
a rapid loss of alveolar bone and periodontal
attachment in otherwise healthy adolescents,
with onset thought to occur after puberty.
It is generally localized to the permanent
first molars and incisors, with little gingival
inflammation, and almost no clinically
detectable dental plaque or calculus on
the affected teeth. Little attention has been
given to the problems encountered by
orthodontists in correcting malocclusions in
patients with JP (formerly known as perio­
dontosis). In the past, the prognosis of the
periodontally affected teeth was considered
poor or hopeless, leading to their extraction
before the initiation of orthodontic therapy.
Previous case reports describing orthodontic
treatment of juvenile periodontitis patients
have dealt primarily with the movement
of unaffected teeth into edentulous spaces
left after extraction of teeth with advanced
alveolar bone loss. However, recent clinical
and laboratory studies on the cause and
management of juvenile periodontitis have
led to a movement in periodontal treatment
philosophy toward more tooth retention, even
if severe osseous defects are initially present.
Active juvenile periodontitis pockets have
been shown to be inflammatory lesions that
harbor specific bacterial populations in the
subgingival dental plaque. These bacteria
differ from the microbiotas characteristic of
healthy periodontal sites. With this insight,
longitudinal therapeutic studies utilizing
nonextraction treatment approaches aimed
at the suppression of periodontopathic
bacteria (for example, root planing with and
without periodontal surgery, plaque control,
antibiotics, use of local chemotherapeutic
agents) have clearly demonstrated that the
dentitions of these patients—including
severely involved teeth—can be retained
for many years without the reappearance of
clinical periodontal deterioration.
Consequently, orthodontists are more
likely to face the challenge of repositioning
teeth in treated juvenile periodontitis patients
that have substantially decreased alveolar
bone support. In addition, placement of fixed
orthodontic appliances is known to enhance
accumulation of dental plaque and can induce
significant increases in periodontopathic
bacteria subgingivally.
Conclusion
There is presently no biologic method that
can effectively determine measure or predict
the actual state of structural and physiologic
balance among a composite of changing,
functioning anatomic and histologic parts,
with or without clinical intervention. If this key
were discovered, a harmonious relationship
between the orthodontist and periodontist
will be a way of life rather than a matter of
semantics.
ORTHODONTIC MANAGEMENT
OF TMJ AND OCCLUSAL
DISORDERS
Over the years functional disturbances of the
masticatory system have been identified by
a variety of terms. Numbers of terms have
certainly created some problem in this area.
In 1934, James Costen described a group
of symptoms that centered on the ear and

temporomandibular joint. Because of this work
the term Costen syndrome developed. Later
the term temporomandibular disturbances
became popular and then in 1959, Shore
introduced the term temporomandibular joint
dysfunction syndrome. Ramfjord and Ash
coined the term functional temporomandibular
joint disturbances. Some term described
the suggested etiologic factors, such as
occlusomandibular nomenclature, such as
pain dysfunction syndrome. Some authors
believe that more collective term should be
used such as craniomandibular disorders.
Bell suggested the term temporomandibular
disorder which was accepted by American
Dental Association.
BIOMECHANICS
The TMJ is a compound joint. Its struc­
ture and function can be divided into two
distinct systems:
1. Joint system is the tissues that surround
the inferior synovial cavity: Since the disk
is tightly bound to the condyle by the
lateral and medial discal ligaments. The
only physiologic movement that can
occur between these surfaces is rotation
of the disk on the articular surface of the
condyle. The disk and its attachment to
the condyle are called the condyle-disk
complex and is the joint system responsible
for rotational movement in the TMJ.
2. The second system is made up of the condyle-
disk complex functioning against the
surface of the mandibular fossa. Since
the disk is not tightly attached to the
mandibular fossa, free sliding movement is
possible between these surfaces in the
superior cavity referred to as translation.
The articular surfaces of the joint have no
Multidisciplinary Orthodontics 463
structural attachment or union, yet contact
must be maintained constantly for joint
stability. Stability of the joint is maintained by
constant activity of the muscles that pull across
the joint, primarily the elevators. Even in the
resting state, these muscles are in a mild state
of contraction called tonus.
The width of the articular disk space
varies with interarticular pressure. The contour
and movement of the disk permit constant
contact of the articular surfaces of the joint,
which is necessary for joint stability. As the
interarticular pressure increases, the condyle
seats itself on the thinner intermediate zone of
the disk. When the pressure is decreased and
the, disk space is widened, a thicker portion of
the disk is rotated to fill the space.
The interarticular pressure and the
morphology of the disk prevent the disk
from being over retracted posteriorly. In
other words, as the mandible moves into a
full forward position and during its return,
the retraction force of the superior retrodiscal
lamina holds the disk rotated as far posteriorly
on the condyle as the width of the articular disk
space permits. It is important to remember
that the superior retrodiscal lamina is the
only structure capable of retracting the disk
posteriorly on the condyle. Attached to the
anterior border of the articular disk is the
superior-lateral ptery­goid muscle, when this
muscle is active, the fibers that are attached to
the disk pull anteriorly and medially. Therefore,
the superior lateral ptery­g oid muscle is
technically a protractor of the disk however,
that this muscle is also attached to the neck
of the condyle. This dual attachment does not
allow the muscle to pull the disk through the
discal space.
During translation the combination
of disk morphology and interarticular
pressure maintains the condyle on the inter-
464 Essentials of Orthodontics
mediate zone and the disk is forced to translate
forward with the condyle. The morphology
of the disk therefore is extremely important
in maintaining proper position during
function. Only when the morphology of the
disk has been greatly altered does the liga­
mentous attachment of the disk affect joint
function. When this occurs the biomechanics
of the joint are altered and dysfunctional signs
begin.
At rest with the mouth closed, the condyle
is positioned in contact with the intermediate
and posterior zones of the disk.
The importance of the function of the
superior lateral pterygoid muscle during
the power stroke becomes apparent when
the mechanics of chewing are observed.
The jaw works as a fulcrum around the hard
food, causing an increase in interarticular
pressure in the contralateral joint and a
sudden decrease in interarticular pressure
in the ipsilateral joint. This can lead to
separation of the articular surfaces, resulting
in dislocation. To avoid this, the superior
lateral pterygoid muscle becomes active
during the power stroke, rotating the disk
forward on the condyle so the thicker posterior
border of the disk maintains articular contact.
Therefore, joint stability is maintained during
the power stroke of chewing.
TEMPOROMANDIBULAR JOINT
PATHOLOGY
A normally functioning joint must distribute
their force vector from the condyle to the disck
to posterior slope of the articular eminence at
an angle of 45o to the FH plane. The only thing
can force condyle to transmit loading forces
of full occlusion to areas other than the disk is
combination of:
i. Dental arch or apical base location and/
or
ii. Occlusal-incisal guidance (or misgui-
dance)
The status of the disk-condyle-fossa
relation­ship is determined by the muscles
during rotation-translation type jaw motion.
This relationship is alterable in the fashion that
the muscles and their actions are alterable.
Once this happens at final closure, the
proprioceptive signals of the periodontal
ligaments of the teeth begin to dominate and
the neuromuscular reflexive activity may have
to be changed. As the inclined planes of the
upper and lower teeth guide the mandible as
a whole to the state of final fully interdigitated
dental occlusion, the inclined planes of the
teeth themselves and their overall relative
antero­posterior and vertical spatial location
become the determining forces of the disk-
condyle-fossa relationship at final occlusion
via new signals sent to the muscles. Muscles
as dictated by the motor impulses provide the
power and them the intercuspation of the teeth
determines the direction these force vectors
will take and where it will be absorbed. Thus
a relationship is generated that lies at the very
heart of all functionally induced TMJ pain-
dysfunction problems.
Joint form and position are a direct result of
tooth form and position. The teeth determine
how the disk-condyle assembly will relate
not vice versa. So, occlusion determines the
muscles to lock up the disk condyle assembly
into a proper or improper, comfortable or
strained relationship to the fossa and articular
eminence to full occlusion. This may range from
a mild to moderate or severe. Once pathology
sets up, TMJ anatomical, biomechanical
and physiological dysfunction starts. It is the
dusfunction of the stomatognathic system, the
dysfunction of various subsystems like sensory,

orthopedic and muscular and neurovascular
systems, that forces the clinicians to take a
needed step to erase the source of problem and
hopefully make a system of functional balance
out of one that is in a state of dysfunctional
imbalance.
Classification system used for diagnosing
temporomandibular disorders:
I. Masticatory muscle disorders
1. Protective cocontraction
2. Local muscle soreness
3. Myofascial pain
4. Myospasm
5. Centrally mediated myalgia.
II. Temporomandibular joint disorders
1. Derangement of the condyle-disk
complex
a. Disk displacements
b. Disk dislocation with reduction
c. Disk dislocation without reduction.
2. Structural incompatibility of the arti­
cular surfaces
a. Deviation in form
i. Disk
ii. Condyle
iii. Fossa.
b. Adhesions
i. Disk to condyle
ii. Disk to fossa.
c. Subluxation (hypermobility)
d. Spontaneous dislocation.
3. Inflammatory disorders of the TMJ
a. Synovitis/capsulitis
b. Retrodiscitis
c. Arthritides.
i. Osteoarthritis
ii. Osteoarthrosis
iii. Polyarthritides
iv. Rheumatoid arthritis.
d. Inflammatory disorders of associ­
ated structure
i. Temporal tendinitis
Multidisciplinary Orthodontics 465
ii. Stylomandibular ligament
inflammation.
III. Chronic mandibular hypomobility
1. Ankylosis
a. Fibrous
b. Bony.
2. Muscle contracture
a. Myostatic
b. Myofibrotic
3. Coronoid impedance.
IV. Growth disorders
1. Congenital and developmental bone
disorders
a. Agenesis
b. Hypoplasia
c. Hyperplasia
d. Neoplasia.
2. Congenital and developmental muscle
disorders
a. Hypotrophy
b. Hypertrophy
c. Neoplasia.
SIGNS AND SYMPTOMS OF TMJ
DISORDERS
Pain
Pain associated with TMJ problems is the
most important symptom as far as the patient
is concerned. It may be dull, intermittent,
sharp and stabbing, localized or radiating
to gonial region suboccipital region, frontal
region or zygomatic region. It can be so
insidious so as to hardly cause a change in a
persons routine and daily schedule, or it can
be so intense as to alter entire lives. If only
one joint is involved it can be unilateral and
if both joints are involved, pain is usually
bilateral. The pain seems to be also related to
the host resistance. Pain may also be detected
in the form of tenderness to palpation in the
466 Essentials of Orthodontics
muscles of mastication and joint area itself.
Pain may be perceived by the patient at a site
that is not the actual source because of referred
pain. Pain may be originating from area of
hyperirritability known as trigger points. Pain
may arise by impingement of the airway due
to neuromuscular reflexive displacement
of mandible causing superior posterior
displacement of condyle. To compensate for
this, patients head is held in slightly irregular
fashion and pain may initiate in the muscles
of the neck.
ORTHOPEDIC DYSFUNCTION
Joint Sounds
There are two main types of joint noise crepitus
and clicking. Both are intimately related to
the status of the functional anatomy of the
joint itself.
Clicking
It is an important clinical finding of the routine
dental examination. The clicks can be of opening,
closing or reciprocal, early, middle or terminal.
The click is commonly reciprocal. The cause
of click is a product of the anatomical shape
of the disk and its stereoscopic relationship of
the head of the condyle at the beginning of the
opening movement. Two clicks can be heard
one in the opening of the mouth and other at the
same point on the closing of mouth. Generally
opening click is loud and audible while the
closing click may or may not be audible. Some
patients with TMJ dysfunction may not show
any noticeable joint sound due to disk ironing,
where posterior heel of the disk has flattened
due to continuous wearing. In some case due to
continuous abuse of the ligaments, the condyle
which starts out off the back edge of the disk at
full occlusion pushes the disk ahead of it during
the entire course of the opening movement
and never regains it. The anterior recess of the
capsule becomes distorted and enlarged to
accommodate to the conglomeration of discal
and associated ligamentous tissues referred
as a ‘balled up disk’. It represents a disk that is
perpetually jammed ahead of the translating
condyle, thus limiting that range of translation
itself. This condition is referred to as ‘clinical
closed lock.’
Crepitus
It is the sound of denued bone on bone.
Chronic abuse of the disk by superior posterior
displacement of condyle can cause perforation
of the disk. The noise of crepitual results from
contact of the head of the condyle with either
the dome or slope of the articular eminence
without any intervening shock absorbing
disk due to perforation. These can result in
osteoarthritic bone remodeling of the head of
the condyle, which can lead to flattening and/or
lipping of the condyle. Crepitus is always a sign
of long-standing and severe superior posterior
displacement of the condyle and an advanced
level of intraarticular degeneration.
Tinnitus which is another perceived sound,
detected only by the patient and it dies not
come from TMJ but is auricular in origin. It
can be perceived by the patient in the form
or ringing, buzzing or hissing. The exact
mechanism is unclear. However, it may be a
matter or impaired circulation and/or direct
physical pressure of the mechanical and/or
hydraulic nature.
Altered Mandibular Movements
The main factors responsible for the restriction
or deviation of movement of the lower jaw are
the condition of the muscles and the status
of the condyle-disk-fossa relationship. As a
protective reflex the muscles rally to the aid

of the actually traumatized joint and/or its
supportive components by going into various
degrees of spasm to immobilize the joint in
an effort to facilitate the body’s attempts at
healing. Attempts at forcing the jaw open past
a given point of restriction will elicit a painful
response and the muscles and joints are usually
quite sensitive to palpation. Another type of
joint-inflated restriction of the movement can
be due to ‘clinical closed lock’situation which
has already been explained. Joint initiated
deviation in mandibular movement can be due
to sudden snapping of the head of the condyle
past the thicker heel of the disk and down
into the center of the disk’s central concavity.
This is especially noticeable when the process
takes place in at different points bilaterally
in the opening and closing arc of movement
from one joint to another. This is referred to as
‘torquing of mandible.’ In this situation while
opening there can be deviation of the mandible
but upon full opening midline coincides. In
another situation where clinical closed click is
present in one side, further opening can lead to
deviation of the mandible on the affected side.
Muscular Dysfunction
When muscles become involved in TMJ
problems they express their displeasure in
primarily two ways; pain and dysfunction. For
a muscle, pain may be expressed in the form
of tenderness to palpation or movement, or it
may exist in the form of outright discomfort
even in the absence of palpation or movement
at rest. Muscles are less efficient when they
are forced to operate at a length different
from their ideal resting length which is
the scene there in TMJ dysfunction where
over contraction of the muscles are altering the
original length. So, muscle splinting consists of
an advanced muscles and a feeling of stiffness
and/or weakness.
Multidisciplinary Orthodontics 467
The teeth are responsible for initiation of
the guidance through the neurological signals
they provide to the brain. The actual work of
directing that arc of closure to full occlusion is
a product of the muscles. All the movement of
the condyle are a direct result of neuromuscular
mechanisms that are generated as a result of the
tactile sensations of the teeth as they contact
one another in condyles are always associated
with overworked musculature, for it is this
musculature that is responsible for pulling the
mandible that far back against the design intent
of the disk, the associated ligaments and even
the muscles themselves.
Neurovascular Dysfunction
Nervous innervation of both sensory and motor
types as well as adequate vascular supply is
critical to proper functioning TMJ. One of the
first neurological symptoms to be noted is the
pain. Referred pain can originate from both
the muscles of mastication and the supportive
musculature by means of mechanism of
trigger point formation. Trigger points may
be defined as a focus of hyperirritability in a
tissue that, when compressed is locally tender
and is sufficiently hypersensitive gives rise to
referred pain and tenderness and distortion
of proprioception. They are present like little
knots in the thread of the muscle fibers. They
may also form in skin, connective tissue and
even periosteum. Trigger points may cause
autonomic responses in the referred sites
as localized vasoconstriction, lacrimation,
salivation, secretion of nasal mucus and
pilomotor stimulation. Even proprioceptive
irregularities might occur due to trigger point
activity, such as tinnitus, vertigo and slight
ataxia problems. Trigger points can be active
or latent.
Overstretching, overworking or chilling
of the muscle activates trigger points to
468 Essentials of Orthodontics
make the muscles stiff and sore. Referred
pain can also come from simple, direct
mechanical pressure from the condylar head
on the auriculotemporal nerve bundle in the
posterior fossa area. The auriculo­tem­poral
nerve is a branch of mandibular division of
trigeminal nerve which anastomoses with
branches of the facial nerve. Thus two great
cranial nerves of the maxillofacial complex and
all their associated neural centers and ganglia
are capable of being interconnected with each
other.
The mechanical and hydraulic pressures
in the posterior joint space are increased due
to condylar intrusion and chronic trauma-
induced inflammation, the circulation
through the superficial temporal artery can be
progressively restricted. This can cause steadily
increasing back pressure to spread out through
the other branches of the external carotid, i.e.
the posterior auricular and temporal lobe and
anastomoses with lachrimal artery. Vascular
distention in these arteries can cause pain in
the areas supplied.
Homeostatic Dysfunction
The secondary etiological agent responsible
for enhancing and accelerating the onset of
condition can be stress. The malocclusion
(mechanical stress) ignites the TMJ fire and all
other forms of stress-emotional, psychological,
physiological, chemical, etc. fan the flames.
The word stress may be defined as “nonspecific
response of the body to a demand”. The human
body is designed for stress, it is designed to
adapt to stresses of all types on all levels. Stress
in appropriate amounts is actually healthy
for the body. When the accumulation of
stress becomes great enough over a sufficient
amount of time, so as to push the limits of his
natural ability, physical degeneration causes in
the form of disease. Thus the stress becomes
pathological.
Hans Selye developed the concept of the
general adaptation syndrome (GAS) and
local adaptation syndrome (LAS). Stressing
the entire body nonspecifically produced
a physiologically repeatable set of general
chemical and neural responses such as adrenal
gland activation, diminution of lymphatic
and reticuloendothelial activities, increased
gastric acidity and digestive response of the
body to stressors was what Selye meant by
GAS. Alternately, when tissues are locally and
acutely stresses as in trauma, infection ot other
localized noxious stimuli, there also appeared
in turn a localized tissue responses that Selye
labelled that LAS. GAS and LAS work hand-in-
hand. Chemically alarm signals are sent out by
locally stresses tissues as a result of LAS being
activated try the noxious stimuli. These signals
reach the CNS via blood stream and stimulate
the control centers of the CNS to initiate the
responses of GAS by means of activation of
endocrine system, especially the pituitary and
adrenal glands.
So, chronic irritation and stressing of local
tissues, such as the TMJ and its supporting
musculature, causes localized tissue damage
in the joint and therefore elicits a chronic
LAS response in the TMJ area. This in turn
stimulates a chronic GAS response throughout
the whole body.
DIAGNOSIS
The proper TMJ diagnostic examination
procedure may be divided into three main
areas, the history, the clinical examination and
the radiographic examination.
History
Detailed medical and dental history is an
important part of diagnosis of a TMJ problem.
It is especially important in the differential

diagnosis between problems of functionally
generated nature and general systemic origin
which mimics common TMJ symptoms of
headache or facial pains.
Clinical Examination
Direct clinical examination of patient involves
four basic procedures: Palpation to identify
the anatomical origins of pain, auscultation
of the joint during function to determine the
presence of joint sounds, range of motion
measurements of the mandible and analysis
of the occlusion, palpation of the joint and
muscles of mastication can be carried out
directly or indirectly by the examining
clinician. Muscle tenderness is indicative of
some level of fatigue and or trauma that is
usually directly proportional to the duration
and level of intensity of the insult. This can
result from simple mechanisms, such as lactic
acidosis or more advanced mechanisms such
as muscle splinting trigger point irritation or
referred pain.
Range of motion measurement is another
important diagnostic criterion. Two types of
motions are measures, the maximum interincisal
opening and the lateral excursive movement.
The normal interincisal opening varies from 40
to 55 mm and normal range of lateral excursion
should be 12 to 15 mm, anything less than 40
mm of interincisal opening and 10 mm of
lateral excursion is considered a sign of joint
dysfunction. Hence the etiology of limitation
of opening can be extracapsular, capsular and
intracapsular.
Radiography
Radiographic procedures as an adjunct to TMJ
diagnosis include orthopantograms, trans­
pharyngeal view, transorbital view, transcranial
radiography, tomography, arthrography,
CT scans, magnetic resonance imaging and
cephalometrics.
Multidisciplinary Orthodontics 469
Occlusal analysis of the cast gives clue of
an occlusal relationship that has an untoward
effect on the functional integrity of the TMJ.
The most common situationare, retroclined
upper anteriors proclined lower anteriors with
labially crowded out incisor, combination of
both, loss of maxillary arch form and balancing
side interference between the lingual cusps
of the upper and buccal cusps of the lower
molars.
Finally, reaching to a particular diagnosis
differ­e ntial diagnosis of craniofacial pain
must be considered. These include disease
of eyes, ear, nose, throat and teeth. Diseases
of the intracranial structure like brain tumor,
vascular malformation, etc. rheumatic,
neuralgic and causalgic types of pain shall also
be ruled out.
MANAGEMENT
Number of treatments for TMJ disorders
have been advocated, none are effective
for every patient at every time. Effective
treatment selection begins with a thorough
understanding of the disorder and its etiology.
So, the treatment modalities of TMJ disorder
can be divided into symptomatic treatment
and definitive treatment:
Symptomatic Treatment
Symptomatic treatment or supportive therapy
is directed towards altering the patient’s
symptoms and often has no effect on the
etiology of the disorder. This can help in
reducing the acute problem and at a later date
suitable definitive treatment can be under­
taken. Etiologic factors need to be addressed
and eliminated. So long-term treatment
success will be achieved. The two general types
of supportive therapies are pharmacologic
therapy and physical therapy.
470 Essentials of Orthodontics
Pharmacologic Therapy
Pharmacologic therapy can be an effective
method of managing symptoms associated
with many TMJ disorders. Patients should be
aware that medication does not usually offer
a solution or cure to their problems. However,
medication in conjunction with appropriate
physical therapy and definitive treatment does
offer the most complete approach to many
problems. It is a general suggestion that when
drugs are indicated for TMJ disorders they are
prescribed at regular intervals for a specific
period. At the end of this time it is hoped that
the definitive treatment will be providing relief
of the symptoms and the medication will no
longer be needed.
Pharmacologic agents used to treat the
symptoms of TMJ disorders are, analgesic anti-
inflammatory agents (Ibuprofen, Paracetamol,
Diclofenac, Piroxicam, etc.) antianxiety agents
(Valium), muscle relaxants (Carbamaxipine)
and local anesthetics which is beneficial in
localized pain and elimination of myofacial
trigger points (2% lignocaine).
Physical Therapy
It represents a group of supportive actions
that is usually instituted in conjunction with
definitive treatment. It is an important part of
the successful management of TMJ disorders.
Most physical therapy fits into one of two
general categories; modalities and manual
techniques.
Physical therapy modalities represent
the physical treatments that can be applied
to the patients. They can be divided into,
thermotherapy, coolant therapy, ultrasound,
iontophoresis, transcutaneous electrical
nerve stimulation (TENS), acupuncture and
laser. Thermotherapy utilizes that as a time
mechanism which increases circulation to
the applied area leading to reduction of the
symptoms. Likewise, coolant therapy has
proved to be a simple and often effective
method of reducing pain. Cold encourages
relaxation of muscles that are in spasm and
thus relives the associated pain. Common
coolant therapy utilizes a vapor spray (ethyl
chloride and fluoromethane). Ultrasound
is a method of producing an increase in
temperature at the interface of the tissues
and therefore affects deeper tissues than does
surface heat. Not only does it increase blood
flow in deep tissues, it also seems to separate
collagen fibers. So, improves the flexibility and
extensibility of connective tissues. Ultrasound
has also been used to administer drugs through
the skin, by a process known as phonophoresis.
Iontophoresis (like phonophoresis) is a
technique by which certain medications can
be introduced to tissues with low electrical
current.
Electrogalvanic stimulation (EGS) therapy
utilizes the principle that electrical stimulation
of a muscle causes it to contract. A rhythmical
electrical impulse is applied to the muscle,
creating repeated involuntary contractions and
relaxations which help to break up myospasms
as well as increased blood flow to the muscles
resulting in reduction of pain in compromised
muscles tissues. Transcutaneous electrical
nerve stimulation (TENS) is produced by
a continuous stimulation of cutaneous
nerve fibers at a subpainful level. The
electrical activity of it decreases the pain
perception. Acupuncture uses the body’s own
antinociceptive system to reduce the levels
of pain felt. Stimulation of certain areas (or
acupuncture points) appears to cause the
release of endorphins which reduce painful
sensation by subthreshold stimuli. These
effectively block the transmission of noxious
impulses and thus reduce the sensations of
pain. Cold or soft laser has been investigated

for wound healing and pain relief. Though it
is not a routine physical therapy, is thought
to accelerate collagen synthesis, increase
vascularity of healing tissues, decrease the
number of microorganisms and decreases
pain.
Manual techniques are divided into soft-
tissue mobilization, muscle conditioning
and joint distraction. Soft tissue mobilization
consists of superficial or deep massage which
reduces pain perception by mild stimulations
of cutaneous nerve. Deep massage can assist
in mobilizing tissues, increasing blood flow to
the area and eliminating trigger points, Muscle
conditioning is a group of physical therapies
aimed at restoring normal muscle function,
e.g. restricted use, relaxation therapy, passive
muscle stretching, assisted muscle stretching,
resistance exercises, clenching exercises and
postural exercises.
Definitive Treatment
Definitive treatment is aimed directly toward
the elimination or alteration of etiologic factors
that are responsible for the disorders.
Orthodontics
Malocclusion like retroclined upper anterior
teeth, crowded lower anterior with labially
placed central incisor, narrowed maxillary
arch and interferences in balancing side
can cause the condyle to be deflected in its
superior posterior aspect in glenoid fossa and
whole set of problems starts. The objectives
are to correctly the local problems and break
the neuromuscular reflexive displacement
of mandible which is causing the condyle to
deflect posteriorly in the glenoid fossa.
Altering the occlusal table by one reasons
or another in order to rearticulate the condyle
in proper relationship to the disk during
function may not always be enough to provide
Multidisciplinary Orthodontics 471
complete fulltime decompression of the joint
if the residual effects of class II musculature
remain uncorrected and formidable.
Occlusal correction confined exclusively
to the dental apparatus only would allow the
mandible to be positioned forward due to
the guiding surfaces of inclined planes of the
occlusal table during function. But without
the benefits of retraining the muscles of
mastication this may result in mandible being
carried at rest more rearward than it would be
in the ‘sling’ of the unretained musculature
while the mandible is not in function. So
when major TMJ structural imbalances
exist, treatment plans must be constructed
that directly address not only the occlusal
table and its relationship and the structural
status of the internal joint components
and their relationships but also the guiding
forces that beings those factors into play, the
functioning masticatory musculature. All three
components of the maxillofacial triangle, teeth,
bones and muscles must be considered in
every treatment plan. Sometimes, treatment
will take the form of muscles learning while
other times actual muscular retaining by
means of functionally altering their lengths
down to a cellular level must be effected to
properly complete the case that is by splint.
Orthotics (Splints)
Splints of variable types may be used, either
as part of an investigative or diagnostic
procedure or as supplements to larger, more
comprehensive treatment plans due to their
palliative effect. Due to repetitive mandibular
arch of closure, the neuromuscular reflexive
‘memory’ can become so ingrained due to
the frequency of the act that the patient will
close easily to this habitual occlusion every
time. The demands of the proprioceptive
occlusal neuromuscular circuit demand it.
472 Essentials of Orthodontics
The myostatic contracture that foreshortend
the muscles reinforces it. Here, splints allows
for better acceptance of the new impulses of
information to be programmed into the CNS
once occlusion is changed. It acts as a CNS
deprogrammer, a biologic circuit breaker.
Although splints types vary widely, they
are of two basic types. The first is articulated
surface or occlusion capturing type of splints
such as Gelb splints, or Levandoski splints,
which provides a new interdigitating occlusal
surface of acrylic for the teeth to occlude
against the forces the mandible to what is
thought will be new and more biocompatible
position for the musculature upon closure.
The second type is a flat plane or occlusion
eliminating type, e.g. Witzig splint for the
upper arch or Sears pivotal splint for the lower
types is to provide a totally flat surface free
of any inclined planes or cuspal guidances
whatsoever against which an opposing dental
arch might occlude. This allows muscles the
option of closing in a more physiologically
acceptable AP and or lateral arc of closure to a
neutral and more forgiving surface of contact
that is more compatible with their demands,
provided of course that the splint is properly
balanced. The third dimension, vertica, can
be controlled by the thickness of the occlusal
acrylic of these types of splints.
So, use of splint breaks the neuromuscular
reflexive displacement, corrects the muscular
sling to right and brings the disk condyle fossa
relationship to a more physiological state
correcting whole raft of problems.
Surgery
Surgical treatment of TMJ is reserved only for
recurrent and chronic TMJ pain which is not
amenable to other forms of treatment. Surgical
management of TMJ problems can be achieved
by various procedures like eminectomy and
menisectomy.
Conclusion
An understanding of the anatomy of the TMJ
and its function is essential to understand
its related pathology. Malocclusion can be
considered as the prime etiology that ignites
the whole problem of TMJ disorders while other
factors like stress (emotional, psychological)
joins it. As etiology sets in the pathology starts.
Understanding of its pathophysiology is very
important to reach a specific diagnosis. The set
pathology like superior posterior displacement
of condyle or anteromedial displacement of
disk is the key behind all the clinical sign and
symptoms. To treat such conditions Functional
Jaw Orthopedic (splint) shall be cautiously
choosen.
ORTHODONTIC MANAGEMENT
OF CLEFT LIP AND PALATE
Clefts involving the lip and palate are the
most commonly seen congenital deformities
that occur at the time of birth. They are
usually not life- threatening unless associated
with some syndrome having other systemic
compli­cations. Clefts of lip and palate can
occur individually or together in various
combinations. They can also occur along with
congenital defects that affect other parts of
the body.
INCIDENCE
The incidence of cleft lip and palate is found
to be different among different races. Studies
in India reveal an incidence of 1 in every
600 to 1000 births. The Negroid race has the
least incidence (1 in every 2000 births) while
Mongoloids have the highest incidence. Cleft
lip is common among males while cleft palate
is more common among females. Unilateral
clefts account for 80% of the incidence while

bilateral clefts account for the remaining 20%.
Among the unilateral clefts, clefts involving the
left side are seen in 70% of the cases, the reason
for this is unknown.
EMBRYOLOGICAL BACKGROUND
The face is formed by the fusion of a number
of embryonic processes that form around the
primitive oral cavity or stomodeum. Around
the fourth week of the intrauterine life, six
branchial arches develop at the site of the
future neck. The first arch, called the mandi­
bular arch, plays a vital role in the develop­ment
of the nasomaxillary complex.
The mesoderm covering the developing
fore­b rain proliferates and overhangs the
stomo­deum. On the either side of the stomo­
deum is the developing mandibular arch, the
dorsal end of which gives off a bud called the
maxillary process. With the formation of the
nasal pits, the frontonasal process gets divided
into a medial nasal process and two lateral
nasal processes. The upper lip and maxilla
is thus formed by the fusion of the maxillary
process with the medial and lateral nasal pro­
cesses.
The palate is formed by the contribution of
the maxillary process and frontonasal process.
The maxillary process gives off palatal shelves
that grow medially. The union of the two
palatal shelves is prevented initially by the
presence of the tongue. Thus the shelves grow
vertically down. Sometime during the 7th week
of intrauterine lift, the tongue descends and
the palatal shelves become more horizontal. By
around 8½ weeks the two shelves are in close
approximation. The palate forms by fusion
of the maxillary shelves with each other and
with the frontonasal process. Failure of fusion
results in clefts of the palate.
Multidisciplinary Orthodontics 473
The mandibular process gives rise to the
lower lip and jaw. Defective fusion or incom­
plete fusion between the various processes
leads to different types of clefting.
Etiology of Cleft Lip and Palate
Cleft lip and palate are believed to occur due
to genetic and environmental factors. Many
workers are of the view that clefts occur due
to a number of causes and no single etiology
can be pinpointed.
Heredity
Heredity has long been considered an impor­
tant etiologic factor for cleft lip and palate. A
study conducted by Drilien reported that 1 in
3 children with clefts had some relatives with
similar congenital defects. Clefts of the lip and
palate can be transmitted as a dominant or a
recessive trait.
Environment
Another possible etiologic factor is terato­
genesis. Teratogens are certain drugs or agents
that cause disturbed growth and development
in the fetus.
Some of the known teratogens are rubella
virus, cortisone, mercaptopurine, metho­
trexate, valium and dilantin.
Multifactorial Etiology
Recent studies have shown that the etiology of
cleft lip and palate cannot be attributed solely
to either genetic or environmental factors.
It seems to involve more than one factor.
They argue that unless a person is genetically
susceptible, the environmental factors may not
be themselves cause clefts.
Predisposing Factors
A number of factors are believed to increase
the risk of cleft lip and palate incidence:
474 Essentials of Orthodontics
Increased Maternal Age
Women who conceive late have an increased
risk of having an offspring with some form of
clefting. The cause remains unknown.
Racial
Some races are more susceptible to clefts
than others. Mongoloids show the greatest
percentage of incidence.
Blood Supply
Any factor that reduces blood supply to the
naso­m axillary area during embryological
development predisposes to clefts.
Classification of Cleft Lip and Palate
A number of classifications have been put
forward by various authors:
Davis and Ritchie Classification (1922)
This is a morphological classification based on
the location of the cleft relative to the alveolar
process. They have classified clefts into three
groups:
Group I-prealveolar clefts: They are clefts
involving only the lip and are subclassified
as:
• Unilateral
• Bilateral
• Median.
Group II–postalveolar clefts: This group
comprises of different degrees of hard and soft
palate clefts that etend upto the alveolar ridge.
Group III–alveolar clefts: They are complete
clefts involving the palate, alveolar ridge and
the lip. They can be subdivided into:
• Unilateral
• Bilateral
• Median.
Veau’s Classification (1931)
Veau classified clefts into four groups:
Group 1: They are clefts involving the soft
palate only.
Group 2: They are clefts of the hard and soft
palate extending up to the incisive foramen.
Group 3: They are complete unilateral clefts
involving the soft palate, the hard palate, lip
and the alveolar ridge.
Group 4: They are complete bilateral clefts
affecting the soft palate, the hard palate, the
lip and alveolar ridge.
Fogh-Andersen’s Classification (1942)
Group 1: They are clefts of the lip. It can be
subdivided into:
Single—Unilateral or median clefts
Double—Bilateral clefts.
Group 2: They are clefts of the lip and the
palate. They are once again subclassified into:
Single—Unilateral clefts
Double—Bilateral clefts.
Group 3: They are clefts of the palate extending
up to the invisive foramen.
Schuchardt and Pfeiffer’s
Symbolic Classification
This classification makes use of a chart made
up of a vertical block of three pairs of rectan­gles
with an inverted triangle at the bottom. The
inverted triangle represents the soft palate while
the rectangles represent the lip, alveolus and the
hard palate as we go down. Areas affected by
clefts are shadowed on the chart. The advantage
of this classification is its simplicity while the
disadvan­tages include difficulty in writing,
typing and communi­cation.
Kernahan’s Striped “Y” Classification (1958)
This is another symbolic classification put
forward by Kernahan and Stark.
The classification uses a striped ‘Y’ having
numbered blocked. Each block represents a
specified area of the oral cavity.
 Multidisciplinary Orthodontics 475

Block 1 and 4—Lip L = Lip

Block 2 and 5—Alveolus A = Alveolus
Block 3 and 6—Hard palate anterior to the H = Hard palate
incisive foramen S = Soft palate
Block 7 and 8—Hard palate anterior to the H = Hard palate
incisive foramen A = Alveolus
Block 9—Soft palate L = Lip
The boxes are shaded in areas where the This classification is based on the fact that
cleft has occurred. clefts of lip, alveolus and hard palate can be
bilateral while clefts involving the soft palate
Millard’s Modification of the Kernahan are usually unilateral. Areas involved in the
Striped “Y” Classification cleft are denoted by specifically indicating the
Millard added two triangles over the tip of the alphabet standing for it. For example:
“Y” to denote the nasal floor. L—S—stands for cleft of right lip and soft
This increased the number of boxes to 11 palate.
as: LA-S—L stands for cleft of right lip alveolus
Block 1 and 5—Nasal floor and soft palate together with left cleft lip.
Block 2 and 6—Lip
Block 3 and 7—Alveolus Kernahan and Stark’s Classification
Block 4 and 8—Hard palate anterior to the (1968)
incisive foramen This classification is given by International
Block 9 and 10—Hard palate posterior to Confederation for Plastic and Reconstructive
the incisive foramen Surgery. This classification is embryological
Block 11—Soft palate. and has three main groups:

Elsahy’s Modification of the Kernahan’s Group I–Cleft of Anterior Primary Palate

Striped “Y” Classification a. Lip—Right side
Elsahy modified the striped “Y” further by Left side
double lining the blocks 9 and 10 in the hard Bilateral.
palate area and used arrows to indicate the b. Alveolus—Right side
direction of deflection in complete clefts. He Left side
also placed a circle 12 under the stem of the “Y” Bilateral.
to represent the pharynx and a dotted line from
the Y to circle 12 reflecting the velopharyngeal Group II–Cleft of Anterior and Posterior
competence. Another circle 13 was also added Palate
to represent the premaxilla, and the amount of a. Lip—Right side
its protrusion was indicated by the dotted line Left side
with an arrow. Bilateral.
b. Alveolus—Right side
Lahshal Classification Left side
This is a simple classification presented by Bilateral.
Okriens in 1987. Lahshal is a paraphrase of the c. Hard palate—Right side
anatomic area affected by the cleft. Left side.
476 Essentials of Orthodontics

Group III–Clefts of Posterior Secondary – Unilateral—Right, left

Palate – Bilateral
a. Hard palate—Right side – Median
Left side – Congenital scar—Right, left,
b. Soft palate—Median. • Clefts of the alveolar process
– Unilateral—Right, left
Rare Facial Clefts – Bilateral
i. Median clefts of upper lip with or without – Median—Submucous
hypoplasia or aplasia of premaxilla. • Cleft of prepalate
ii. Oblique clefts. – Prepalate protrusion
iii. Transverse clefts. – Prepalate rotation
iv. Clefts or lower lip, nose and other very – Prepalate arrest
rare defects. Any combinations of above.
2. Clefts of palate
American Cleft Palate Association • Cleft soft palate
Classification (1962) (Figs 13.3A to L) – Extent
1. Clefts of prepalate – Palatal shortness—None, slight, sev­
• Cleft lip ere

A B C D

E F G H

I J K L
Figures 13.3A to L: Cleft lip and palate

– Submucous cleft
• Cleft of hard palate
– Extent
– Vomer attachment—Right, left, ab­
sent
– Submucous cleft
3. Cleft of hard and soft palate
4. Clefts of prepalate and palate
Any combinations of clefts described under
clefts of prepalate and clefts of palate.
International Confederation for Plastic and
Reconstructive Surgery Classification (1968)
Group I: Cleft of anterior primary palate
Lip—Right, left, both
Alveolus—Right, left, both
Group II: Clefts of anterior and posterior palate
Lip—Right, left, both
Alveolus—Right, left, both
Hard palate—Right, left, both
Group III: Clefts of posterior secondary palate
Hard palate—Right, left
Soft palate—Median.
Problems associated with clefts: A cleft lip
and palate patient is affected by a number of
problems. They can be broadly classified as:
Dental: The presence of the cleft is associated
with division, displacement and deficiency of
oral tissues. Cleft lip and palate patients can
have one or more of the following features.
Congenitally missing teeth, presence of
natal or neonatal teeth, presence of super­
num­erary teeth, extopically erupting teeth,
anomalies of tooth morphology, enamel hypo­
plasia, microdontia, fused teeth, aberrations in
crown shape, macrodontia, mobile and early
shedding of teeth due to poor periodontal
support, posterior and anterior cross bite,
protruding premaxilla, deep bite, spacing and
crowding.
Multidisciplinary Orthodontics 477
Esthetic Problems
The clefts involving the lip can result in facial
disfigurement varing from mild ot severe. The
oro-facial structures may be malformed and
congen­itally missing. Deformities of nose can
also occur. Thus esthetics is greatly affected.
Hearing and Speech
Cleft lip and palate are sometimes associated
with disorders of the middle ear which may
affect hearing. The presence of hearing
problems can cause difficulties in language
uptake and speech.
Psychological Problems
Cleft lip and palate patients are under lot of
psychological stress. Due to their abnormal
facial appearance they have to put up with
staring, curiosity, pity, etc. They also face
problems in obtaining jobs and making
friends. Studies have shown that these patients
fare badly in academics. This is usually as a
result of hearing impairment, speech problems
and frequent absence from school.
Management of Cleft Lip and Palate
Children born with cleft lip and palate have
a number of problems that have to be solved
for successful rehabilitation. The complexity
of the problem requires that a number of
health care practitioners cooperate to ensure
comprehensive care of the patient. This led
to the concept of a multidisciplinary cleft
palate team comprising of the pediatrician,
pedodontist, orthodontist, oral and maxillo­
facial surgeon, prosthodontist, social worker,
genetic scientist, ENT surgeon, plastic surgeon,
psychiatrist and a speech pathologist.
The individuals of the cleft palate team
should be flexible and respect each others
478 Essentials of Orthodontics
opinion. The cleft lip and palate team has been
described as a close, cooperative, democratic,
multiprofessional union devoted to the single
cause of the patient well-being.
The management of cleft lip and palate can
be divided into the following stages:
Stage I treatment: This comprises of the treat­
ment done from birth to 18 months of age.
The treatment modalities carried out
during the first stage include:
Passive maxillary obturator: The maxillary
obtur­ator is an intraoral prosthetic device
that fills the palatal cleft and thus provides
false roofing against which the child can
suckle. It thus reduces the incidence of feedi­
ng difficulties such as insufficient suction,
excessive air intake and choking. It also provides
maxillary cross arch stability preventing the
arch from collapsing.
The obturator is fabricated using cold cure
acrylic after selective blocking of all unde­
sirable undercuts. Clasps can aid in retention.
In case of insufficient retention, wings made of
thick wire can be embedded in the acrylic and
made to follow the cheek contour extraorally.
These wings can be stabilized against the
cheeks using micropore adhesive tape.
Presurgical Orthopedics
The aim of presurgical orthopedics is to achi­
eve an upper arch form that conforms to the
lower arch. The absence of variable amount
of lip tissue and the division in the alveolus
and palate results in outward displacement
of the premaxilla (in case of bilateral clefts)
or the greater segment (in case of unilateral
clefts). The orthodontist should try to correct
these displacements by extraoral strapping
across the premaxilla, attached directly to the
face or to some form of headcap. A micropore
adhesive tape can also be strapped across the
premaxilla.
In case of a narrow, collapsed maxillary
arch, the expansion can be achieved by a
suitable appliance incorporating expansion
screws or springs.
The advantages of a presurgical orthopedic
phase are:
i. It reduces the size of the clefts thereby
aiding in surgery.
ii. Partial obturation of the cleft assists in
feeding.
iii. Improved speech as size of the defect is
reduced.
iv. It reassures the parents at a crucial time.
Surgical Lip Closure
It is not within the scope of this book to discuss
the surgical procedures undertaken. However
the orthodontist should know at what time
the surgery should be performed. Surgeons
have for a long time disagreed on the timing
of cleft lip surgery. Some prefer early surgery
soon after birth while others recommend a
late lip surgery.
The early school suggests that surgery
should be performed within 45 days of birth.
According to them, the soon after birth there is
a marked immunity to surgical shock. The early
surgery also improves the facial appearance
and therefore improves child acceptance and
reduces parent apprehension.
The late school suggests that surgery should
be postponed till the completion of dentition.
They reasoned that the tissues would be able
to grow and mature thereby giving the surgeon
more muscle mass to work on.
Millard has suggested the rule of ten.
Surgery should not be performed less than 10
weeks of age, when the body weight is not less
than 10 pounds and the blood hemoglobin not
less than 10 gram%.

Surgical Palate Closure
The palatal repair should be attempted between
12 to 24 months of age. This facilitates normal
speech, hearing and improves swallowing. The
palatal repair can be accomplished by using
bone transplants that are taken from rib, iliac
bone, mandibular symphysis, tibial bone or
outer table or parietal bone.
Stage II treatment: This is from the 18th month
to the fifth year of life. It generally corresponds
to the primary dentition stage.
This comprises the treatment carried out
during the primary dentition. The procedures
carried out during this phase are:
i. Adjustment in the intraoral obturator to
accommodate the erupting deciduous
teeth.
ii. To maintain a check on eruption pattern
and timing.
iii. Oral hygiene instructions.
iv. Restoration of decayed teeth.
No orthodontic treatment is usually initi­
ated during this phase as the benefits desired
would be lost as soon as the deciduous teeth
are shed.
Stage III treatment: This includes treatment
that is carried out during the mixed dentition
stage. It spans from the sixth to the eleventh
year of life.
Stage three includes treatment carried
out during the mixed dentition phase. The
orthodontic procedures usually carried out are:
i. Correction of anterior cross bites using
removable or fixed appliances. The
anterior cross bite should be corrected to
avoid functional mandibular displace­
ment and retardation of maxillary
growth due to locked in maxilla. Remov­
able appliances incorporating Z spring
can be used to treat the anterior cross
bite.
Multidisciplinary Orthodontics 479
ii. Buccal segment cross bites are also
treated using quad helix or expansion
screws.
Stage IV treatment: This stage consists of
treatment during the permanent dentition.
The patient is treated using a fixed orthodontic
appliance. All local irregularities like crowding,
spacing, cross bites and overjet or overbite
problems are corrected. Patients with hypo­
plastic maxilla may be given face mask to
advance the maxilla. Prosthesis can be given
in case of missing teeth after completion of
orthodontic therapy.
Retention in Cleft Lip and Palate
Following the orthodontic treatment pro­
cedures, the patient should be put on a
retention phase to maintain the orthodontic
corrections. Most cleft lip and palate patients
require long-term if not permanent retention
for the following reasons:
i. Inadequate bone support
ii. Absence of some teeth
iii. Presence of stretched scar tissue
iv. Abnormal tongue position.
This is a multidisciplinary approach and
made to serve both as retainer and a prosthetic
replacement for missing dental units.
Thus, removable retainer acts as rehabilit­
ation, retention and prosthetic replacement
and speech aid.
Fixed retainers are the fixed anterior
bridge work that spans the cleft and thereby
unifies the segments. Success of this approach
is enhanced with alveolar bone grafts to
bridge the bony segments and to support any
secondary lip or nose revisions planned by the
surgeon. Later bony implants overmaxillay
alveolar process may be advisable and
desirable for cosmetic purpose; in selected
cases cosmetic overdentures can also be given.
480 Essentials of Orthodontics
The key to the successful rehabilitation of a
cleft lip and palate patient includes flexibility
and a multidisciplinary approach. More
than this the patient should be treated with
sympathy and concern.
FAMILY COUNSELING
This helps us to eliminate those clefts with a
pure genetic etiology or have a pronounced
environ­mental or teratogenic involvement
and which will therefore, follow the counseling
based on multi­factorial inheritance.
i. The affected female has a greater chance
of having an offspring than an affected
male, although both have 40 times
greater risk than population incidence
of 1:1000.
ii. More severe the cleft greater the
offsprings are affected.
iii. First degree of relatives has the highest
risk—40 times population incidence.
Inter­m ediate risk in second degree
relatives—7 times whereas it is only
3 times risky in third degree relatives.
iv. Risk for second child to be affected
increases rapidly if one child is already
affected. This rises to 4% for one affected
child to 9% for two affected children
with unaffected parents. But for an
affected parent with one affected child
the risk is 17%.
ORTHODONTIC MANAGEMENT
OF CRANIOFACIAL SYNDROMES
ORTHODONTIC MANAGEMENT OF
CLEIDOCRANIAL DYSPLASIA
Clinical Features
The cleidocranial dysplasia has an inheritance
pattern that is autosomal dominant with a high
incidence of new mutations. The cleidocranial
dysplasia patient is typically of short stature
with a brachycephalic skull and bossing of the
parietal and frontal bones. There is hypoplasia
of midface, the skull sutures and fontanelles
exhibit delayed closure and secondary centers
of ossification occur in these areas, with the
formation of wormian bones. The development
of clavicles is defective and ranges from a small
medial gap to total absence in severe cases.
The palate is narrow and occasionally high
and there is normal eruption and number of
the deciduous teeth. The permanent molars
usually erupt late, but spontaneously. While
the remainder of the permanent dentition,
the successional teeth, exhibits very delayed
or noneruption. Additionally, supernumerary
teeth develop in the successional teeth areas
in numbers that typically vary from none to
around 12 in general. The vertical growth of the
alveolar process is generally deficient, which
leaves the patient with a very shallow labial and
lingual sulcus in both jaws. Reduced eruptive
force, although eruptive tooth movements are
evident. Delayed but normal eruption of first
and sometimes second permanent molars
in both arches. Late dental development as
judged by the root development of permanent
teeth, 12-year-old patient will typically show a
9-year-old patient.
Management
Removable prosthesis: The most popular
approach has been to provide a patient with
removable partial or full dentures, which
fulfills all the immediate needs of the patient.
This is done only after removal of all the
deciduous teeth.
Surgical relocation: Surgical removal of super­
numerary teeth followed by careful dissection
of the unerupted teeth and their repositioning
or transplantation into artificially prepared
sockets has been proposed.

Orthodontics and surgery: The method used
to bring about the eruption of the teeth was
to extract the deciduous teeth, surgically
remove the unerupted supernumerary teeth
and expose the buried permanent teeth with
or without the use of a surgical pack. When the
teeth reaches sufficiently accessible position,
the orthodontic bands or bonds are placed
and assisted eruption is carried out. Within
this modality three different courses of action
have been suggested over the past few years
they are:
Toronto-Melbourne Approach
This method was originated by a team from
Toronto and was later further developed in
Melbourne. Surgical procedures are performed
in a stage by stage series with the degree of root
development of the permanent teeth dictating
the timing of each stage.
Thus, initially the deciduous incisor teeth
are extracted at 6 years of age followed by the
deciduous canines and molars at 9 to 10 years.
Supernumerary teeth overlying the crypts
of unerupted permanent teeth are removed
together with substantial amounts of bone to
uncover the crowns of permanent teeth to their
maximum diameter. The teeth are left widely
exposed, bands are placed in lately erupted
first molars only at the age of 10 to 11 years
and separate surgery is performed to once
again expose the incisors. When convenient
orthodontic brackets are bonded to individual
teeth and these are drawn to a light arch wire,
which spans the unsupported premolar canine
areas, from banded molars to one or more
anteriorly erupted incisors.
Belfast-Hamburg Approach
Simultaneously, but quite independently
Belfast and Hamburg team proposed a
diametrically opposite method of treatment of
Multidisciplinary Orthodontics 481
cleidocranial dysplasia. They recognized that,
while there is the need for extensive surgery,
in these cases, this could all be completed
at one time, including the extraction of all
deciduous teeth and supernumerary teeth and
the exposure of all unerupted permanent teeth.
The remaining teeth are left open to encourage
epithelialization of the exposed tissue, which is
the essence of healing by secondary intention.
During the succeeding weeks, these surgical
packs remain in place and perhaps changed
over a further shortish period, until brackets
may be conveniently bonded to the exposed
teeth. As with Toronto-Melbourne approach,
appliances consist of molar bands, and bonded
brackets with long spans of unsupported and
relatively fine arch wire used to vertically
develop the partially erupted teeth.
Jerusalem Approach
This method was presented in Jerusalem and
is based on rationale that is related to the
abnormal dental development of the patient
and on the factors that produce it.
The timing regarding the actual exposure
of the permanent teeth is critical, and only
two interventions are planned at distinct
points in time, depending upon the extent
of root development, at 7 to 8 years the
anterior deciduous teeth, together with all
the supernumerary teeth in both the anterior
and posterior areas, are extracted. The anterior
permanent teeth whose roots are sufficiently
developed are surgically exposed attachments
are placed immediately and flaps fully closed.
The chronological age of the patient is around
10 to 12 years. At this time posterior permanent
teeth are at an early stage of development, with
their roots less than half their expected final
length. Actual exposure of developmentally
immature posterior permanent teeth is not
undertaken, and their dental follicles are left
482 Essentials of Orthodontics
intact until later time. The vertical corrections
of incisors are completed at this stage of
orthodontic treatment followed by correction
of crowding and proclination and rotations.
Second intervention is done at age of 10 to
11 years (chronological age 13–15years),
because the root development of the posterior
successional teeth will be sufficiently well-
advanced, and eruption and alignment of
the incisor teeth will have been achieved.
This intervention involves the exposure of
the teeth in the canine and premolar regions
and immediate placement of orthodontic
attachments and occlusally directed forces
are applied to the posterior teeth immediately
following the second intervention. Vertical
corrections are first carried out by orthodontic
extrusion of posterior teeth and later the axial
correction and root corrections are carried out.
Retention: Once the permanent teeth have
all reached their final positions in the arch,
the removal of the fixed appliances are
undertaken. After a short period of time
with conventional removable retainers, fixed
multistranded bonded retainers are applied to
upper and lower anteriors.
ORTHODONTIC MANAGEMENT
OF OBSTRUCTIVE SLEEP APNEA
SYNDROME
Obstructive sleep apnea (OSA) occurs because
of recurrent occlusion of the upper airway
during sleep. The majority of patients with OSA
are obese; however, some patients with OSA
are not obese and only a small proportion of
overweight subjects develop OSA. A previous
overemphasis on obesity may have caused
some investigations to overlook other potential
factors that may predispose to this condition.
Classification of OSA into different subtypes
may improve our understanding of the
path­­o­­genesis of this disease. Few attempts
to classify the OSA patient population from
this viewpoint have been reported. Partien et
al subdivided patients with OSA on the basis
of BMI, respiratory disturbance index (RDI),
airway size, and hyoid bone position. However,
the categori­zation was carried out only on a
subjective basis. Lowe et al divided patients
into four skeletal subtypes according to conven­
tional cephalometric criteria and evaluated
airway and two- and three-dimensional
skeletal structures. To our knowledge, this is the
first report to classify patients with OSA on the
basis of an interrel­ationship between obesity
and the severity of OSA.
These two groups may represent different
disease entities. It is suggested that these two
distinct subgroups should not be considered as
one when pathologic or therapeutic approaches
are considered. Surgical procedures such as
uvulopalatopharyngoplasty (UPPP) or mandi­
bular/maxillary osteotomy are frequently
recommended to patients with OSA, but it is
well-known that all patients do not respond to
surgery. Both nasal continuous positive airway
pressure (CPAP) therapy and some dental
appliances are not always effective. According
to our results, the high AI/low BMI group could
respond well to the procedures that advance
the mandible forward. In contrast, weight
reduction and/or UPPP may better contribute
to the improvement of OSA symptoms for the
low AI/high BMI group. In conclusion, these
two groups may represent two distinct OSA
subgroups. The high AI and low BMI group
appears to have a skeletal mismatch that may
contribute to the cause of their OSA, whereas
the low AI and high BMI group appears to have
atypical soft tissue structures.

ORTHODONTIC AND
TEMPOROMANDI­BULAR JOINT
CONSIDERATIONS IN TREATMENT
OF PATIENTS WITH
EHLERS-DANLOS SYNDROME
The Ehlers-Danlos syndrome(s) are a group of
heterogeneous inheritable connective tissue
diseases. They share cardinal features of joint
hypermobility and hyperextensibility, plus
fragility and tendency toward bruising of the
connective tissues, grossly characterized as
excessive elasticity of the skin and laxity of the
joints.
Orthodontic Considerations
When a practitioner considers orthodontic
treat­ment for a patient with EDS, a number
of tissue responses and precautions should
be anticipated. Because of the problems
with tissue repair, slow healing after dental
extractions, slowly forming new bone in
sockets and soft tissue scarring may occur.
The dentist may have to be careful to prevent
dislocation of the mandibular condyles
during treatment. An orthodontic appliance
for a patient with EDS should be smooth and
relatively simple in spring design, so that the
tongue and buccal mucosa are not abraded.
Because of the cross-link defect in collagen, it
can be expected that for a given moment-to-
force ratio, as applied for tooth movement, the
periodontal ligament of a patient with EDS may
show a larger strain than that of a normal child.
It has been shown that when a colla­gen
matrix is stressed in vitro, the prostagl­andin
E2 (PGE2) production of osteocytes grown in
this matrix is altered. Similarly, radioimmuno­
histochemical studies have documented that
cyclic adenosine monophosphate cAMP is
elevated at these tissue sites. This altered
Multidisciplinary Orthodontics 483
level of PGE2 and cAMP related to physical
perturbations may act as a signal to initiate
cell migration and cell differentiation into
osteoclasts. These cells, in turn, produce lactic
acid to dissolve mineral and procollagenase.
The collagenase digests the organic collagenase
proteins and the bone resorbs. Therefore tooth
movement might be expected to be more
rapid for a constant appliance activation. The
mobility of teeth during the tooth movement
phase may be greater than normal.
The tooth mobility may be caused by many
of the stressed periodontal fibers on the tension
side being stretched, torn, or rendered slow in
repair. Similarly, the gingiva may be more prone
to inflammation. In both cases, there may be
an excessive amount of microhemorrhagic
events. With the added dental mobility of
the teeth, slowed repair processes, and poor
organization of periodontal collagen, retention
after completion of the case may be longer.
Although anatomic defects in root structure
have been described in patients with EDS,
the molecular composition of the dentin has
not been studied. If changes do exist, root
resorption could be a problem.
In a recent (subjective) survey study assisted
by the EDS Foundation, patients with EDS were
compared with a control sample of patients
without EDS, with respect to their orthodontic
and temporomandibular disorder experiences.
The results indicated that the majority of those
with EDS types I, III, and VI experienced diffi­
culty in their orthodontic treatment. Those with
EDS type II found it tolerable, with a 25% split
between easy and difficult. The others generally
reported no difficulties. This compared with
a control group that unanimously reported
orthodontic treatment as being either easy
or tolerable. Frequent subluxation of the TMJ
was found in all patients with EDS. This is a
484 Essentials of Orthodontics
particular problem in EDS type II, IV, V and VI
patients. Subluxation was not reported in our
orthodontically treated control sample.
In summary, the Ehlers-Danlos syndrome
is a collection of unusual hereditary connective
tissue diseases that may have many effects
on the dentition and perioral structures of
the patient. With suitable understanding of
the underlying disease manifestations and
appropriate precautions, most dental treat­
ments can be done with minimal untoward
effects.
ORTHODONTIC MANAGEMENT
OF MEDICALLY COMPROMISED
PATIENTS
Orthodontics is a dynamic and exciting speci­
alty of dentistry. The nature of the orthodontic
patient base continues to evolve, and the
practicing orthodontist will be increasingly
challenged to assist in the diagnosis and
management of patients with special medical
needs.
It has generally been accepted that dental
procedures performed without appropriate
precautions on patients with predisposing
conditions, such as rheumatic heart disease,
congenital cardiac malformations, previous
cardiac surgery and the use of prosthetic
heart valves, may lead to the development
of infectious endocarditis. Diabetes, hyper­
tension, rheumatoid arthritis and other sys­
temic diseases are taken care so that no further
complication arises.
MANAGEMENT OF PHYSICALLY
HANDICAPPED CHILD
A handicapped child is one who has a mental-
physical or social condition that prevents
the child from achieving full potential when
compared to other children of same age.
Initial dental examination is similar as for
general child; first appointment sets a stage
for subsequent appointments by scheduling
the patient early in the day and by allowing
sufficient time to talk with the parents and
the patient before initiating any orthodontic
treatment, thus the orthodontist can establish
a good relationship with the parent and
patient.
Radiographs are essential for treatment
planning, assistance from parents and
auxiliaries are required. Preventive dental
programs is essential for an handicapped child
because of predisposing social economic,
physical and medical factors that make good
dental care harder to obtain even though it
is necessary they may formulate a individual
program adequate communication is vital.
The parents have the initial responsibility for
establishing good oral hygiene in the home.
Reinforcement is provided through mass
media communication with other people and
school activities. Home dental care should
begin in infancy; the dentist should instruct the
parents to gently cleanse the incisors daily with
a soft cloth or a infant toothbrush. Wrapped
tongue blades helps to keep the childs mouth
open on plaque removal.
Encouraging the child in its ow n
responsibility is must. Parents should supervise
the child, brushing in child must be simple
and effective. Horizontal scrub technique
is easy and gives good result. It consist of
gentle horizontal strokes on cheek, tongue
and biting surfaces of all teeth and gums with
a soft multituted brush, gripes at the end of
toothbrush helps in custom design handle
and gives good results. Riley plaque score
(RPS) provides determination of patients
assessment.

Diet and nutrition influence the dental
caries and malnutrition; fluoride therapy
should be instituted with use of fluoride
dentifrices. Regular dental examinations are
essential professional prophylaxis; restorations
and topical fluoride therapy are required.
Management of Handicapped Child
during Dental Treatment
Hospital visits and previous appointments
with a physician frequently results in the
development of apprehension in patient.
Additional time with parent and child is
necessary to establish rapport and dispel
childs anxiety. If cooperation cannot be
obtained dentist considers physical restraints
and premedication to perform necessary
procedures.
Management of Deaf Child
Prepare the patient and parent before first
visit via welcome board. Through parent
determining the initial appointment has the
patient desires to communicate. Assess speech
and language ability and impairment. Face the
patient and speak at a natural pace, lip reading
is for 30 to 40% success. Watch the patient’s
expression and to understand, reassure the
patient with physical contact hold patients
hand initially and tap on shoulder. Employ
tell show do technique allow patient to use the
instruments and demonstrate how they work.
Use smiles and reassuring gestures to build up
confidence and reduce anxiety. Avoid blocking
patient’s visual field. Adjust the hearing aid.
Management of Blind Child
Determine the degree of visual impairment.
Find out the companion and interpretor. Avoid
expressions of pity or references to blindness.
Do not grab, move or stop the patient without
verbal warning. Describe the office setting;
Multidisciplinary Orthodontics 485
always give adequate descriptions before
any procedures. On physical contact do so
reassuringly. Introduce other office personnel
very informally. Allow patients to ask questions
about the course of treatment and answer
them, keeping in mind that the patient is highly
individual sensitive and responsive. Allow a
patient who wears eye glasses to keep them
for protection. Avoid sight references. Rather
than Tell show do techniques invite the patient
to touch, taste or smell recognizing senses.
Describe in detail the instruments and objects.
Demonstrate a rubber cup or the patient’s
fingernail. Holding the patients hand often
promotes relaxation. Use dental materials
with smaller quantities. Explain procedures
of oral hygiene and assist brushing. Use audio
tapes and Braille dental pamplets explaining
sufficient information. Announce exits and
entrances cheerfully, keep minimal avoid
unexpected noices. Limit the dental care to
one dentist. Maintain a relaxed atmosphere.
MANAGEMENT OF ORTHODONTIC
PATIENTS WITH A HISTORY
OF RHEUMATIC FEVER OR
CONGENITAL HEART DISEASE
Endocarditis is defined as an inflammation
of the endocardium (lining membrane of
the heart). It may involve only the mem­
brane covering the valves (valvular) or the
general lining of the heart (mural). When
the endocardium becomes infected with
microorganisms that have entered the cir­
cul­a tion (via dental procedures, through
the gingiva, and/or the oral mucosa), the
progressive destruction of the endocardium
may lead to anemia, toxemia, and ultimately
cardiac failure, the most common cause of
death in these patients.
486 Essentials of Orthodontics
The orthodontic procedures considered
likely to need antibiotic coverage were banding,
manipulation of an attachment to an impacted
tooth and debanding. Any oral procedures that
would cause bleeding may be considered a risk
to these patients.
It is preferable that oral hygiene be maxi­
mized before orthodontic procedures are
undertaken. The oral hygiene aid devices most
frequently recommended were the toothbrush
and the Water-Pik. Dental floss, Perio-aid,
tongue scraper and diet control can be used.
When at-risk patients developed gingivitis
during the course of orthodontic treatment,
their treatment was discontinued.
Patients are more susceptible to gingival
tissue problems when orthodontic appliances
are placed. Oral hygiene and periodontal
conditions should be closely scrutinized
since the American Heart Association stated:
“Even in the absence of dental procedures,
poor dental hygiene or other disease such
as periodontal or periapical infections may
induce bacteremia.”
The American Heart Association further
suggested that the toothbrush, floss, disc­
losing tablets, diet control, and fluoride be
used. In these patients dental floss should
never be snapped into the gingivae but should
be moved carefully up and down, scraping
the sides of the tooth. Mention was made that
oral irrigation devices may cause bacteremia
and that patients should check with their
physicians before using such devices.
Although intravascular localization of
microbes was a rare event, considering
the frequency of bacteremia, it has been
demon­s trated by Morgan and Bland that
there was an 8 to 9% recurrence rate of
bacte­r ial endocarditis in patients with a
previous episode. Premedication for routine
appointments such as changing of orthodontic
arch wires is not necessary but depends
upon the judgment of the dentist and the
maintenance of good oral hygiene by the
patient. It should be noted that “home-
care” procedures, such as flossing (which is
accompanied by bleeding), should be cause
for concern and the patient’s physician may
be consulted. However, bacterial endocarditis
associated with the use of dental floss has not
been reported. Similarly, the spontaneous
loss of deciduous teeth has not been shown
to cause bacteremia.
ORTHODONTIC MANAGEMENT
OF PATIENTS WITH BLEEDING
DISORDERS
Patients with mild bleeding disorders do not
pose many problems to orthodontist. However,
those with severe bleeding disorders will
pose problems during orthodontic treatment.
In addition to hemophilia A, a number of
congenital coagulation disorders due to other
clotting factors have been recognized. As the
prevalence of malocclusion in these children
is similar to the rest of the population and
the long-term outlook is good orthodontic
treatment is often requested. Patients with
hemophilia and related bleeding disorders
require special consideration in two areas.
The majority of patients with severe
hemophilia who were treated with appropriate
concentrates had evidence of infection
with either hepatitis C or HIV from human
derived concentrates. However, the continued
use of concentrates, despite careful donor
selection and screening, and improved
methods of manufacture, still carries a small
risk of transmitting serious transfusion
derived viral infection. Most patients with
moderate to severe hemophilia A require
Factor VIII concentrate infusion before oral
surgical procedures. The recent introduction of

genetically manufactured Factor VIII products
and their current widespread use in affected
children have further reduced the risk of viral
transmission.
Generally orthodontic treatment is not
contraindicated in children with bleeding
disorders. If tooth extraction or other surgery
is required in patients with severe bleeding
disorders they are usually hospitalized and
given transfusions of the missing clotting factor
in advance of the procedure. Where possible a
non-extraction approach should be adopted.
Special Orthodontic Considerations
1. It is desirable to prevent gingival bleeding
before it occurs. This is best achieved by
establishing and maintaining excellent oral
hygiene.
2. Chronic irritation from an orthodontic
appliance may cause bleeding and special
efforts should be made to avoid any form
of gingival or mucosal irritation.
3. Arch wires should be secured with
elastomeric modules rather than wire
ligatures, which carry risk of cutting the
mucosal surface. Special care is required
to avoid mucosal surface. Special care
is required to avoid mucosal cuts when
placing and removing arch wires.
4. The duration of orthodontic treatment for
any patient with a bleeding disorder should
be given careful consideration. The longer
the duration of orthodontic treatment the
greater the potential for complications.
ORTHODONTIC MANAGEMENT OF
PATIENTS WITH HEMATOLOGIC
MALIGNANCIES
Given the age range of the majority of ortho­
dontic patients, it is important that the
Multidisciplinary Orthodontics 487
orthodontist understand the basic manage­
ment of hematologic malignancies and specific
considerations in orthodontic treatment of
these patients. Treatment of malignancies is
advancing rapidly. With an understanding of
the fundamental disease and the therapy for
hematologic malignancies, the orthodontist
can be a positive part of the health care team
and support a family in crisis.
Role of the Orthodontist
Not all patients show intraoral signs of
hematologic malignancy. Although oral
symptoms do not play a major role in the
diagnosis of chronic leukemia, it has been
reported that between 12 and 17% of patients
with acute leukemia first sought medical care
because of an oral problem. Oral changes
that should raise the orthodontist’s index
of suspicion are gingival oozing, petechiae,
hematomas, ulcerations, gingival pain, gingival
hypertrophy, mucosal pallor, pharyngitis, and
lymphadenopathy. Referral to a physician is
indicated for patients exhibiting these oral
symptoms without evidence of accompanying
local causative factors.
Once a diagnosis of malignancy has been
made, the goal of the dental team, including the
orthodontist, is to prevent and to eliminate oral
infections for these patients. Patients receiving
chemotherapy have increased predisposition
to infection; infection is the leading cause
of death in immunocompromised patients.
Elimination of infectious foci that cause
septicemia is preferable to treatment for
infection. The prevalence of a probable or
possible oral origin of septicemia in the
immunosuppressed population has been
reported as 31%.
The orthodontist should be aware of the
implications of the presence of a preexisting
infection in a patient about to undergo
488 Essentials of Orthodontics
chemotherapy. This point should be reinforced
with the family dentist who must evaluate for
any potential source of infection including the
possibility of pericoronitis around erupting
third molars. If a potential source of infection
is identified, the physician must be consulted
since one must weigh the risk of the infection
versus the delay in initiation of chemotherapy
necessitated by the dental treatment.
It is important that the orthodontist contact
the patient’s physician for a realistic appraisal
of the prognosis. This prognosis should be kept
in mind in all contact with the patient and the
family. Given the generally good long-term
prognosis of most hematologic malignancies,
the orthodontist can be relatively upbeat and
positive in interactions although this must
be counter-balanced with the reality of the
seriousness of the disease. The time of diag­
nosis is very stressful for the patient and the
family, and they may react with anger at the
situation. All health care providers should be
sensitive to these emotions.
It is difficult for an orthodontist to discon­
tinue treatment on a patient who is only part
way through orthodontic treatment and, in
the early stages of hematologic malignancy,
may not be exhibiting any oral symptoms.
Chemotherapy usually causes significant oral
complications. Orthodontic appliances cause
stress to the oral mucosa and ulcerations
may occur in reaction to the slightest oral
insult because the neutropenia resulting
from chemotherapy impairs the regenerative
capability of the mucous membrane. Mucositis
may progress from swelling, soreness and
whitening of the mucosa to glossitis, cheilitis,
and stomatitis, which can be so severe that
morphine or meperidine is required for
palliation of pain. Moniliasis is common. Oral
infection by opportunistic organisms may also
occur. Xerostomia can be a side effect from
chemotherapy or the radiation treatment given
before bone marrow transplant.
Patients and their families sometimes resist
the recommendation to terminate orthodontic
treatment. Ideally, there should be a joint
consultation among all the parties involved—
patient, parents, physician, family dentist, and
orthodontist—before discontinuing treatment
so that everyone is in agreement that what is
being done is in the best interest of the patient.
It should be stressed that the orthodontist is
not “giving up” on the patient when halting
treatment. In situations with a good prognosis,
the emotional acceptance of appliance removal
may be enhanced by a careful selection of
words by the orthodontist. The appliance
removal can be presented as a transition point
that divides the orthodontic treat­ment into
two distinct stages. The patient’s comfort and
safety during all phases of chemotherapy are
enhanced if all fixed appliances are removed.
Removable retainers should fit well so they do
not become a source of irritation, ulceration
and infection.
Orthodontic treatment is an elective
procedure for most patients. For patients
undergoing treatment for hematologic
malignancies, the risk benefit balance is
heavily weighted against ongoing orthodontic
treatment. Once a patient has completed
chemotherapy and is in long-term remission,
orthodontic treatment can be restarted with
the goal of achieving the originally planned
outcome of orthodontic treatment.
ORTHODONTIC MANAGEMENT
OF PATIENTS WITH ENDOCRINE
DISORDERS
The endocrine system is an important consi­
deration for adult patients, many of whom are

osteopenic, because hormones help control
calcium metabolism and bone remodeling.
Hyperthyroidism and hypothyroidism will
alter the bone resorption patterns and hence
orthod­ontic treatment should be undertaken
with caution. Hyperparathyroidism will
increase bone resorption and the orthodontic
treatment are usually contraindicated in these
patients.
ORTHODONTIC MANAGEMENT OF
PATIENTS WITH DIABETES
Diabetes mellitus (DM) is diagnosed in 3 to
4% of the population. This metabolic disorder
is characterized by hyperglycemia caused by
the body’s deficient management of insulin.
Two main types of DM exist: type1 is a total
deficiency in insulin secretion, and type
2 is a combination of resistance to insulin
action and inadequate compensatory insulin
secretion. Diagnosis and monitoring of DM
is based on blood glucose concentration or
glycosylated hemoglobin concentration. The
dental practitioner should be aware of the oral
manifestations of DM in order to spot initial
symptoms of the disease. When treating DM
patients, the practitioner must understand
the consequences of the disease in relation to
dental treatment.
Orthodontic Considerations
Having knowledge of the oral complications of
DM, the dental practitioner should consider
them when treating a DM patient; the key to
any orthodontic treatment is good medical
control. Orthodontic treatment should not
be performed in a patient with uncontrolled
diabetes. If the patient is not in good metabolic
control (HbA1c – 9%), every effort should
be made to improve blood glucose control.
Multidisciplinary Orthodontics 489
For DM patients with good medical control,
all dental procedures can be performed
without special precautions if there are no
complications of DM.
There is no treatment preference with
regard to fixed or removable appliances.
It is important to stress good oral hygiene,
especially when fixed appliances are used.
These appliances might give rise to increased
plaque retention, which could more easily
cause tooth decay and periodontal breakdown
in these patients. Daily rinses with a fluoride-
rich mouth rinse can provide further preventive
benefits. Candida infections can occur, and
then blood glucose levels should be monitored
to rule out deterioration of the DM control.
Diabetes-related microangiopathy can
occasionally occur in the periapical vascular
supply, resulting in unexplained odontalgia,
percussion sensitivity, pulpitis, or even
loss of vitality in sound teeth. Especially
with orthodontic treatment when forces
are applied to move teeth over a significant
distance, the practitioner should be alert to
this phenomenon and regularly check the
vitality of the teeth involved. It is advisable
to apply light forces and not to overload
the teeth. Holtgrave and Donath studied
periodontal reactions to orthodontic forces.
They found retarded osseous regeneration,
weakening of the periodontal ligament, and
microangiopathies in the gingival area. They
concluded that the specific diabetic changes
in the periodontium are more pronounced
after orthodontic tooth movement. Because
DM patients, and especially those who are
uncontrolled or poorly controlled, have a
higher tendency for periodontal breakdown,
they must be considered in the orthodontic
treatment plan as periodontal patients and
treatment considerations must accordingly
be made. Especially in adults, it is important,
490 Essentials of Orthodontics
before starting orthodontic treatment, to
obtain a full-mouth periodontal examination
including probing, plaque, and gingivitis
scores, and to evaluate the need for periodontal
treatment. The periodontal condition must be
improved before beginning any orthodontic
treatment. During orthodontic treatment, the
orthodontist should monitor the periodontal
condition and control inflammation. As with
all orthodontic patients, maintaining strict oral
hygiene is very important. If plaque control
is difficult to achieve with mechanical aids
such as toothbrush and interdental brush,
then using a disinfectant mouth rinse of the
chlorhexidine type as an adjuvant chemical
plaque control can be considered. To minimize
the neutralizing effect of the toothpaste on
the chlorhexidine molecule, there should
be at least a 30-minute interval between
toothbrushing and the chlorhexidine rinse.
Chlorhexidine is cationic and forms salts of low
solubility with anions, resulting in a reduced
antimicrobial effect. Such an anionic is sodium
lauryl sulphate, which is widely used as a
detergent in toothpaste. Because today there is
no upper age limit for orthodontic treatment,
the practitioner will see both type 1 and type 2
DM patients. Type 2 patients can be considered
more stable than type 1 patients, who can be
presumed to be “brittle”: strict compliance
with the medical regimen is of the utmost
importance to maintain control of blood
glucose levels. Deviations from appropriate
diet and the schedule of insulin injections will
result in distinct changes in the serum glucose
level. Hypoglycemic reactions might occur
more often in these patients. Type 1 DM is more
often encountered in younger patients who
frequently come for orthodontic treatment.
Morning appointments are preferable. If a
patient is scheduled for a long treatment
session, e.g. about 90 minutes, he or she should
be advised to eat a usual meal and take the
medi­cation as usual. At each appointment,
before the dental procedure starts, the dental
team should determine whether the patient
has fulfilled these recommendations, to avoid
a hypoglycemic reaction in the office.
DM and especially uncontrolled DM,
is potentially life-threatening as result of a
hypoglycemic reaction. Dental practitioners
must recognize the symptoms and diagnostic
aspects of DM. A patient’s medical history is
crucial in the clinical examination. Any patient
suspected of having DM should be referred for
medical evaluation. Well-controlled DM is not
a contraindication for orthodontic treatment.
During treatment, special attention is required
with regard to periodontal problems.
Patients should be told about the greater
propensity for gingival inflammation when
fixed appliances are planned and the
importance of maintaining good oral hygiene
to prevent the progression of periodontal
breakdown. Especially in type 1 DM patients
who are presumed to be more brittle, the oral
cavity must be monitored regularly because
they are more prone to gingivitis, periodontal
breakdown, and candida infections. When a
type 1 patient frequently has hypo­glycemic
comas, one can assume that the diabetic state
is not well-controlled. The physician should
try to obtain better glycemic control. If during
orthodontic treatment signs of deterioration
of the glycemic control are noticed, the
orthodontist should advise the patient to
consult his or her physician. Orthodontic
treatment should be avoided in patients
with uncontrolled or poorly controlled DM.
Patients with good metabolic control, without
local factors such as calculus, and with good
oral hygiene, have a similar gingival status
as healthy patients and thus can be treated
orthodontically.

ORTHODONTIC MANAGEMENT
OF PATIENTS WITH CYSTIC
FIBROSIS
Cystic fibrosis is an autosomal recessive disor­
der of the exocrine glands. It is the commonest
inherited disease among Caucasians with
an incidence of one in 2500 live births. The
main clinical manifestations of cystic fibrosis
relate to changes in the mucous glands of
the pulmonary and digestive systems. Males
and females are equally affected. Males tend
to live longer and are usually infertile. The
lungs are invariably involved and there is
a nonproductive cough that leads to acute
respiratory infection, bronch­opneumonia,
bronchiectasis, and lung abscesses. The
disease pursues a relentless course and until
recently, the life expectancy was not much
more than the second decade. Heart and lung
trans­plantations have proved successful in a
small group of patients with respiratory failure.
The current median survival for subjects with
cystic fibrosis is 30 years.
Orthodontic Considerations
1. Before contemplating orthodontic
treatment for patients with cystic fibrosis
the patient’s physician should be contacted
to determine the severity of the problem
and the likely prognosis.
2. General anesthesia should usually be
avoided and any orthodontic extractions
should be delayed until an age when
extraction under local anesthesia is
feasible. Local anesthesia combined with
inhalation sedation has an important
role to play in the management of these
children.
3. It has been suggested that for the majority
of these children only limited orthodontic
treatment should be contemplated.
However, life expectancy varies and
Multidisciplinary Orthodontics 491
orthodontic management will depend on
the general prognosis of each individual
case.
4. It should also be remembered that salivary
glands, particularly the submandibular
glands are often affected by cystic fibrosis.
Salivary volume can be reduced and there
may be an increased risk of decalcification
during orthodontic treatment, due to
changes in saliva or dietary alterations.
Appropriate preventive measures must be
instigated from the outset including dietary
advice and daily fluoride mouth rinses.
ORTHODONTIC MANAGEMENT
OF PATIENTS WITH JUVENILE
RHEUMATOID ARTHRITIS
Juvenile rheumatoid arthritis (JRA) is an
inflam­m­­atory condition occurring before
the age of 16 years and now embraces Still’s
disease. It is a variable condition with several
clinical sub­g roups. Although uncommon
compared with adult rheumatoid arthritis, at
its worst, this is considerably more severe than
the adult disease and leads to gross deformity.
One form of this disease which affects girls in
late childhood may involve virtually any joint
and is associated with rheumatoid nodules,
mild fever, anemia and malaise. Damage to the
TMJ has been described, including complete
bony ankylosis. It has been suggested that
restricted growth of the mandible resulting in
a severe Class II jaw discrepancy occurs in 10
to 30% of subjects with this form of arthritis.
Classic signs of rheumatoid destruction of the
TMJ include condylar flattening and a large
joint space.
Orthodontic Considerations
1. If the wrist joints are affected these patients
can have difficulty with toothbrushing.
492 Essentials of Orthodontics
They may require additional support
from a hygienist during their orthodontic
treatment and the use of an electric
toothbrush should be considered.
2. Some authors have suggested that ortho­
dontic procedures that place stress on the
TMJs such as functional appliances and
heavy Class II elastics should be avoided
if there is rheumatoid involvement of the
TMJ. Instead, consideration should be given
to using headgear to treat children with
rheumatoid arthritis who have moderate
mandibular deficiency. However, others feel
that functional appliances may unload the
affected condyle and act as a joint protector.
3. It has been suggested that in cases of severe
mandibular deficiency mandibular surgery
should be avoided and a more conservative
approach using maxillary surgery and
genioplasty should be considered.
ORTHODONTIC MANAGEMENT OF
PATIENTS WITH RENAL FAILURE
Chronic renal failure may be due to a variety
of causative factors, which leads to a loss of
kidney function. Initially, treatment may involve
dietary restriction of salt, protein and potassium
depending on the degree of renal failure. As
the disease progresses, conservative medical
management may be inadequate, and either
artificial filteration of the blood by dialysis
or transplantation of a kidney is required. In
children with chronic renal failure growth can
be retarded and tooth eruption delayed.
Orthodontic Considerations
Three types of patients with renal problems
may be referred for orthodontic treatment:
Patients with chronic renal failure who are not
dialysis dependent: The orthodontist should
consult with the patient’s physician and
orthodontic treatment should be deferred
if the renal failure is advanced and dialysis
is imminent. If the patient’s disease is well-
controlled orthodontic treatment can be
considered.
Orthodontic care for patients on dialysis: Most
children wait less than 18 months for kidney
transplant. The majority of children receive
their dialysis at home using the continuous
ambulatory peritoneal dialysis (CAPD)
technique. Again, the orthodontist should
discuss any proposed orthodontic treatment
with the patient’s physician. There is no major
contradiction to orthodontic treatment in
these children. Indeed, if it is possible, there
may be merit in commencing orthodontic
treatment prior to kidney trans­p lantation
before immunosuppression creates problems
with gingival overgrowth.
Children who have received their kidney
transplant : Renal transplant units use
c o mb i nat i o n o f i m mu n o su p p re ssa nt
drugs such as azathioprine, prednisolone,
cyclosporin, tacrolimus and mycophenolate
mofetil to prevent graft rejection. These
patients may also receive calcium channel
antagonists such as amlodipine or nifedipine.
Children with renal transplants often exhibit
drug-induced gingival overgrowth as a
consequence of their long-term medication.
There is large individual variation in the extent
of gingival hyperplasia seen in these patients.
Orthodontic appliances, especially fixed
appliances, can produce a dynamic response
in the gingival tissues even when no gingival
overgrowth is present before orthodontic
treatment.

The following treatment approach is
recom­mended:
1. Prior to commencing orthodontic treat­
ment all renal transplant patients should
be examined to assess the extent of drug
induced gingival overgrowth.
2. Orthodontic treatment should not comm­
ence until the oral hygiene is very good and
the use of 0.2% chlorhexidine mouthwash
is advisable in these patients.
3. If gingival overgrowth is present orthodontic
treatment should be delayed until the
excessive gingival tissue has been surgically
removed and the patient can demonstrate
an adequate level of plaque control.
4. As far as possible, the treatment time
with fixed appliances should be kept to a
minimum consistent with a high standard
of occlusal result.
5. These patients should be seen on a regular
basis by a hygienist during the course of
their orthodontic treatment.
6. In some patients recurrence of gingival
overgrowth may be a problem. Surgical
removal of excessive gingival tissue is
sometimes necessary during orthodontic
treatment. The patient and parents should
be warned of this in advance.
FORENSIC ORTHODONTICS
FORENSIC DENTISTRY
Forensic dentistry is one of the most rapidly
developing branch of forensic medicine and
forensic science. This is mainly due to the
immense importance of dental evidence in
the identification of victims of mass disaster,
abuse or organized crimes. A comprehensive
understanding of this science is absolutely
necessary for the orthodontist. They can play
a valuable role by helping the forensic experts
in identifying the affected victim or criminal.
Multidisciplinary Orthodontics 493
Definitions
Forensic medicine: Forensic medicine is
defined as the branch of medicine wherein
the knowledge of medicine is applied to the
knowledge of law in order to derive justice
(Rao 2000).
Forensic science: Forensic science is a study of
physical information connected with crimes
or collection of evidences by scientifically
examining the objects or substances that are
involved in the crime.
Forensic odontology: Forensic odontology is
defined as the branch of the dentistry which
in the interest of the law, deals with the proper
handling and examination of dental evidence
and the proper evaluation and presentation of
such evidence (Kieser Neilson 1981).
History: Forensic dentistry, though a relatively
new area of forensic science, has a long history
that starts from 2500 BC. When the first
evidence was found in the pyramid of Giza in
Egypt, in a skull with a gold wire holding two
molar teeth. In 70 AD, at Rome, the dental
findings being used as evidence first time in
forensic manner where the king Nero had
killed his mother who was identified by two
maxillary canine teeth.
Major Fields of Forensic Odontology
1. Civil—Noncriminal
a. Identification of an individual remains
where death is not due to any suspicious
circumstances. This covers majority of
the work expert carry out.
b. Mass disastes identification of victims of
hotel fires, aircraft and other transport
accidents.
c. Craniofacial superimposition for iden­
tifi­­cations
2. Criminal
a. Identification of persons from their
dentition or teeth (Living persons or
dead persons)
494 Essentials of Orthodontics
b. Dealing with bite marks identification
(Food stuff, the victim)
3. Research
a. Academic training courses
b. Postgraduate training.
ROLE OF ORTHODONTIST
The most significant role is of an orthodontist
is to create awareness of this specialty in the
society. The other common areas of interest
of an Orthodontist in Forensic odontology
include:
1. Child abuse/neglect: In the recent time
with introduction of Child Protection
Act and increase trends towards modern
lifestyle, both child abuse and neglect are
on the verge of increase. The orthodontist
who handles children is required by law
in abuse and neglect. A conscious effort
should be made to eradicate completely
this highly criminal activity in the society.
2. Mass disaster: Aircraft accidents are one
of the common causes of most of the
disasters worldwide. The task of identifying
is very complicated. The vast numbers
of victims are burnt, decomposed and
mutilated. Therefore, these cases can be
systematically examined and identified
skillfully by the dentist as the previous
records show that when trained experts are
utilized, the identification rates are high
and accurate.
3. Accidental and nonaccidental oral trauma:
Another area is which the dentist can paly
an important role is in the examination of
children who have sustained accidental and
non-accidental trauma involving orofacial
structures via accident, negligence,
malpractice or child abuse. In such cases,
a detailed and accurate examination
supported with tests, radiographs and
photographs will be required by the
inquiring agency as often these cases are
challenged in the court.
4. Dental fraud: Dental fraud is another
emerging area of litigation. With the
introduction of Consumer Protection Act,
the orthodontist is required to examine
patients carfully and records are to be
maintained properly to defend himself
if needed. Also records are to determine
whether a treatment paid for by a third
party has actually been performed or not.
5. Age determination: In routine identification,
determination of age of the unknown
remains in various stages of decomposition
or recog­n ition of the accused person
who is suspected in the crime is vital.
Since, the tooth is the only tissue that can
resist the highest temperature and other
decomposition changes, age determination
with the help of human dentition or their
bite marks have proved to be of great
importance.
6. Bite marks evidence: The bite marks
investigation is equally important and
interesting for the orthodontist. Until
recent times the bite marks produced by
suspect were looked upon by the other
investigators as bruises. However, through
constant education, these marks have been
recognized for what they are.
7. Lip and tongue print identification: The role
of the skin as a repository and marker of
evidence is evaluated in identification of
victims and suspects and it is found that
no two individuals have the same patterns
of the skin on the lip and tongue. Thus,
the application of Cheiloscopy is being
developed in identification by use of lip-
prints.
8. Poisoning: Various metallic poisonings
may have manifestations in the oral cavity.
They are most commonly associated

with a metallic taste and a nonspecific
ulcerative gingivitis, accompanied by
varying amounts of pigmentation. With
child labor still a menace in certain parts
of the country, an alert Orthodontist
may come across cases of chronic metal
poisoning and should be able to diagnose
it by the clinical signs and symptoms,
coupled with history.
9. Dental records: Teeth are unique in
individuality, resistant to destruction and
their records can be maintained well along
with noting of developments variations
and appliances delivered if any to children.
Thus, routine findings of the patients
preserved in the form of their radiographs,
photographs and study models are often
used for identification.
DERMATOGLYPHICS
Dermatoglyphics (Derma-skin; glyphe-curve)
implies the study of dermal ridges seen on the
palmar and plantar surface. Dermatoglyphics
as a science has multiple applications
in various fields such as criminology,
anthropology, cyto­g enetic studies, etc. Its
main advantages being that it is cost effective,
does not require extensive equipments and is
atraumatic. Dermal ridges appear at 12 weeks
of intrauterine life and are established by the
24th week. Thereafter, they remain constant.
The fact that development of teeth and
palate occur during the same period as the
development of dermal patterns, led to an
extensive research to establish the genetically
congruent factors affecting both. It is a known
fact that any factor active during the time
Multidisciplinary Orthodontics 495
period of genetic expression is bound to affect
all the developing structures. Hence, deviation
from normal occlusion due to extraneous
factors at the time of development will also
reflect in the dermal patterns.
Dermatoglyphic patterns are studied by
rolling complete palm and fingerprints of
both hands on a smooth white paper by ink
and roller method as suggested by Cummins
and Midlo. The palm and fingerprints of the
individuals were studied under the following
headings:
1. Type of pattern on the fingers of both right
and left hands
2. Total finger ridge count (TFRC)
3. a-t-d angle of each hand
4. t-a-b angle of each hand
5. a-b ridge count of each hand
6. Presence or absence of patterns in
hypothenar area, thenar or first interdigital
area and I2, I3, and I4 interdigital areas.
Conclusions that have drawn from these
dermal patterns include:
i. When compared with normal occlusion,
Class I and Class III malocclusions are
associated with an increased frequency of
whorls at the expense of ulnar loops and
Class II Div.1 malocclusions are associated
with an increased frequency of ulnar loops
at the expense of whorls. Both Class I and
Class II Div.1 malocclusions are associated
with an increased frequency of radial loops
and arches. While the arches decrease in
Class III malocclusions, the radial loops
remain the same.
ii. There is an increased frequency of
patterns in the hypothenar area in all
the malocclusion groups as compared to
normal occlusion.
496 Essentials of Orthodontics
CHAPTER
Community
14 Orthodontics
ORTHODONTIC PRACTICE
When orthodontists are asked to describe what
their job is, some will say, “I am an Orthodontist.
My job is to straighten teeth.” Others will say,
“I am a Dentofacial Orthopedist” still others
will say, “I offer a service. I improve people’s
appea­rance, function, and oral health.” Some
may go a step beyond and say, “I do all that,
and through all that I help people to have
happier, healthier, more productive, more
successful, more satisfying lives.” Some may
take a different tack and say, “I make a good
living for myself and my family” and some may
say, “I am a manager.” The ortho­dontist is all of
these, but the orthodontist who realizes that he
is a manager has an under­standing of what an
orthodontist is or ought to be in today’s world.
The problem is that most orthodontist
has no training in or feeling for management.
If anything, we have been trained to believe
that business functions are incompatible with
professional functions. Still, when a professional
practice declines or actually fails, it is usually not
because of professional incompetence. It is
because of poor management.
It is essential for orthodontists to study
management and apply the principles of
modern business management to their
practices.
IDEAL ORTHODONTIC SERVICES
The orthodontic services provided by Ortho­
dontist to the community may fall into any one
of these four types:
1. Observation and preventive (10%)
2. Guidance and interceptive (20%)
3. Partial corrective mechanotherapy (25%)
4. Comprehensive orthodontics (45%).
TYPICAL ORTHODONTIC
PRACTICE ORGANIZATION
Many orthodontic practices have a hierarchical
structure with the doctor as the “boss” at the
top of a pyramid type of organization, with
such emotional ties to his “baby,” the practice
that he built from zero, that he may be able to
delegate responsibility, but not authority. This
is typical of professional practices and small
businesses. At the other end of the spectrum,
we sometimes see orthodontic practices aspire

to an organi­zational structure like that of a
big business. It is paradoxical that while some
orthodontic practices are looking for a structure
like a big business, many large businesses such
as Hewlett-Packard and Rockwell International
are seeking to develop a work environment like
what we already have in orthodontics. They
like the size, the cohesiveness, the informal
structure within which workers can work
toward a common goal and see the results
of their effort. In such an environment, it is
possible to develop a true team effort. Most
large organizations encourage mediocrity.
Small organizations have a need to excel, and
a need for a structure which fosters excellence.
Functional excellence is important, but
the danger is that it can become the end in
itself; and then success of the enterprise in the
orthodontist’s eyes is measured in terms of the
performance of the function, and not in terms
of the contribution that the performance of the
function makes to the success of the enterprise.
The orthodontist who feels that way tends to
organize his employees on the basis of their
craftsmanship. Even in a small enterprise like
an orthodontic office, a spin off of this attitude
can be a departmentalization according to
functions. The result can be little empires
functioning in a separate, uncoordinated
manner. Typically, the people in front do
not know what the people in back do, yet the
people in front are scheduling for the people
in back.
Typical Orthodontic Management
Style
Frequently in orthodontic practice, overlaid
on the hierarchical organization by functions,
we find a form of scientific management.
Scientific management was developed by
Frederick W Taylor in the latter part of the
last century as a method of analyzing work
Community Orthodontics 497
and organizing it into efficient sequences of
its simplest components, with the idea that
improvement in overall performance comes
from improved performance of the individual
parts. This fostered time and motion studies
and concepts of efficiency derived from them.
There is a place for scientific management
in analyzing and organizing work. The flaw
in it is that it separated planning from doing.
Planning was the prerogative of an elite
management. Doing as he was told was the
role of the worker. The trouble with this is that
if a worker is taught how to do, even how to do
efficiently, and not taught to understand what
he is doing, he requires more supervision; and
his dedication, if any, is to the function and
not to the enterprise, because he does not see
beyond the function. In addition, any change
is difficult for him, and threatening to his
psychological security.
As machines have replaced people for
routine tasks, and with the social changes we
are experiencing today, it is not surprising to
find that you do not just hire a hand. A whole
person comes along with it; and today’s worker
needs more from the enterprise than a fair
day’s pay. He needs meaningful work in which
he can take active responsibility, from which
he can derive fulfillment and opportunity for
advancement. In turn, the enterprise needs
more from the worker than a fair day’s work. It
needs his willing, active, creative contribution
to a team effort working for the success of the
enterprise. That attitude cannot come from a
worker who feels that he is working for profits
for the boss and a fair day’s pay for himself.
It would be a mistake to believe that these
concepts have gained universal acceptance.
Key to a Better Way
Even with systematic organization and a
maximum of delegation of functions, there is
498 Essentials of Orthodontics
probably more in an orthodontic practice than
one person can manage effectively. The solution
is to delegate managerial responsibilities.
Since not every worker is a highly motivated,
highly skilled team player, with managerial
potential, management’s task is to find those
who are, hire them, and let them develop in the
organization through participation, acceptance
of responsibility, and exercise of authority.
The key to entry into this world for the ortho­
dontist is to free himself from salary limitations
in the management level immediately below
his own, and rather aim for the person to
whom he would feel comfortable surrendering
authority. It will be a reasonable price to pay
to get that type of person. You will have a start
toward building an organi­zation in which you
can delegate managerial responsibility.
Nature of Participation
When you feel comfortable delegating mana­
gerial responsibility, the risks of sharing
authority and participation with employees
diminish. If you want active, dedicated, loyal,
involved workers, you have to understand what
real participation is. It is not a democracy in
the orthodontic office. It is not surrendering
the boss’s real prerogatives. It is not throwing
people into sink or swim. It is letting workers
participate in setting rules and solving problems
in their own work and giving them some
authority to go with this responsibility.
Participation depends on information.
But, information is power. Withholding infor­
mation is withholding power. Giving infor­
mation is surrendering power. The risk of loss
of power through releasing information to
employees needs to be weighed against the
reward of better performance by employees.
The danger in giving orthodontic assistants
enough information to understand what
they are doing and, therefore, to be able
to work independently to a greater extent,
is that assistants may then want to work
independently of the orthodontic office, as
denturists want to work independently of the
dental office. For many orthodontists, this
is sufficient reason to postpone the day and
to continue orthodontic practice utilizing
auxiliary personnel for many technical tasks,
but with­holding information, such as why an
arch wire is bent in a certain way.
Since, survival is a priority instinct, ortho­
dontists cannot be faulted for continuing to
practice in this way. Still, it would be a stretch of
the imagination to think that denturists know
more than the technical steps in fabricating
a denture, yet they have made surprising
advances toward their goal; and, if it is possible
to train an assistant to perform so many of
the technical tasks in orthodontics in a highly
satisfactory manner in a matter of months, it
may be a greater risk to pin one’s future on
withholding information than on developing
auxiliaries’ ability to the fullest, and permitting
the orthodontist to develop his ability in
the many directions that could elevate his
professional position in a parallel manner.
The more obvious of these are diagnosis and
treatment planning; functional occlusion; pain
in the face, head, and neck; TMJ dysfunction;
airway; and communication and management.
Delegating Authority with
Responsibility
Just as encouraging employees to accept
responsibility is not for the purpose of making
the worker happy, but necessary for the greater
success of the enterprise, providing the worker
with information is not a question of how much
he wants, but of how much he needs to perform
in a highly effective manner. Delegating autho­
rity with responsibility, providing necessary
information and giving workers opportunities

for participation in decisions affecting their
lives are basic management tools and the
extent to which an orthodontist can make use
of these tools may well influence the quality
and quantity of his success.
As we continue to experience increasing
costs and double-digit inflation, staying even
is falling behind; and today it takes more than
a 10% annual increase in gross income to stay
even. But, an orthodontist who, either by choice
or by abiding by the limitations of a more
restrictive dental practice act does not delegate
has a limitation on how many cases he can treat
with his own two hands. As an orthodontist
delegates, he increases the number of cases he
and his staff can treat. The more of his personal
supervision needed over the work he delegates,
the smaller the additional case load that can
be handled. If he expands indiscriminately,
delegating authority and responsibility to a
technically capable but uninformed staff, the
quality of the service must decline. This can
be counter productive, if you consider that
high quality work is essential to the continued
satisfaction of your referral base.
ORTHODONTIC WORK
ENVIRONMENT
It will be up to each orthodontist to decide
how far he may feel like going in providing
infor­­mation to his staff. But, without regard to
how far that may be, the orthodontic office is
an excellent environment for the application of
impro­ved management principles for impro­
ved practice performance. It lends itself to
flexible work schedules. Jobs can be mixed,
enriched, and inter­esting. They need not be
repetitive and boring, not overlaid with several
layers of supervision. Japanese managers have
used this approach to gain dramatic increases
Community Orthodontics 499
in productivity. Typically, a specialist worker
is rotated in all departments. Their success
suggests that American orthodontists might
benefit by hiring workers who are capable of
the most demanding of the specialized tasks,
which is probably the expanded duty chair
side auxiliary and rotating them throughout
the office. There is a certain amount of logic
in keeping people in specialized tasks which
they are performing in a satisfactory manner;
but, as Japanese managers have learned, there
is more to a successful enterprise than a group
of highly efficient fun­ctions.
Building a career-oriented professional
team requires mutual respect and trust. The
orthodontic office has multiple opportunities
to show that respect and trust and to recognize
achievement—through open and implied
approval, salary levels and salary increases as
a share in the good fortune of the enterprise
to which all have contributed, liberal fringe
benefits, impulsive gifts, time off, group staff
activities. Also, new lifestyles dictate changes
for the traditional workplace. Offices will
increasingly have to recognize that female
workers today need greater flexibility on the
job, to accommodate their additional roles
as wives and mothers. One way to satisfy this
need is by providing supervised child day care
centers on the premises. There are so many
benefits in this to the enterprise, and to mother
and child, especially infant children, that it is
surprising that it has taken so long to come
about.
The benefits to the enterprise are in
sta­b ili­z ing the employment of dedicated
wor­kers, in opening the door to a broader
segment of talen­ted people, and in providing
another dimension to the real and emotional
benefits from being a part of an enterprise
with a genuine concern for its employees. The
benefits to the mother and child are in the close
500 Essentials of Orthodontics
proximity, in the ability to visit and to nurse
the child, in the reduction of stress concerning
the child’s safety, in reduction in cost (if the
enterprise offers the service as a fringe benefit
without charge), and in the security derived
from being a part of an enterprise that is really
a surrogate family at a time when families are
disappearing from the scene. Not only does
an additional feeling of good will pervade the
office, but there are overt gains in dedication
of the entire staff to pro­duction, efficiency and
quality; and to the growth and success of the
enterprise.
One more observation about choice of
empl­o yees, orthodontists have made an
apparently erroneous assumption that young
assistants relate better to young patients.
Apart from the fact that the age of orthodontic
patients is moving in an upward direction, it
has been shown that the basic premise may
be invalid. Nevertheless, an orthodontist may
prefer to work with a younger staff; and they,
in turn, may prefer to work with people their
own age. There is nothing wrong with having
a young staff. What is wrong is hiring young
employees for the wrong reasons— because
the orthodontist thinks that staff turnover is
a good thing, or that it keeps salaries low, or
because the factors of youth and turnover limit
retirement plan contributions for the staff. If
the mission of the orthodontic staff is to form
a team dedicated to the growing success of the
practice, high turnover and low salaries may be
contrary to and detrimental to the goals of the
enterprise. The object is not to see how little
you can do for employees, but how much; and
when you have the right employees, you don’t
have a problem feeling this way.
Communicating with Patients
It seems logical that, in the absence of adequate
information, one can delegate limited responsi­
bility and little or no authority. That is as true
in patient management as it is in personnel
manage­­ment. Yet, it is almost a pattern
for orthodontists to withhold information
from patients. From the beginning of the
relation­ship to the end, ortho­dontists do not
supply patients with an adequate amount of
information to assure acceptance of treatment,
to motivate cooperation in treatment, and to
make patients into sources of referral.
There is a process in the way that people
make a buying decision. First comes recog­
nition of need, then a search to fill the need
and some kind of postpurchase evaluation to
reassure oneself that the right buying decision
was made. Orthodontists must recognize
that they have a role in the buying process—
in helping people identify their need for
orthodontics, in convincing them that there
is no more satisfactory solution available,
that the fee is acceptable, that the decision
cannot or should not be postponed (if that is
the case), and to reinforce the patient through
posttreatment evaluation and conference that
the treatment did come up to expectations.
A corollary to this is that if a buyer does
not see a difference between two items, he
will buy either one, and the difference has to
be sub­stantial to be perceived. If there is no
difference or if it is hard to identify, the buyer’s
decision is likely to be made on a basis of
price, convenience, or style. The welfare of the
orthodontist and his practice requires that he
provide patients with enough information to
help them establish three levels of perception—a
perception of need, a perception of value, and a
perception of difference.
Many orthodontists believe that people
are knowledgeable about orthodontics these
days, know what is involved, what to expect
in the office, including fee. In light of this, they
also believe that it is a waste of their time and

the patients’ time to spend any amount of it
with lengthy explanations. They will typically
examine a patient briefly and confirm a need
for orthodontic treatment. They may indicate
that four teeth will have to be removed, which
would be confirmed with a more thorough
diagnostic workup after the patient accepts
the fee, which is then quoted. The effect of this
is to force the patient’s decision to be made
on the strength of the referral and on the fee.
Unless one has a low fee or the lowest fee, it
is foolhardy to make price the determinant of
patient acceptance.
It is also foolhardy to make a diagnosis
without adequate diagnostic materials, espe­
cially to make a diagnosis of tooth extraction
without adequate diagnostic records; if only
for the fact that people today are increasingly
questioning professional opinion and opinion
needs to be supported with evidence. A typical
reaction to diagnosis without that support is
related by a parent who took his child to an
orthodontist and was told that four permanent
teeth would have to be removed. The parent
said he would have to think it over. When he
thought it over, it weighed on him that this
was the last set of teeth his child would ever
have, and he decided to get another opinion.
Right at that point, the first orthodontist lost
the case. If the second orthodontist said that
extractions were not necessary, the parent was
ready to accept that. If the second orthodontist
said that extractions were necessary, the parent
said he would not feel good about returning
to the first orthodontist after challenging his
opinion, and would likely remain with the
second orthodontist in that event also.
Patient referrals are the only source of the
scarce raw materials in orthodontic practice.
Not many orthodontists have enough of
them to squander them foolishly. Case
presentation should not be made without
Community Orthodontics 501
complete diagnostic materials and a thorough
diagnostic workup. First of all, the patient
does not know his real orthodontic need,
although he may have some conception or
misconception about it. The dentist who
may have referred the patient does not know
the patient’s real orthodontic need; and the
orthodontist upon examination does not know
the patient’s real orthodontic need. He may
have a reasonably good idea and he might
be right on or reasonably close to the final
diagnosis a good percentage of the time. But,
there is no reason to gamble on whatever the
percentage of cases in which he might not be
correct and, furthermore, there is the obligation
to help the patient to understand his need for
orthodontics, and to offer sufficient evidence
to create confidence in the orthodontist’s
judgment. An orthodontist should have at
least a 90% acceptance rate. Why risk losing
a case because of an inadequate diagnosis or
inadequate infor­mation?
Proper Case Presentation
In a proper case presentation, with all parties to
the buying decision present, the orthodontist
gives the patient enough information to help
him to establish what his real need is and to
make an intelligent choice of treatment plan
by partici­pating in the diagnostic decision. In
a proper case presentation, it is not necessary
for the ortho­dontist to tell the patient that
teeth need to be removed. The patient tells
the doctor. When that happens, the patient
truly understands his need, he has a stake
in the treatment plan, his search to fulfill the
need is over, and there is no more satisfactory
solution to his problem. Frequently, under
these circumstances, the patient forgets to ask
what the fee will be, and the orthodontist has to
remind him that there is one more agreement
that is needed, because fee has become almost
502 Essentials of Orthodontics
irrelevant in the patient’s mind. Not only does
the patient now have a perception of need, but
also a perception of value and a perception of
difference. An orthodontist who skips this key
step, or takes it lightly, threatens the success of
his entire enterprise. These perceptions should
be nurtured throughout treatment.
Patient Communication during
Treatment
If patient feedback is to be believed, they
require more information during treatment
than most orthodontists are accustomed to
offer. The following is a typical set of patient
responses, when they were asked what they
liked most and what they liked least about their
orthodontic treatment.
Chief Complaints
Parents—Lack of communication (regarding
progress). Size of fee.
Child patients—Kept waiting. Lack of comm­
uni­­cation (what will be done and why). Painful
treatment.
Adult patients—Lack of communication (what
will be done and why). Kept waiting. Size of fee.
Painful treatment.
Chief Praise
Parents—Good-looking, modern, well-
equipped office. Friendly staff. Good treatment
result.
Child patients—Good treatment result. Frien­
dly staff.
Adult patients—Good-looking, modern, well-
equipped office. Friendly staff. Good treatment
result.
This was from an office that thought it was
communicating, and it probably was communi­
cating better than most. It was soliciting feed­
back. Yet, a universal complaint was “lack of
comm­uni­c­ation.” This was from an office that
thought it was paying attention to scheduling,
yet “kept waiting” is at or near the top of the
list of complaints. This office should also be
concerned that parents and adult patients
are complaining about fee. There has to be
something wrong with case presentation.
Finally, orthodontists tend to minimize the
pain of orthodontic treatment, while patients
do not.
Note the difference between adult and
child when it comes to praise of orthodontic
treat­ment. The child’s primary concern is
the treatment result: simply, what is going to
happen to his body. This may stem to some
extent from the fact that the treatment decision
is by parents, that the transaction is between
parents and orthodontist, that not enough
effort is made to inform the child about his
need and about what will be done to correct
it—what is going to happen to him and why.
Adults, on the other hand, seem to assume that
the doctor is competent and that the treatment
will succeed. They are more impressed by
office environment.
To complete the information cycle, post-
treatment evaluation and presentation are
essential in reassuring the patient that he made
the correct buying decision, and reinforcing
him as a referral source; and in quality control.
Management by Exception
Orthodontists tend to manage by exception.
Things that are going along well are permitted
to manage themselves. When things are not
going along well is considered the time to step
in and do something. Apart from being the
line of least resistance, this is not the efficient
use of management time that it is presumed
to be. Often, it is a lack of management. Many
ortho­dontists take their practices for granted
and only become agitated when they become
aware of a practice decline. This is a mistake.

Everyone needs to keep his finger on the pulse
of his practice and understand that net income
is a more important measure of income than
gross income, that profit per patient is a better
measure of profitability than profit percent,
that cases finished is a better measure of
productivity than cases started, and balance
of contracts written is a better measure of the
economic health of the practice than current
income.
Another result of management by exce­
ption is that the “good guys” get little time and
attention, while the “bad guys” get an inordi­
nate amount of it. How many orthod­ontists
have said to parents at case presentation, “If
things go along all right, chances are you will
never hear from me again. You can be sure
that if things are not going along all right, you
will hear from me?” What a mistake. Parents
want and deserve progress reports on a regular
basis, and a posttreatment report. Patients
thrive on recog­nition that they are performing
well, to sustain them through the long days
and nights of orthodontic treatment. What a
mistake to take for granted the good work of
the cooperative patients and dwell on those
whose treatment is not going well.
It is the parents of patients who are succee­
ding that are the real source of referral in
the parent group, not the parents of those
who are not succeeding or who are receiving
constant negative reports about their child. I
would not under­estimate child patients as a
potential source of referral. You can be that
successful patients will make better referrers
than problem patients.
How many orthodontists take their dentist
refe­rrers for granted, and only become con­
cerned about them when they stop referring?
And, if a dentist referrer does stop referring,
how many orthodontists are quickly aware of
it and call up to find out why?
Community Orthodontics 503
Orthodontic staff is not different from par­
ents, patients, and referring dentists in want­ing
recognition and communication. How many
orthodontic staff meetings are only called
when there are problems? How many regularly
held staff meetings are only concerned with
problems, with what is not going right?
This is not to suggest that problems do not
need solving, nor that treatment that is not going
well does not need attention. But an office that
spends a majority of its human relations time on
the problems and putting out fires has a general
negative pall hanging over it. When more
time is spent on positive communication with
the positive patients and parents and dentist
referrers, and on staff meetings that are positive
communications aimed at developing a team
effort for growth and success in the practice, the
whole spirit of an office can change. It is not just
the power of positive thinking. Management by
exception is not suited to the private practice of
a personal service.
Conclusion
It is reasonable to expect that we will see
orthodontic practices in the future conducted
in a variety of ways. I believe that at the bottom
will be the orthodontist who is stuck at the
craftsman level, with himself or herself doing
substantially all the work. Next comes the
orthodontist who will delegate some responsi­
bilities, but who will withhold authority and
information from employees. At the top will
be the orthodontist who understands that
he is essentially a manager; who maintains a
base of functional excellence, but develops a
team that is dedicated to the growing success
of the enterprise, and a management style that
meets the needs of today’s workers and today’s
patients. This requires delegation of responsi­
bility to personnel with the authority to go
with it; provision of information needed by
504 Essentials of Orthodontics
personnel to do an optimum job; expansion of
the ortho­dontist’s own professional horizons;
provision of the information needed by patients
to understand their orthodontic need, to accept
the treatment plan and fee, to be motivated to
perform their part in treatment in an optimal
fashion, and to be confirmed as a referral
source. That is the formula for future success
and happiness in an orthodontic practice; and
it begins with the practice of management.
MEDICOLEGAL
CONSIDERATIONS IN
ORTHODONTICS
Orthodontists can be the subject of a malpra­
ctice suit. Costs of professional liability and
insurance will continue to increase dram­
atically; of course, insurance is only one of the
potential costs of a malpractice suit. Not to be
overlooked are losses in professional time and
the confidence of other patients or prospective
patients.
LEGAL PRECEDENTS
A suit against an orthodontist can be either
settled out of court or decided at the trial
(district) court. If the judgment obtained in
trial court is unacceptable to either party,
then it can be appealed to the appellate court.
Orthodontic malpractice cases are usually
filed in state courts, but high courts can have
jurisdiction if a government entity is involved.
Researching cases at the trial court level is
difficult and usually incomplete. Because of the
large number of cases considered at this level,
the records are often retained within each court
rather than being reported in bound volumes.
Most research into case law precedence—
the guidance a court uses in its determinations—
occurs at the appellate court level. Cases at this
level are reported in bound volumes and on
computer and are readily accessible in most
law libraries.
The appellate case law is used for trial
preparation by the attorneys representing
the disgruntled patient, or plaintiff and the
orthodontist, or defendant.
The cases can be divided into three
categories—dissatisfaction with treatment,
misdiagnosis and violation of state board
regul­ations.
Contracts and Statutes of Limitations
An orthodontic malpractice suit can be based
on contract theory or tort theory. In a contract
suit, it is usually claimed that the orthodontist
guaranteed specific results, either orally or in
a written contract. Therefore, it is legally dan­
gerous for an orthodontist to give an expressed
or implied guarantee of results. Without such
guarantee, the burden is on the plaintiffs to
present evidence of malpractice.
Most orthodontists know that giving written
warranties may prompt suits, but they may not
realize that they are just as liable in cases of
implied contract, however inadvertent. An
orthodontist who casually says, “We will make
your teeth look like Brooke Shields,” is implying
a result that could later be contested.
Of the nine cases involving patient dissatis­
faction, the orthodontist was found liable in
every case in which an expressed or implied
contract guaranteeing results was present.
Statutes of limitations, which vary from
state-to-state, set out the time periods
during which suits must be filed or else be
“time barred.” In most states, the statute of
limitations for a tort claim is two years. Statutes
of limitations for contract claims are usually
four years or more.
The situation is quite different for ortho­
dontic treatment results, because young
children cannot understand that a harmful
act has caused a problem worth litigation until

they are older. In some states, this means the
statute of limitations might not begin to run
until age 18, or the age of majority.
If this is true in your state, you should save
all posttreatment records until the patient is at
least 20-year-old.
Negligent Treatment
To establish negligence, the plaintiff must show
that the defendant breached the applicable
standard of care followed by orthodontists, that
he or she (the patient) actually was injured,
and that the breach was the proximate cause
of the injury.
Tort law has established a general standard
of care, which is the degree of care that a
reasonably prudent person would use in the
same or similar circumstances. A professional
is presumed to possess greater skill and
knowledge than a lay person, and is therefore
held to a higher standard. One who holds
himself or herself out as a specialist is generally
expected to have greater skill and knowledge
than a general practitioner in that field.
States use varying methods to determine
the degree of care that a reasonably prudent
orthodontist would use. Some have a “same or
similar community” rule—the reasonably prudent
orthodontist is required to use that care and skill
as practiced in the same or similar locality.
An increasing number of states use the
“national custom standard,” which is a general
standard for that profession throughout the
country. This assumes that there is a prevailing
treatment method for each type of problem.
The “national custom standard” has been
criticized on the grounds that “customary
medical practice” may not be synonymous
with “good medical practice.”
Additionally, an orthodontist must exercise
reasonable care and diligence in treating pati­
ents. Diligence means following reasonable
treatment plans based on proper information
Community Orthodontics 505
without undue delay. An orthodontist who uses
a method of treatment that a reasonable and
prudent orthodontist would use under the same
or similar circumstances is not subject to liability.
As in other health professions, the courts
do not automatically assume that orthodontic
treatment will be 100% successful or that the
patient will be 100% satisfied with the result. It
is the plaintiff’s burden to prove that the ortho­
dontist has deviated from the acceptable standard
of care. In other words, a Class II malocclusion
that is never corrected—whether from lack of
cooperation or lack of growth—is unsuccessful
treatment, but not necessarily malpractice.
Several other cases, however, involved
orthodo­ntists’ failure to take complete pretreat­
ment records—panoramic and cephalometric
radio­g raphs, photographs and models.
Treatment was initiated without written,
formal treatment plans, and the patients won
suits against their orthodontists.
Expert witnesses would be hard pressed
to comment favorably on an orthodontist’s
treatment methods when proper diagnostic
records are absent.
Misdiagnosis
The second major area of concern is misdiagnosis,
usually related to periodontal disease or TMJ
disorders. Again, every orthodontist must
have proper pretreatment records, including
documen­tation of existing periodontal and
TMJ condition.
An informed consent document, explained
to and signed by the patient, is essential. Bone
recession and root resorption, for example, can
occur even in “normal” and “conventional”
orthodontic care, and a patient who is thus
informed before treatment should not be able
to claim negligence later.
A proper informed consent form discloses
all possible risks or hazards so that a reasonable
person can decide to give or withhold consent
506 Essentials of Orthodontics
to treatment. Statutes governing the wording
of such forms differ from state-to-state.
Periodontal or TMJ problems that arise
during treatment should be documented in
the same way as those seen before treatment.
Negligence on the patient’s part should always
be noted on the chart. Some orthodontists
rate patients’ toothbrushing on an arbitrary
scale—perhaps 1 for a terrible brusher and 5
for an ideal brusher. This documents a pattern
of care shown by the patient.
Frequent periodontal probings should also
be performed during treatment, especially
on adult patients, and likewise should be
documented.
Of paramount importance are proper
referrals, backed by records of telephone
calls and duplicates or photocopies of all
written correspondence. Referrals should be
timely, and the need for them should be clearly
communicated to patients.
Once the referral has been made, the next
practitioner should be able to address the
problem effectively.
One possibly dangerous situation is
when the orthodontist knows or should
know that the standard of care given by the
recommended practitioner does not meet
the normal standard of care. Therefore,
orthodontists should be very careful to whom
they refer patients.
Another potential problem is when the
orthod­ontist goes into the operating room with
a surgeon. The orthodontist would not be liable
for a surg­eon’s slip of the scalpel, but could be
liable for his or her portion of the treatment—
for instance, planning or directing a tooth to
be extracted.
State Dental Regulations
Most orthodontic offices seek to improve their
efficiency by delegating duties to assistants, but
a prudent orthodontist is aware of and follows
the state regulations regarding delegation.
State boards of dental examiners have legal
power to reprimand anyone in violation of these
laws. The state’s dental legislative act exists to
protect the health and welfare of the public,
and police action on behalf of a valid public
interest is not subject to judicial interference if
the means employed are fair and just.
State dental examiners can also address
orthodontists’ competence to practice. They
generally apply the same comparison as would be
used in court—the standard of care as practiced
by a reasonable and prudent orthod­ontist.
CONCLUSION
Intelligent and cautious orthodontists can pro­
tect themselves from liability while striving to
provide the best possible service. As indicated
by these appellate court cases, an orthodontist
needs to:
• Keep accurate records and maintain them
well after treatment
• Exercise due care and diligence in diagnosis
• Avoid written and implied warranties
• Write formal treatment plans
• Take complete pretreatment records
• Maintain proper care and diligence during
treatment
• Have detailed informed consent forms
signed and stored in the permanent
records
• Keep detailed treatment and patient coo­
per­­ation records
• Make referrals only to qualified specialists
• Follow state dental rules and regulations.
Knowing the potential pitfalls will help you
build a successful practice without becoming
the subject of litigation. You and your patients
will benefit.
 Materials Used in Orthodontics 507

CHAPTER
Materials Used in
15 Orthodontics

ORTHODONTIC MATERIALS
Advancements in orthodontics have made
possible a constant improvement in the quality of
orthodontic treatment ultimately, benefiting the
patient. An analysis of the various dimensions of
orthodontic advancement reveals two important
truths. Firstly, the biologic problems have rema­
ined singularly unchanged. New solutions to
the old problems have resulted principally
from advancements in orthodontic materials
and their cascading end effects on appliance
design and treatment strategies. Virtually every Figure 15.1: Materials used in orthodontics
facet of ortho­dontic treatment has been changed
for the better thanks to the advancement in the
orthodontic material arena. 1. Gold
Orthodontic material science is an emer­ 2. Stainless steel (SS)
ging sub-discipline of orthodontics. The earlier 3. Chrome cobalt (Elgiloy)
we recognize and initiate efforts to foster it, the 4. Nickel titanium (NiTi)
better it would be for orthodontics. i. Martensitic
ii. Austenitic
iii. Superelastic
CLASSIFICATION OF iv. Thermodynamic or temperature
ORTHODONTIC APPLIANCE transforming (CuNiTi)
MATERIALS (FIG. 15.1) 5. Beta titanium (TMA)
i. Untreated
Arch Wire Materials ii. Surface treated (Ion implanted)
Based on material constituent: 6. Alpha titanium
508 Essentials of Orthodontics

7. Polymeric materials Orthodontic Cements

8. Composite coated arch wires (Optiflex) A. Based on the material content:
9. Titanium niobium 1. Zinc phosphate cement
10. Timoloum. 2. Polycarboxylate cement
3. Glass ionomer cement
i. Chemical curing
Bracket and Attachment Materials ii. Light curing
Based on the material content: iii. Dual curing
1. Stainless steel (SS) B. Based on the incorporation of fluoride:
2. Polycarbonate 1. Fluoride releasing
3. Fiber glass reinforced plastic 2. Non-fluoride releasing.
4. Ceramic
Alumina based Sealants and Adhesion Promoters
i. Monocrystalline A. Sealants: Nonfluoridated and fluoridated
ii. Polycrystalline sealants
iii. Laminated brackets B. Adhesion promoters
Zirconia based i. To metal
5. Nickel free bracket materials—Titanium ii. To plastic
brackets iii. To porcelain
6. Composite brackets iv. To gold
7. Bass. v. To fluorosed tooth.

Conditioning and Crystal Growth

Bonding Materials
A. Based on the basic bonding system type:
1. Acrylic resin based system—Polymethyl
methacrylate system
2. Diacrylate based systems—Bis-GMA
systems
3. Glass ionomer systems
i. Chemical cured
ii. Light cured
iii. Dual cured
B. Based on fluoride content
1. Fluoride releasing systems”
2. Nonfluoride releasing systems
C. Based on curing systems
1. Self-cured system
2. Light cured system
3. Dual cured systems
D. Based on the filler content
1. Lowly filled bonding systems
2. Highly filled bonding systems.
Systems
A. Based on the acid used
1. Phosphoric acid based systems
2. Polyacrylic based systems
3. Miscellaneous acid systems
i. Citric acid
ii. Maleic acid
iii. Nitric acid
iv. Hydrofluoric acid 1.6%
B. Based on incorporation of fluoride
i. Fluoridated etchants
ii. Nonfluoridated etchants
C. Gel-based and liquid-based systems
D. Crystal growth systems
i. Polyacrylic based
ii. Lithium based
E. Self-etching primers.
Force Delivery Systems
A. Elastomerics:
 Materials Used in Orthodontics 509

1. Latex and latex-based systems —Elastics ORTHODONTIC ARCH WIRE

i. Plain MATERIALS
ii. Colored
iii. Intraoral and extraoral Rapid strides have been made in the field of
2. Polyurethane based systems arch wire materials, producing in its wake a
i. Plain and colored plethora of arch wires varying widely in material
ii. Fluoride releasing and nonfluoride geometry, configuration, manufacturing
releasing process and physical properties.
3. Silicon based—Positioner materials
B. Coil springs: General Properties of Orthodontic
1. Stainless steel Wires
2. NiTi Orthodontic wires are formed into various
i. Open coil springs confi­gurations or appliances in order to apply
ii. Close coil springs. forces to teeth and move them into a more
desirable align­ment. The force is determined
Auxillary Force Delivery Systems by the appliance design and the material
Magnets: properties of the wire.
1. Aluminum based—AlNiCo magnets The following properties are important in
2. Samarium based—Samarium cobalt orthodontic treatment:
magnets Force: The force applied to a tooth is
3. Neodymium based—Neodymium iron proportional to the wires stiffness. Biologically,
boron magnets. low constant forces are less damaging. This
is best achieved by large elastic deflections
Soldering and Welding because they produce a more constant force
Soldering materials: and have a greater ‘working range’. Range is
i. Solder defined as the distance that the wire will bend
ii. Flux elastically before permanent deformation
iii. Anti-flux. occurs.
Springiness: Springiness is a measure of how
Other Dental Materials far a wire can be deflected without causing
1. Impression materials permanent deformation.
i. Alginate Stiffness: Stiffness is a measure the amount of
ii. Elastomeric materials force required to produce a specific deformation.
2. Gypsum products Stiffness = 1/Springiness.
i. Plaster of Paris Resilience: Resilience is the energy storage
ii. Dental stone capacity of the wires which is a combination
3. Bite registration waxes of strength and springiness.
4. Acrylic materials Formability: Formability is the amount of
i. Self-cure acrylic permanent bending the wire will tolerate
ii. Heat cure acrylic before it breaks.
5. Finishing and polishing materials Ductility: Ductility of the wire is ability to form
6. Implant materials. round wire on pulling.
510 Essentials of Orthodontics
Ease of joining: Most wires can be soldered or
welded together.
Corrosion resistance and stability in the
oral environment.
Biocompatibility in the oral cavity.
Elastic Properties of Orthodontic
Wires
Elastic properties of wires are explained based
on the stress-strain or a load deflection curve.
Stress-to-stress relationships are associated
with intrinsic properties of the wire related
to its composition. The ratio of stress to strain
in the elastic portion of the curve defines
the modulus of elasticity of the wire (e). The
modulus of elasticity is constant for the wire
as it reflects the intrinsic properties of the
wire. Load, or force, deflection rate refers to
the amount of force produced for every unit
of activation of an orthodontic wire.
The slope of stress-strain curve within its
elastic limit is an indicator of the stiffness or
flexibility of a wire. A flexible wire has a flatter
slope, and a rigid wire has a steeper slope.
There are three points on the load deflection
curve that are of clinical importance in
appliance design: elastic limit, ultimate tensile
strength, and failure point (Fig. 15.2).
The elastic limit (Proportional limit, or
yield strength) is the point at which any greater
force leads to permanent deformation of the
wire. The amount of deflection that a wire can
withstand before permanent deformation
reflects an appliances elastic range. A high
elastic range in a wire enables activation of a
wire to a greater extent with a lesser chance of
its undergoing permanent deformation. On the
other hand, the ability to permanently deform
a material beyond its elastic limit enables the
clinician to place bends in the wire.
The ultimate tensile strength is the
maximum force a wire can withstand before
Figure 15.2: Stress-strain curve
the material begins to weaken. It corresponds
to the peak of the force deflection curve. The
portion of the force deflection curve from the
elastic limit to the ultimate tensile strength
is the plastic range of the wire. The extent
to which an appliance returns to its original
form when deflected into its plastic range
determines its springiness. A wire with an
extended plastic range is more formable, which
means it can be bend several times without
undergoing failure. If a wire is deflected past
its ultimate tensile strength, it will eventually
fail by breaking.
Wires with a low load deflection are
preferred in orthodontics in areas where
large tooth movements are required because
they maintain a fairly constant force as the
tooth moves and the appliance is deactivated.
In areas where minimal tooth movement
is desires, such as in maximum anchorage
extraction cases or during finishing, a high load
deflection rate is desirable.
Gold Alloys
Prior to the 1950s, precious metal alloys were
routinely used for orthodontic purposes,
primarily because alternate materials available
would not tolerate the exacting intraoral

conditions. Pure gold by itself is too soft for
all dental purposes. However, its alloys can
be used orthodontically. Their marginal
properties had made precious metal alloys
obsolete for orthodontic purpose much before
the price increase of the 1970’s made them also
prohibitively expensive for use.
Stainless Steel
In the mid century, stainless steel was applied
to dentistry and orthodontics although it was
between 1903 and 1921 that Harry Brearley of
Sheffield and M Becket of US, Benno Strauss and
Edward Maurer of Germany shared the honours
for the development of the material. Ever since
almost all orthodontic practioners have relied
on it.
Steel is an iron based alloy which contains
less than 1.2% carbon. When chromium
(12–30%) is added to steel, the alloy is called
as stainless steel. Elements other than iron,
carbon and chromium may also be present,
resulting in a wide variation in composition
and properties of the stainless steels.
These stainless steels are resistant to tarnish
and corrosion, because of the ‘passivating
effect’ of the chromium. A thin, transparent
but tough and impervious oxide layer forms
on the surface of the alloy when it is exposed
to air, which protects it against tarnish and
corrosion. It loses its protection if the oxide
layer is ruptured by mechanical or chemical
factors.
Cold Working
The process of plastically deforming a metal
at a temperature below that at which it
recrystallizes new grains, which is usually
one-third to one-half times is absolute melting
point temperature (e.g. the deformation of
space lattices of stainless steel by mechanical
manipulation at room temperature). If a metal
Materials Used in Orthodontics 511
is continuously stressed it becomes stiffer and
harder.
Hardening of a metal by cold working is
called strain hardening of work hardening.
During strain hardening dislocations tend
to build up at grain boundaries. The barrier
effect of grain boundaries will cause further
slip to occur at intersecting slip planes. Point
defects increase resulting in a distorted grain
structure.
Consequences of cold working are:
• Increased surface hardness.
• Greater yield and ultimate strength.
• Less ductility.
• Proportional limit is increased.
• Reduced resistance to corrosion.
• No change in elastic modulus.
Majority of these properties is due to
a phase change from FCC to BCC lattice
structure.
Heat Treatment
Heat treatment is the general process of using
thermal energy to change the characteristics of
metallic alloys as in tempering, precipitation
hardening or annealing.
Annealing
The effect associated with cold working such
as strain hardening, low ductility and distorted
grains can be reversed by simply heating the
metal.
The greater the amount of cold working
the more rapidly the effects can be reserved
by annealing.
Stages of Annealing
Recovery: Cold work properties begin to
disappear.
Slight decrease in tensile strength and no
change in ductility.
All the residual stress is relaxed.
512 Essentials of Orthodontics

Recrystallization: Old grains disappear totally diffusionless transformation to a body centered

and are replaced with strain free grains. tetragonal (BCT) structure called martensite.
Occurs mostly in regions where defects This is a highly distorted and strained lattice
have accumulated. which results in a very hard, strong but brittle
It attains it is soft and ductile condition at alloy.
the end of this stage. Properties and uses: Corrosion resistance of the
martensitic stainless steel is less than that of
Grain Growth the other types. Because of their high strength
The grain size and number of the recrystallized and hard ness, martensitic stainless steels are
structure depends on the amount of prior cold used for surgical and cutting instruments.
working.
On repeated annealing larger grains Austenitic Stainless Steel
consume smaller grains. At the end of At temperature between 912 and 1394°C, the
annealing the number of grains decreases stable form of iron is a face centered cubic
and size increases. (FCC) structure called austenite. The austenitic
stainless steel alloys are the most corrosion
Hardening Heat Treatment resistant of the stainless steels.
There is no hardening heat treatment for
austenitic steel due to its stability. Composition
It can only be hardened by cold working. Iron = 75–80%
Chromium = 18%
Types Nickel = 8%
There are thre types of stainless steel based Carbon = 0.08–0.15%
upon the lattice arrangements of iron.
Chromium (11–26%)—Improves the corrosion
Types Chromium Nickel Carbon resistance.
Ferritic 11.5–27% 0 0.2% Max Nickel(0–22%)—Austenitic stabilizer copper,
Austenitic 16–26% 7–22% 0.25% manganese and nitrogen—similar amount of
Martensitic 11.5–27% 0–2.5% 0.15–1.2% nickel added to the alloy adversely affect the
corrosion resistance.
Carbon (0.08–1.2%)—Provides strength and
Ferritic Stainless Steels reduces the corrosion resistance.
Pure iron at room temperature has body Silicon (low concentrations)—Improves the
centered cubic (BCC) structure and is referred resistance to oxidation and carburization at
to as ferrite, which is stable up to 912°C. high temperatures.
Properties and use: The ferritic alloys have Sulfur (0.015%)—Increases ease of machining
good corrosion resistance, but less strength Phosphorus—Allows sintering at lower
and hardness. So, they find little application tempera­tures.
in dentistry. But both sulfur and phosphorus reduce the
corrosion resistance.
Martensitic Stainless Steels This alloy is also called as 18-8 stainless
When austenite is cooled very rapidly steel. These are used most commonly by the
(quenched) it will undergo a spontaneous, orthod­ontist in the form of bands and wires.

Type 316L (contains carbon 0.03% maximum)
is the type usually used for implants.
Advantages
Austenitic steel is preferable to the ferritic
alloys because of the following properties:
1. Greater ductility and ability to undergo
more cold work without breaking.
2. Substantial strengthening during cold wor­
king.
3. Greater ease of welding.
4. The ability to readily overcome sensitization.
5. Less critical grain growth.
6. Comparative ease in forming.
Sensitization
The 18-8 stainless steel may lose its resistance
to corrosion if it is heated between 400 and
900°C (temperature used during soldering
and welding).
The reason for a decrease in corrosion
resis­tance is the precipitation of chromium
carbide at the grain boundaries at these high
temperatures. The small, rapidly diffusing
carbon atoms migrate to the grain boundaries
from all parts of the crystal to combine with the
large, slowly diffusing chromium atoms at the
periphery of the grain. When the chromium
combines with the carbon in this manner, its
passivating qualities are lost and the corrosion
resistance of the steel is reduced.
Stabilization
Stabilization is the process that will minimize
the sensitization.
From a theoretical point, reduce the carbon
content of the steel to such an extent that
carbide precipitation cannot occur, however,
this is not economically practical.
By stabilization, an element is introduced
that precipitates as a carbide in preference
to chromium. Titanium is commonly used.
Titanium at six times the carbon content,
Materials Used in Orthodontics 513
inhibits the precipitation of chromium carbide
at soldering temperatures. These are called as
stabilized stainless steels.
Mechanical Properties
In orthodontic wires, strength and hardness
may increase with a decrease in the diameter
because of the amount of cold working in
forming the wire.
Tensile strength = 2100 MPa
Yield strength = 1400 MPa
Hardness = 600 KHN.
Braided and Twisted Wires
Very small diameter stainless steel wires
(about 0.15 mm) can be braided or twiseted
together to form either round or rectangular
shaped (about 0.4 to 0.6 mm in cross-section)
wires. These braided or twisted wires are able
to sustain large elastic deflections in bending,
and apply low forces for a given defection when
compared with solid stainless steel wire.
Solders for Stainless Steel
Silver solders are used. The soldering
temperatures for orthodontic silver solders
are in the range of 620 to 665°C.
Fluxes
It is similar to that recommended for gold
soldering with the exception of, the addition
of the potassium fluoride. Fluoride helps to
dissolve the passivating file supplied by the
chromium.
Boric acid is used in a greater ratio to the
borax, which lowers the fusion temperature.
Australian Wire
A round austenitic stainless steel wire,
introduced by the AJ Wilcock Co. in Australia,
and selected by PR Begg as the main material
from which arch wires were made for his light-
wire technique. The wire is heat-treated and
514 Essentials of Orthodontics

cold-drawn down to its proper diameter from be hardened by heat treatment, the procedure
round wire of larger diameter. It exhibits high increasing its strength significantly.
toughness and tensile strength, combined
with increased resilience, but low corrosion Composition
resistance because of the presence of copper Cobalt = 40%
as an alloying element of the steel. There Chromium = 20%
are various grades of Australian wire, but Nickel = 15%
Begg mainly used the 0.016-inch (0.41- Molybdenum = 7%
mm), so-called “Special Plus” wire. Another Manganese = 2%
characteristic of the wire is its brittleness. It is Carbon = 0.15%
recommended that when bending Australian Beryllium = 0.04%
wire, the flat rather than the round beak of the Iron = 15.8%.
pliers be used and that the bend be placed very
slowly, to avoid breakage. Following bending, Heat Treatment
the arch wire can be heat-treated, which makes Softening heat treatment: 1100 to 1200°C
it harder and more resistant to permanent followed by a rapid quench.
deformation. Hardening heat treatment: 260 to 650°C,
e.g. 482°C for 5 hours.
Duplex Steels The wires are usually heat treated and
Both austenite and delta ferrite grains are supplied in several degrees of hardness
present. It shows increased toughness and (soft, ductile, semispring temper, and spring
ductility than ferritic steels. It has twice the temper).
yield strength of austenitic steels and lower Chrome Cobalt alloys are available in
nickel content. Used in the manufacturing low four color coded grades depending on their
nickel attachments like brackets and tubes. properties:
• Blue—soft
Teflon (PTFE, • Yellow—ductile
Polytetrafluoroethylene) Coated • Green—semiresilient
Stainless Steels • Red—resilient.
Teflon is a material with the lowest coefficient
of friction. Teflon-coated stainless steel Physical Properties
ligatures and arch wires are available as a Tarnish and corrosion resistance is excellent.
means for reducing frictional resistance to Hardness, yield strength and tensile strength
tooth movement with sliding mechanics. similar to those of 18-8 stainless steel.

Chrome Cobalt Alloys (Elgiloy) Nickel Titanium Alloys (NiTi)

Chrome cobalt alloys were simultaneously
developed in the mid century and this had
physical properties very similar to that
of stainless steel. However they had the
advantage that they could be supplied in the
softer and more formable state and then could
Nickel titanium alloy marketed as Nitinol was
developed for space program but has proved
to be very useful in clinical orthodontics. The
alloy was developed by William F Buehler,
a research metallurgist at Naval Ordinance
Laboratory, now called the naval surface

Weapons center in Silver springs, Maryland in
1960. The name Nitinol is an acronym derived
from the elements which comprises the alloy
(Ni-Nickel, Ti-Titanium, nol-Naval Ordinance
Laboratory). Nitinol has excellent springback
property but it dies not possess shape memory
or super elasticity as it was manufactured by a
work hardening process.
Nitinol as reported by Anderson et al in
1982 is obtained in two types:
i. The elastic nitinol which comprises of
nickel and titanium without cobalt is
popular due to its outstanding character­
istics of elasticity and flexibility.
The advantage is its outstanding
characteristic of elasticity and flexibility
which result in lighter continuous force.
ii. The thermal nitinol comprises of nickel,
titanium and cobalt. By varying the
nickel and cobalt content it is possible
to alter the temperature transition range
(TTR). In order to bring the TTR to
37°, the amount of cobalt added to the
alloy is 1.6%. This wire is characterized
by a unique shape memory effect,
which allows the wire to be plastically
deformed or stretched and formed
at a temperature below its transition
temperature range and to maintain
form until it is heated through the TTR
at which time the wire will deform
to the original prestreched from. The
alloy has a martensitic grain structure.
The transition brings about a change in
the grain structure from martensite to
austenite. The alloy is shape memory in
the martensite form and this property
is exploited. The arch wire is formed to
the desired shaped in the martensite
form and it goes through the TTR to
the austenite grain structure. In the
austenite grain structure it is deformed
Materials Used in Orthodontics 515
to confirm to the irregularities in the
arch form taking the wire through TTR
again will result in its original shape in
the martensitic form.
Two new nickel titanium wires with
primarily austenitic grain structure has been
reported:
i. Chinese NiTi as reported by Burstone
in 1985 is basically austenitic NiTi and
has a history of little work hardening.
The transition temperature in this alloy
is much lower than that of Nitinol.
ii. The Japanese NiTi is a nearly equiatomic
intermetallic compound. At high
tempera­tures, the crystal structure of
the alloy is in an austenite phase which
is BCC lattice. The martensite phase
which is a closed packed hexagonal
lattice exists at a low temperature
range. By controlling the low and
high temperature ranges a change in
crystal structure called martensitic
transformation occurs.
This phenomenon is said to cause a change
in its physical properties in the martensitic
phase, the metal is ductile and acts like a safety
fuse to readily induce a change shape in the
austenitic phase, and at high temperatures it
is more difficult to induce deformation.
When an external force is applied,
most metals deform due to a slip of lattice.
Deformation of NiTi alloy is induced with
martensitic transformation the martensitic
transformations can be reversed by heating the
alloy to return to the austenitic phase and it is
gradually transformed by reversing it back unto
the energy stable condition this means that the
alloy can return to the previous shape and this
phenomenon is known as “shape memory.”
Although the two alloys Nitinol and
Japanese NiTi belong to the same class of
Nickel Titanium alloys they differ in their
516 Essentials of Orthodontics
manufacturing process and physical properties.
Nickel is basically in the martensitic phase and
its physical properties have been improved by
a work hardening process. Japanese NiTi on the
other hand is in the austenitic phase and has
been manufactured in a different manner to
exhibit different properties from that of Nitinol.
Shape Memory and Superelasticity
The nickel titanium alloy exists in various
crystallographic forms. At high temperature, a
stable body centered cubic lattice (austenitic
phase) exists. On appropriate cooling, or an
application of stress, this transforms to a close
packed hexagonal martensitic lattice with
associated volumetric change. This behavior
of the alloy (austenite to martensite phase
transition) results in two features of clinical
significance called as shape memory and
superelasticity or pseudoelasticity.
The memory effect is achieved by first
establishing a shape at temperatures near
482°C. The appliance, e.g. arch wire is then
cooled and formed into a second shape.
Subsequent heating through a lower transition
temperature (37°C) causes the wire to return
to its original shape.
The phenomenon of superelasticity
is produced by transition of austenite to
martensite by stress due to the colume change
which results from the change in crystal
structure.
Stressing an alloy initially results in
standard proportional stress strain behavior.
However, at a stress where it induces the
phase transformation, there is a increase
in strain, referred to as superel­asticity, or
pseudoelasticity. At the completion of the
pahse, behavior reverts to standard pro­
portional stress-strain behavior. Unloading of
the wire results in the reverse transition and
recovery. This characteristic is useful in some
orthodontic situations because it results in
Figure 15.3: NiTi load deflection curve
low forces and a very large working range or
springback (Fig. 15.3).
Copper NiTi Alloy (CuNiTi)
This is the most recent introduction in the
family of NiTi alloy wires. It was introduced by
Rohit Sachdeva and Suchio Miyasaki in 1994.
It is quaternary alloy of copper (5.64%),
nickel (49.87%), titanium (42.99%), and
chromium (0.50%). The material is shown to be
austenitic, in comparison to super elastic NiTi
wires the CuNiTi wires show a significantly low
hysterisis which can be clearly seen in the load
deflection curves. It delivers more constant
force especially for small activations compared
to superelastic wires. It makes possible the
insertion of larger size wires and better bracket
slot engagement early in treatment without
causing pain and patient dis­comfort.
Titanium Molybdenum Alloys (TMA)
Like stainless steel and nitinol, pure titanium
has different crystallographic forms at high
and low temperatures. At temperatures below
885°C the hexagonal close packed (HCP)
or alpha lattice is stable, whereas at higher
temperatures the metal rearranges into a body
centered cubic (BCC) or beta crystal.
Alpha titanium is used in orthodontic
applications during finishing stages of the
treatment for finishing and detailing. The beta

for of titanium can be stabilized down to room
temperature by the addition of elements like
molybdenum. Beta titanium alloy in wrought
wire form is used for orthodontic applications.
Composition
• Titanium = 80%
• Molybdenum = 6%
• Zirconium = 4%
• Tin and Manganese = Trace.
Mechanical Properties
Modulus of elasticity = 71.7×103 MPa
Yield strength = 860-1170 MPa
The high ratio of yield strength to modulus
produces orthodontic appliances that can
undergo large elastic activations when
compared with stainless steel.
Beta titanium can be highly cold worked,
it can be bent into various configurations
and has formability comparable to that of
austenitic stainless steel.
Welding: Clinically satisfactory joints can be
made by electrical resistance welding of beta
titanium.
Corrosion resistance: Both forms have excellent
corrosion resistance and environmental
stability.
Alpha Titanium
Manufactured by AJ Wilcock company:
• Titanium—90%
• Aluminum—6%
• Vanadium—4%.
In contrast to TMA it has got close packed
hexagonal lattice arrangement.
Alpha stabilizing elements are present—
Aluminum, gallium, germanium, carbon,
oxygen and nitrogen.
Properties
Heat treated to improve strength:
Materials Used in Orthodontics 517
Satisfactory creep properties—finishing
and breaking arches.
Wire becomes hard in the oral environment
due to hydrogen absorption and becomes
titanium hydride.
Less ductile—one slip plane and nickel
free.
Titanium-Niobium
Titanium-niobium alloy was developed by
M Dalstra et al as nickel-free titanium alloy
for finishing.
Composition
Ti - 82% Ti - 74%
Mo - 15% (or) Nb - 13%
Nb - 3% Zr - 13%.
Properties
Easy to bend, fomability is less than TMA,
when lower forces are used than TMA. Stiffness
of titanium niobium is – ¾ of SS, and - ¼ of
TMA. Load deflection rate is lower than TMA
and Yield strength is lower than SS.
BRACKET AND ATTACHMENT
MATERIALS
The first orthodontic attachments were made
of gold. Since the introduction of Stainless
steel it has remained the most widely used
material in the manufacture of orthodontic
attachments. Plastics were introduced in the
late sixties and ceramics have been introduced
in the mid eighties.
Stainless Steel
Most of the stainless steel (SS) metal brackets
are made from SS austenitic steel. AISI series
303, 304, 316 and 317 are the major classes of
stainless steel being used by manufacturers.
The emerging trend in stainless steel usage is
518 Essentials of Orthodontics
the increasing use of 316L (low carbon content)
and 317L steel in bracket manufacturing.
These steels are extremely hard and are
difficult to machine. Hence, the manufacturing
process has changed from milling casting,
sintering or metal injection moulding (MIM).
These processes particularly sintering and
MIM produce brackets with very smooth
surfaces decreasing friction and makes
possible compound surface contours possible.
Another distinct trend is the use of AISI series
630 stainless steel called the precipitation
hardening stainless steel. This class of stainless
steel contains very low levels of chromium and
nickel compared to the AISI 303 or 304. Duplex
stainless steel which contains delta ferritic
phase is also used in bracket manu­facturing.
Titanium
Titanium-based brackets is the most recent
development in this area. This emerging trend
is in line with current concerns about heavy
metals and their biologic effects and certain
European countries introducing legislation
banning the use of Nickel releasing alloys.
Titanium brackets are single piece cast
brackets. Titanium is a soft metal though
possessing high resistance to tarnish and
corrosion.
Polycarbonate and Fiber Glass
Reinforces Esthetic Brackets
Polycarbonate brackts were described and
tested by Newman in 1969. They have had
limited popularity because of the clinical
problems of staining rendering them
unesthetic, distortion and tearing of the
bracket particularly form torsional forces.
Brackets with steel inserts were also introduced
but have not been clinically popular. A recent
introduction has been fiber glass rein­forced
esthetic brackets. These brackets are basi­cally
polycarbonate that is approximately 60%
reinforced with fiber glass. These fibers are
about 2 to 3 mm in length and approximately
0.8 mm in diameter. The plastic conditioner
is methyl­metha­crylate monomer to dissolve
the polycarboxylate base to enhance adhesion
with the adhesive.
Ceramic Brackets
Ceramic brackets were first introduced in 1987
and today it has found wide acceptance and
still holds more promise. Ceramic brackets
may be monocrystalline or polycrystalline
based on the structure. Ceramic bracket
technology has evolved rapidly. The number
of problems such as excessive bond strength,
enamel fracture on debonding, brittleness of
the bracket and surface finish has been largely
addressed in the second generation of ceramic
brackets.
BONDING MATERIALS
The first material to be used as an orthodontic
adhesive material was essentially acrylic resin
which was very soon replaced by diacrylate
popul­arly known as composite resin. Still
com­p osite resins with various modified
formulation is the mainstay for orthodontic
adhesive materials.
Classification
Based on Generations
First Generation (mid 1970s): Acrylic resins
and epoxy resins.
Second Generation (late 1970s): Stabilized/
filled acrylics; UV light cured acrylics and com­
posites.
Third Generation (early 1980s): Composite
resin two paste systems.

Forth Generation (mid 1980s): Composite
resin one paste (no-mix) system and conven­
tional GIC.
Fifth Generation (late 1980s): Visible light
cured composites; Dual cure composites.
Sixth Generation (1995): Resin reinforced
GIC light cured, dual cured, tricured; Com­
pomers; UDA based composites.
Seventh Generation (2000): Cyanoacrylates.
Eighth Generation (2005): Nano based
resins.
Classification Based on Bonding
Systems
I. Acrylic resin based systems:
i. Self-cured (Orthomite and Genie)
ii. U-V light cured
II. Composite resin based on BIS-GMA
system:
a. Chemically cured
i. Two paste system (Concise, Phase II)
ii. Single paste Nomix system (3M
unite, Rely bond, Monolok, Right-
on, Q-sar)
b. Visible light cured system/single paste
(Transbone XT, Resilience L3, Light
bone)
c. Dual cured
(Band lock)
III. Glass ionomer based systems:
a. Conventional GIC
(Ketac Cem, Fuji I, II)
b. Resin reinforced GIC (RRGIC)
i. Chemically settable—Dual cure
(Advance, Fuji ortho)
ii. Visible light cured GIC—Tri cure (Fu­
ji Ortho LC, Photacfil, and Vitaemer)
c. Polyacid modified composite resin/
Compomers
(Dyract ortho, Ultra bandlock, Com­po­
glass)
Materials Used in Orthodontics 519
IV. Cyanoacrylate based systems:
(Smart bond)
ADA classification: Composites are classified
by ADA specification no. 27 as:
Type I: Polymer based materials suitable for
restorations involving the occlusal
surface.
Type II: Other polymer based materials
Class I: Self-cured materials
Class II: Light cured materials
Class III: Dual cured materials.
Acrylic Resins
It was the first materials to be used as
orthodontic adhesive. They had good flow
and wettability. But they were lacking sufficient
bond strength. High degree of polymerization
shrinkage and great differences in coefficient
of thermal expansion between tooth and resin
further affected bond strength. Chemically
they are linear cross-linked polymer of methyl
methacrylate.
Epoxy Resins
Epoxy resin polymerization reaction leads
to give a three dimensional cross-linkage,
which improved greater strength, lower water
sorption and less polymerization shrinkage.
But these resins due to their large molecular
size had more viscosity and less wettability to
tooth surface.
Composite Resins
This BIS-GMA resin has again some appreciable
amount of polymerization shrinkage and lack
of sufficient strength which was compensated
by addition of filler of various particle size
depending upon the requirement. Some new
composite resins have matrix other than BIS-
GMA like UDA and TEGDMA but BIS-GMA
is most common. In true sense this was the
520 Essentials of Orthodontics
material which exhibited adequate bond
strength. This increased bond strength of
composite resin has led to its widespread use.
Polymerization of composite resin can
be accomplished by, chemical reaction,
activation by U-V or visible light and heat.
Chemically Activated Systems
They polymerize as a result of two components
being brought together. Among the chemically
activated materials the single paste system
has the advantage of no air bubble, firm
consistency, no bracket drift and good
strength. But liquid of this no-mix system is
more cytotoxic to oral fibroblasts than any
other system.
Composition
Adhesive paste:
• BIS-GMA matrix
• Colloidal silica—filler
• Benqoyl peroxide—initiator
• Hydroquinone—inhibitor
• Primer liquid:
• N,N dimethyl toluidine—activator
• HEMA
• TEGDMA
• Methacrylate monomer.
Light Activated System
The light activated system polymerize upon
exposure to light of appropriate wavelength.
U-V light = 364 to 637 nm
Visible Light = 440 to 480 nm.
Ultra violet light is not used now due
to reasons like retinal damage, more time
required for curing, visible light has advantage
of great depth of curing in lesser time.
Composite
Adhesive paste:
• BIS-GMA—Matrix
• Colloidal silica—Filler
• Camphoroquinone—Photoinitiator
• 0.15% dimethylaminoethyl methacrylate—
Accelerator
• 0.01% butylated hydroxytoluidine—
Inhibitor
• Primer liquid—Methacrylate monomer.
TEGDMA
Upon exposure with light of appropriate
wave­length, initiator, accelerator get activated
by a absorbing photon energy giving rise
to a chemical reaction which results in
polymerization.
Cyanoacrylates
Cyanoacrylates are widely used as superglue
in the manufacture of automobile and light
aircraft. In medicine it is used for fracture
fixation, skin suture and cardiac surgery.
In dentistry Cyano­veneer a luting atent is
used for nearly 20 years. Very recently ethyl
cyanoacrylates have been introduced for
orthodontic bonding, it has got acceptable
bond strength, and polymerization starts in
presence of pressure and moisture. It does
not require light for curing, and bonds with
com­p osite and cemaric brackets and is
biocompatible.
ORTHODONTIC CEMENTS
Dental cements and resins are used intraorally
to secure fixed orthodontic devices. Although
cements are still used, the popularity of
resin and resin-cement hybrid materials
is increasing because of their improved
physical properties and low solubility in oral
fluids. Some cements bond chemically to
enamel, but bond strengths are low because
cements are brittle and fracture cohe­sively.

Resin adhesives penetrate micropores in
etched enamel and mechanical retentions in
orthodontic devices, resulting in higher bond
strengths because resins are more fracture
resistant than cements. Resins, however, do
not bond well in the presence of moisture,
and their attachment to surfaces is primarily
mechanical. Hybridized materials combine
the advantages of cements and resins but
also have certain disadvantages. Optimal
material selection and application require an
understanding of the chemical differences
and physical limitations of today’s orthodontic
cements, resins, and hybrid materials.
Zinc Phosphate Cements
The basic constituent of zinc phosphate
powder is zinc oxide. Magnesium oxide and
bismuth oxides are present in small quantities.
The liquid is phosphoric acid, water, aluminum
phosphate and zinc phosphate.
When powder is mixed with the liquid,
the phosphoric acid attacks the surface of the
particles, dissolving the zinc oxide. Aluminum
in liquid is essential to cement formation. The
set cement is a cored structure consisting of
primarily of unreacted zinc oxide particles
embedded in a cohesive amorphous matrix
of zinc alumino-phosphate.
Working time is the time during which
the viscosity of the mix is such that it flows
readily under pressure forming a thin film.
Working time for zinc phosphate cement
is 3 to 4 minutes. Setting time is around 5
to 9 minutes. Compressive strength of zinc
phosphate is 103 MPa (15000 psi). The reco­
mm­e nded water powder ratio is 1.4 g to
0.5 ml of liquid. The retention provided by zinc
phosphate cements is mechanical.
Zinc Silicophosphate
Zinc silicophosphate cements are a combi­
nation of silicate and zinc phosphate cements.
Materials Used in Orthodontics 521
The powder contains a silicate glass in relatively
high percentages and zinc oxide powder. The
liquid is phosphoric acid, water and zinc and
aluminium salts. The cement does not bond
to enamel and provides only mechanical
interlock. By virtue of fluoride in silicate glass
component of powder they release fluoride
and thereby inhibit caries. The mechanical
properties are somewhat similar to that of zinc
phosphate cement.
Zinc Polycarboxylate Cements
Polycarboxylate of polyacrylate cement, as
it is sometimes called was the first cement
system that developed an adhesive bond to
the enamel.
The liquid is an aqueous solution of
polyacrylic acid or a copolymer of acrylic acid
with other unsaturated carboxylic acids. The
powder composition is similar to that of zinc
phosphate. Water settable versions are also
available. The cement bonds chemically to the
tooth structure.
Glass Ionomer-based Cements
Glass ionomer is the generic name of this
cement system since the powder is a glass and
the setting reaction and the adhesive bonding
to the tooth structure involve ionic bonds.
They are often referred as polyalkeonate
cements or abbreviated as GIC. They are
most commonly used to cement the bands in
ortho­dontics.
The cement is a powder-liquid system;
liquid consists of aqueous solutions of polya­
crylic acid, itaconic, maleic or tricar­boxylic
acids. The powder is an acid soluble calcium
fluoroaluminosilicate glass, similar to that of
silicate cement.
The set cement consists of an agglomeration
of unreacted powder particles surrounded by a
silica gel in an amorphous matrix of hydrated
calcium and aluminium poly salts.
522 Essentials of Orthodontics
Working time is about 3 to 4 minutes and
setting time is about 6 to 9 minutes.
Compressive strength is 86 MPa (12500 psi)
and film thickness is 24 microns.
Reaction between zinc ox ide and
polycarboxylic acid has little effect on oral
tissues; thus, it is consid­ered biocompatible
cement. Despite polycarboxylate cement’s
chemical bonding to dental and orthodontic
substrates, its relatively high solubility and
relatively low fracture resistance limit its
clinical use. Glass ionomer cements (GICs)
capitalize on carboxyl chelation to enamel,
dentin, and most metals by employing
various mixtures of carboxyl-containing
acids (polyalkenoic acids) reacted with
aluminosilicate glass. Aluminosilicate glass
fused in the presence of fluoride fluxes results
in an alkaline composition that releases
fluoride ions when reacted with acids. Fluoride
release has been measured during the GIC
setting reaction and after setting. Additional
fluoride is released when GICs are exposed to
acids. Caries inhibition has been associated
with a sustained low-level fluoride release from
GICs. Furthermore, GICs contain hydrogel
phases, supporting the movement of calcium,
strontium, and other ions associated with
the remineralization of enamel and dentin.
GIC hydrogel phases are thought to be
responsible for the uptake and rerelease of
added environmental fluoride from topical
gels, rinses, and dentifrices. Compared with
polycarboxylate cements, GICs show higher
bond strengths to enamel, dentin, and metals.
Mixing GICs, however, is technique sensitive,
and the hydrogels desiccate and crack in dry
environments.
Low fracture resistance limits their ortho­
dontic use primarily to band cementation;
how­e ver, clinical use of GICs for bracket
bonding has been reported. The development
of capsulated GICs eliminated most mixing
variables. GICs inhibition of demineralization
in adjacent enamel and its improved band
retention are the chief reasons that it remains
useful to orthodontists for cementing bands
in caries-prone patients. GICs have been
used for orthodontic bracket bonding, but
bracket retention was poor compared with
resin controls. There is agreement among
orthodontists that conventional GICs lack
the physical properties necessary to retain
brackets throughout treatment. Despite the
low bracket-retention rates of GICs, their
chemical adhesion and moisture tolerance
eliminate the need for acid etching and drying.
Resin-modified Cements
The orthodontic use of GICs increased dramati­
cally with the development of resin-modified
GICs (RMGIC). The addition of 10% to 20%
resin monomers to the GICs resulted in cement
that is initially hardened with the use of either
light or chemical activators to polymerize the
monomers. RMGICs are adhesive cements
with improved physical properties and
more stable hydrogels compared with GICs.
Capsulation of RMGIC powder and liquid
components simplified mixing procedures with
a triturator. Although a limited amount of resin
monomer can be added to the polyalkenoic
acid solution, polymerization of the resin
monomers hastens the initial hardening of
RMGICs without inter­fering significantly with
the acid-base setting reaction, the fluoride
release, or the chelation of carboxyl groups to
metal and tooth surfaces. In addition to the
chemical bonding of RMGICs, resin monomers
penetrate surface irregularities to produce
a micromechanical interlock (bond) after
polymerization. In addition to the advan­tage
of operator-controlled setting, light-acti­
vated polymerization proceeds significantly

faster than acid-base (cement forming) rea­
ctions, resulting in improved early physical
properties, especially fracture resistance.
Maturation hardening, sustained fluoride
release/recharge, and caries inhibition are
similar compared with conventional GICs and
RMGICs. Also similar are the abilities of both
GICs and RMGICs to chemically bond in the
presence of moisture.
Resins
Resin adhesives consist of resin monomers and
inert fillers. Similar to Resin Modified GICs,
polymerization can be either light activated,
chemically activated, or dual cured with both
light and chemical activation. Light activated
resin adhesives are always single-component
materials stored in opaque packages. Single-
component resins are convenient because no
mixing is required, thus eliminating technique
variables. However, because resins harden
solely through a polymerization reaction,
they neither contain nor form hydrogels, and
water is not a significant component. Although
some resin adhesives release fluoride, the
amount is quite low and most likely has no
effect on caries. Certainly, without an acid-
base reaction, the release of reminerali­zation
ions other than fluoride is unlikely unless the
resin contains soluble glass filler. Soluble fillers
are subject to dissolution and ion release.
However, without hydrogel formation, there
is little fluoride recharge and movement of
remineralization ions. Resin adhesives attach
to dry, etched enamel by the same mechanical
bonding mechanism as do RMGICs. Because
resin monomers contain few, if any, carboxyl
groups, chelation to enamel, dentin, and metal
surfaces does not occur. Optimal adhesion
with resins requires acid etching or other
surface treatments and a dry operating field.
Resin polymerization with light activation
Materials Used in Orthodontics 523
is operator controlled, and resin adhesives
acquire their optimal physical properties
quickly. Generally, resins are less brittle and
more fracture-resistant than cements.
Polyacid-modified Composite Resins
(Compomers)
Polyacid-modified composite resins, also
known as compomers, were developed to
bring the features of caries inhibition and
carboxyl chelation to resins. Compomers
are single-component systems consisting
of aluminosilicate glass in the presence of
carboxyl-modified resin monomers and
light-activated conventional resin monomers.
Although the alkaline glass and acidic carboxyl
compo-nents are packaged in the same
Container, allegedly no acid-base setting
reaction occurs because water is absent from
the composition.
However, after light-activation of the com­
pomer, it is postulated that water sorbs into
the compomer, allowing a delayed acid-base
reaction that may release fluoride and other
remineralizing ions from the aluminosilicate
glass. The relatively weak acid-base reaction
does not result in increased physical properties
of the compomer. The absence of hydrogels
restricts ion uptake and release, although
fluoride recharging of compo­mers has been
reported and can be explained by water
sorption and diffusion dynamics. Compomers
have been linked to caries inhibition in
vitro because of fluoride release from the
aluminosilicate glass filler at low pH. Acid
etching or other surface treatment is required
before compomer orthodontic adhesives
are used, and bonding surfaces must be dry.
Carboxyl chelation with cations on enamel,
dentin, and metallic surfaces has not been
shown to occur with com­pomer adhesives.
Physical properties are acquired quickly as
524 Essentials of Orthodontics
compomers polymerize, and their early setting
strengths are superior to those of the RMGICs
but inferior to those of the resin adhesives.
Summary
Cements differ from resins in that cements are
2-component systems that harden because
of acid-base reactions between components.
Cements contain water and, in the case of
carboxyl-containing cements, will bond
to moist surfaces. The water in hardened
dental cements in the form of hydrogels
supports ion movement within the cement
and ion exchange between the cement and
its environment. Ionically active cements
are associated with caries inhibition, remin­
erali­­zation, and chemical bonding to enamel,
dentin, and many metals. Orthodontic resin
adhesives do not inherently contain water
and therefore bond best to acid-etched or
roughened, dry surfaces through mechanical
retention rather than chemical bonding. Light-
activated resin adhesives are single component
materials, are easier to manipulate than
cements, and have better physical properties.
Resins harden through a poly­m erization
reaction and have limited ionic activity. Water-
soluble elements added to resins will diffuse
into the environment, but their effect on caries
inhibition and remineralization appears to be
insignificant. Compomers behave much like
resin adhesives; they bond primarily through
physical interaction with dry surfaces. Although
compomers contain carboxylmodified
resin monomers, they are packaged as
singlecomponent materials, suggesting limited
reactivity between alkaline glass and acidic
monomers. Studies characterizing the setting
reaction of compomers confirm that little
setting occurs after light activation, despite
the acid-base reaction. Com­pomer bonding
studies have failed to confirm the chelation
of carboxyl groups to enamel or dentin. The
fluoride release from compomers is lower than
that from GICs but higher than that from resins.
Fluoride recharging and caries inhibition
of compomers have been reported. This
information is intended to clarify the chemical
and physical distinctions among various
orthodontic bonding materials. Clinicians
need to be knowledgeable about the various
cements and orthodontic bonding adhesives
so that they may select and use these materials
appro­priately.
SEALANTS AND ADHESION
PROMOTERS
Bonding of brackets on surfaces of Ceramic,
Metal, Amalgam and other surfaces are
achieved by adhesion promoters. With
adult orthodontics becoming more popular,
there is an increasing percen­tage of patients
with prostheses and restorations seeking
orthodontic treatment. Rou­ghening of the
surface with sand blasting using Al2O3 (30–50
µ) increases the surface roughness and surface
energy. Chemical adhesion promoters have
been introduced which enhances bond
strength with resins.
Adhesion Promoters for Gold
1. Resin with adhesion promoters: (e.g.
Superbond CB, C and B metabond,
Geristore) these are metal bonding agents
that contains 4 metha­cryloxyethyl trimel­
titate anhydrade PMMA powder and 4
tributylborane as activator.
2. Intermediate primers:
i. All bond 2 (A and B): Contains biphenyl
dime­t hacrylate and MG salt of N
tolyglycine—Glycedyl methacrylate in
acetone.

ii. Scotchbond multipurpose adhesive
system: It is aqueous solution of maleic
acid, HEMA and traces of methacrylic
acid.
Adhesion Promoters for Porcelain
Bonding to porcelain is also enhanced by
the use of adhesion promoters principally
organosilanes Examples are All bond 2, Ormco
Ceramic Primer, Scotch prime. One difference
from gold is that an etching process is the use of
2.5% Hydrofluoric acid. Etching time is 90 sec;
Hydrofluoric acid dissolves the crystalline and
glassy phase of porcelain and thus enhancing
the surface area and energy.
Acidic Primers
This type of primer incorporates acid which
is helpful in etching before bonding. The
advantage being single step of bonding is done
without need for etching.
Moisture Resistant Primers
Moisture resistant primers can be used in cases
where moisture control is very difficult or in
cases of surgical exposure of impacted tooth
where moisture control is difficult. This primer
contains hydrophilic methacrylate monomer
that will wet enamel contaminated with saliva.
The bond strength is adequate and it provides
more freedom to operator.
CONDITIONING AND CRYSTAL
GROWTH SYSTEMS
Etchants
Acid etchants are also called enamel
conditioners; they are available in gel, paste,
or liquid form.
Types
1. Mineral acids: Phosphoric and nitric acids
Materials Used in Orthodontics 525
2. Organic acids: Citric, maleic, and tartaric
acids
3. Polymeric acids: Polyacrilic acid.
Objective
Objective of acid etching of enamel is to
remove the smear layer by demineralizing
enamel. Significantly rough enamel surface
is produced with high surface energy suitable
for bonding.
Clinical Procedure
Etchants are applied to enamel for about 15
to 30 sec (120 sec for deciduous teeth, since
the enamel is more mineralized) then washed
with water spray; surface is dried with air or
cotton. Care should be taken not to dessicate
the enamel, good etching is usually followed
by appearance of frosty appearance of enamel.
Air Abrasion (Microetching)
Fine particles of aluminum oxide are propelled
against the surface of enamel with high
pressure, causing abrasion. Usually intraoral
sandblaster is used in this technique. The bond
strength is only half that of acid etching.
Laser Etching
Application of LASER to enamel causes
localized melting and ablation of enamel
surface. Neodymium yttrium aluminum garnet
laser is used. This causes micro-explosion of
entrapped water in enamel, with some melting
of hydroxyapatite crystals. The bond strength
is less and it is very expansive.
Crystal Growth Systems
Crystal growth system relies on the creation
of a micro-mechanical crystalline, retentive
surfaces on the enamel to which bonding
adhesives are applied. This system was first
described by Smith and Cortez in 1973. The
material used is sulphated polyacrylic solution
526 Essentials of Orthodontics
for crystal growth. Later potassium, lithium
and magnesium sulphate were used as crystal
growth agents.
Advantages of crystal growth systems
include, minimal effect on enamel layer,
achieves clinically adequate bond strength,
and fewer resin tags are left behind.
ELASTICS AND ELASTOMERICS
Elastomer is a general term that encompasses
materials that, after substantial deformation,
rapidly return to their original dimensions.
Natural rubber, probably used by the ancient
Incan and Mayan civilizations, was the first
known elastomer. It had limited use because
of its unfavorable temperature behavior and
water absorption properties. With the advent
of vulcanization by Charles Goodyear in 1839,
uses for natural rubber greatly increased. Early
advocates of natural latex rubber elastics in
orthodontics included Baker, Case, and Angle.
Synthetic rubber polymers, developed
from petrochemicals in the 1920s, have a weak
molecular attraction consisting of primary
and secondary bonds. At rest, a random
geometric pattern of folded linear molecular
chains exists. On extension or distortion, these
molecular chains unfold in an ordered linear
fashion at the expense of the secondary bonds.
Cross-links of primary bonds are maintained
at a few locations along the molecular chains.
The release of the extension will allow for
return to a passive configuration provided the
distraction of the chains is not sufficient to
cause rupture of these primary bonds. If the
primary bonds are broken, the elastic limit has
been exceeded and permanent deformation
occurs.
Synthetic polymers are very sensitive to
the effects of free radical generating systems,
notably, ozone and ultraviolet light. The
exposure to free radicals results in a decrease
in the flexibility and tensile strength of
the polymer. Manufacturers have added
antioxidants and antiozonates to retard these
effects and extend the shelf life of elastomerics.
Elastomeric chains were introduced to the
dental profession in the 1960s and have become
an integral part of many orthodontic practices.
They are used to generate light continuous
forces for canine retraction, diastema closure,
rotational correction, and arch constriction.
They are inexpensive, relatively hygienic,
easily applied and require little or no patient
cooperation. Elastomeric chains, however,
are not without their disadvantages. When
extended and exposed to an oral environment,
they absorb water and saliva, permanently
stain, and suffer a breakdown of internal
bonds that leads to permanent deformation.
They also experience a rapid loss of force due
to stress relaxation, resulting in a gradual loss
of effectiveness. This loss of force makes it
difficult for orthodontists to determine the
actual force transmitted to the dentition.
The extensive body of literature regarding
the properties of these elastomeric chains
has been difficult to evaluate because of the
variable nature of the investigative methods.
Further, the proprietary information about
the individual products also complicates
comparisons of various manufacturers’
wares. There have been studies concerning
the force delivery and degradation properties,
the effects of prestretching, the influence of a
changing environment or composition, and
some miscellaneous information.
MAGNETS IN ORTHODONTICS
Magnetic force, as a viable alternative to traditi­
onal force systems used in orthodontics, was
demonstrated in an animal study reported

by Blechman and Smiley. This animal study
used AlNiCo (aluminum-nickel-cobalt)
magnets as the source of corrective force
and demonstrated the feasibility of this new
technology. These early results suggested
the biologic safety and mechanical efficacy
of permanent magnets for application in
orthodontics and held promise for potential
new operator-controlled procedures.
In this application, samarium cobalt
(SmCo) magnets were chosen over AlNiCo
magnets for their superior properties.
Certain physical properties of magnets
generally and of SmCo specifically, which
have a direct bearing on generated force, were
considered. For example, energy-product,
air gap (space bet­w een magnetic poles),
geometric configuration, and size and mass
of the magnet were all exam­ined. The energy
product, which is calculated by multiplying the
field flux density (B), and the magnetomotive
force (H), is an indication of stored energy and
potential force generated. Currently available
SmCo magnets are capable of expressing
an energy product which varies between 14
and 31 million gaussoersted (14-31 MGOe).
As with most electromagnetic fields, the
inverse-square law applies in a very general
sense (with limitations), so that small air
gaps between attracting or repelling poles
generate proportionately high forces and
large air gaps generate relatively small forces.
In addition, force is approximately pro­por­
tional to magnet size and shape. While an
app­roxi­mate cube produced optimum force
values in tests of SmCo, natural buccolingual
constraints necessitated a relatively flat square
or rectangular shape. Other intraoral size
limitations also required certain accommod­
ations. For example, if there is a 1 mm air
gap between the attracting poles of a pair
of magnets of the shape and if they have an
Materials Used in Orthodontics 527
energy product of 26 mega oersteds, then
there is available a potential force of between
50 and 300 grams, depending on the mass of
the magnet.
In addition to the obvious advantage of
providing intermaxillary force of sufficient
intensity and duration independent of
patient cooperation, theoretically, another
advantage in using magnetic force systems in
the treatment of malocclusions is better vector
control. The horizontal vector component
generated by 100 gm Class II elastic will be
less than 100 grams, depending on the degree
of mouth opening. By comparison, a magnetic
force system incorporating SmCo magnets is
capable of generating essentially horizontal
force. The force generated may average 120
grams, which may be controlled by operator
adjustment of the air gaps.
Forces were checked initially on an Instron
device and later on a sophisticated strain
gauge. In this pilot study it was found that,
as the air gap decreased between attracting
magnets, a situation unique in orthodontic
force systems developed; the force generated
increased gradually with time and with the
distance that the teeth moved. On the other
hand, repulsive force appeared to have a wider
range of motion because tooth movement
could be started from a 0 mm air gap since
there is no natural stop, as with attraction (that
is, when the poles contact) (Figs 15.4A and B).
Magnetic moments are another unique
characteristic of magnetic force application.
By laterally offsetting the poles in attraction
or repulsion, in addition to the obvious
vertical and horizontal vectors, a third vector
force can be generated in the third plane.
This lateral three-dimensional component
can be adjusted in the mouth for desirable
application. Theoretically, for example,
this application could be used with Class II
528 Essentials of Orthodontics
A B
Figures 15.4A and B: Magnetic appliances
mechanics to establish posterior intrusion
or extrusion with simultaneous cross bite
correction, and it is operator controlled.
When only two-dimensional control
is required, magnets can be used for
intermaxillary mechanics in deep bite or
open bite cases. In theory, attracting magnets
can extrude posterior segments in deep bite
cases and result in opening the bite as well as
in moving the teeth mesiodistally. In openbite
cases, magnets in repulsion can be used to
intrude posterior segments and result in bite
closing as well as in moving teeth mesiodistally.
Obviously, traditional arch wire manipulation
will generate reciprocal equal and opposite
forces in the anterior segments. However,
posterior magnetic intrusion or extrusion may
also be used independently without base arch
wire control if the situation requires it. Likewise,
the same magnetic forces may be localized to
the anterior segments alone.
Finally, SmCo magnets also possess very
large demagnetization properties in the
second quadrant of the hysteresis curve (which
describes the physical behavior of permanent
magnets). This material is, therefore, far
superior in resisting loss of magnetic energy
with time as compared to most other magnetic
alloys. In oral applications, SmCo magnets are,
therefore, advantageous since they are less
likely to be affected by most physical, chemical,
and thermal perturbations.
SOLDERING AND WELDING
Metal joining operations are usually divided
into three categories welding, brazing and
soldering.
Welding
The term welding is used if two pieces of similar
metal are joined together without the addition
of another metal that is, the metal pieces are
heated to a high enough temperature so they
join together by melting, flowing, heat and
pressure.
Brazing and Soldering
The words soldering and brazing are used if
two pieces of metal are joined by means of a
third (filler) metal.
Brazing
Brazing is a process where metal parts are
joined together by melting a filler metal
between them at a temperature below the
solidus temperature of the metal being joined
and above 450°C .

Soldering
Brazing is a process where metal parts are
joined together by melting a filler metal
between them at a temperature below the
solidus temperature of the metal being joined
and below 450°C .
Note: In dentistry, the joining of metal parts
is done at temperatures above 450°C, and
therefore the operations should ideally
be called brazing. However, most dentists
still prefer to use the word soldering. Some
authors use the term brazing filler metal for
solder.
Solder
Solder is a filler metal used to join the two
parent metals during soldering or brazing.
Ideal Requirements of a
Dental Solder
1. It should melt at low temperatures than the
parent metal.
2. When melted, it should be wet and flow
freely over the parent metal.
3. Its color should match that of metal being
joined.
4. It should be resistant to tarnish and
corrosion.
5. It should resist pitting during heating and
application.
6. It should be biocombatible.
Types of Solders
(Brazing Filler Metal)
They may be divided into two major groups:
Soft Solders
Soft solders have low melting range of about
260° C. They can be applied by simple means
like hot soldering iron. They lack corrosion
resistance and so are not suitable for dental
use, e.g. lead-tin alloys (plumbers’ solders).
Materials Used in Orthodontics 529
Hard Solders
These have a higher melting temperature
and have greater strength and hardness. They
are melted with the help of gas blow torches
or occasionally in an electric furnace. Hard
solders are more commonly used in dentistry
and orthodontics. They are also used for
industrial purposes and in the jewellery trade,
e.g. gold solders and silver solders.
Applications
In dentistry they are used as follows:
1. For soldering various types of wires and
wires with bands.
2. In fixed prosthodontics for joining various
components of fixed partial prosthesis and
repair of crowns and bridges.
3. In removable partial prosthodontics for
soldering of clasps.
Composition
Gold Solders
In the past solders were preferred to by a carat
number. The numbers did not describe the
gold content of the solder but rather the carat
of gold alloys for which the solder was to be
used. In recent years the term fineness has
been substituted for carat.
The compositions of gold solders vary
considerably depending on its fineness.
Gold = 45–81%
Silver = 8–30%
Copper = 7–20%
Tin = 2–4%
Zinc = 2–4%.
Silver Solders
Silver solders are more commonly used in
orthodontics and are used for soldering
stainless steel or other base metal alloys like
cobalt chromium alloys.
530 Essentials of Orthodontics
• Silver solders are composed of:
• Silver = 10–80%
• Copper = 15–50%
• Zinc = 4–35%.
Cadmium or phosphorus may be present
in small amounts.
Properties of Dental Solders
Fusion temperature: The fusion temperature
of the solder should be atleast 50°C lower than
the parent metal.
Gold solders = 690 – 870°C
Silver solders = 620 – 700°C.
Flow: A good flow and wetting of the parent
metal by the solder is essential to produce a
good bond.
The following factors affect flow:
Melting range: Solders with short melting
ranges have better flow.
Composition of parent metal: Gold and silver
based alloys have better flow than nickel based
alloys.
Oxides: Presence of an oxide layer on the
parent metal reduces the flow.
Surface Tension of Solder
Color
The color of gold solders varies from deep
yellow to light yellow to white. In practive,
most dental solders are able to produce an
inconspicuous joint.
Tarnish and corrosion resistance: Tarnish
resistance increases as the gold content
increases. However, lower fineness gold alloys
also perform well clinically without any serious
tendency to discolor.
Silver solders have reduced tarnish resis­
tance when compared to gold alloy solders.
Mechanical properties: Gold solders have
adequate strength and hardness and are
comparable to dental cast gold alloys having
a similar gold content.
Silver solders also have adequate strength
and are similar to the gold solders.
Microstructure of soldered joints: Microscopic
examination of an ideal well formed soldered
joint shows that the solder alloy does not
combine excessively with the parts being
soldered. There is a well defined boundary
between the solder and the soldered parts.
If the heating is prolonged diffusion takes
place and the new alloy formed has inferior
properties.
Fluxes
The Latin word ‘flux’ means flow. For a solder
to wet and flow properly, the parent metal must
be free of oxides. This is accomplished with the
help of flux.
Function of Flux
1. To remove any oxide layer on the parent
metal.
2. To protect the metal surface from oxidation
during soldering.
Types
Fluxes may be divided into three activity types:
Protective: This type covers the metal surface
and prevents access to oxygen so no oxide
can form.
Reducing: This reduces any oxide present to
free metal and oxygen.
Solvent: This type dissolves any oxide layer
present and carries it away. Most fluxes are
combinations of two or more of the above.
The commonly used fluxes are:
Boric and borate compounds: Boric acid and
Borax, they are used with noble metal alloys.
They act as protective and reducing fluxes.
Fluorides: Potassium fluorides. These are
used on base metal alloys and are usually
combined with borates. They help to dissolve
the more stable chromium, nickel and cobalt
oxides.

Fluxes may be supplied as:
1. Liquid (applied by painting)
2. Paste
3. Powder
4. Fused onto the solder
5. Prefluxed solder in tube form.
Heat Source
The heat source is a very important part of
brazing. The most commonly used heat source
is a gas-air or gas-oxygen torch. The other
source is an electric furnace.
The flame must provide enough heat
not only to melt the filler metal but also to
compensate for heat loss to the surroundings.
Thus, the flame should not only have a high
temperature but also high heat content. Low
heat content of fuels lead to longer soldering
time and more danger of oxidation. Heat
content is measured in Btu per cubic foot of
gas.
The various gases used are:
Hydrogen: It has the lowest heat content (275
Btu) and therefore heating would be slow. This
flame is not indicated for soldering of large
bridges.
Natural gas: It has a temperature of 2680°C and
heat contyent is four times that of hydrogen
(1000 Btu). However, normally available gas
is non-uniform in composition and frequently
contains water vapor.
Acytelene: It has the highest flame temperature
(3140°C) and a higher heat content than
H 2 or natural gas. However, it has certain
problems. Temperature from one part of its
flame to another may vary by more than 100°C.
Therefore, positioning the torch is critical and
proper part of the flame should be used. It is
chemically unstable and decomposes readily
to carbon and hydrogen. The carbon may get
incorporated into the Ni and Pd alloys, and
hydrogen may be absorbed by the Pd alloys.
Materials Used in Orthodontics 531
Propane: It is the best choice. It has the highest
heat content (2385° C).
Butane: It is more readily available in some
parts of the world and is similar to propane.
Both propane and butane are uniform in
quality and water free.
Oven Brazing (Furnace Brazing)
An electric furnace with heating coils may be
used for brazing. The furnace also provides
heated surroundings, so less heat is lost to
other parts of the bridge and the atmosphere.
Technique of Soldering
Two techniques of dental soldering are
employed to assemble dental appliances:
1. Free hand soldering: In free hand soldering
the parts are assembled and held in contact
manually while the heat and solder are
applied.
2. Investment soldering: In investment
soldering, the parts to be joined are
mounted in a soldering type of investment.
The hardened investment holds it is
position while the heat and solder are
applied.
3. Infrared soldering:1000 watt tungsten
filament quartz iodine bulb is used. It is
mounted at the primary focal point of a
gold plated elliptical reflector and used as
the heat source.
Steps in Soldering Procedure
1. Selection of solder
2. Cleaning and polishing of components
3. Assembly of the bridge in soldering
investment
4. Application of flux
5. Preheating the bridge assembly
6. Placement of solder
7. Application of hot gas flame to joint and
solder
532 Essentials of Orthodontics
8. Cooling of assembly followed by quenching
in water.
Requirements for Successful Soldering
Cleanliness: Metal should be free of oxides.
Gap: Gap between the parts, the liquid solder
is drawn into the joint through capillary action.
Thus, an optimum gap is necessary for proper
flow and strength of the joint and to avoid
distortion of the assembly. Gap width ranging
from 0.13 to 0.3 mm has been suggested as
optimum.
If the gap is too narrow, strength is limited
due to:
i. Porosity caused by incomplete flow
ii. Flux inclusion.
If the gap is too great:
i. The joint strength will be the strength of
the solder
ii. There is a tendancy for the parts to draw
together as the solder solidifies.
Selection of solder: Proper color, fusion
temperature, and flow.
Flux: Neutral or reducing in nature.
Flame: Neutral or reducing in nature, the
portion of the flame that is used should be
neutral or slightly reducing. An improperly
adjusted and positioned flame can lead
to oxidation and or possibility of carbon
inclusion. Once the flame has been applied
to the joint ares, it should be removed until
brazing is complete. Due to its reducing nature,
the flame gives protection from oxidation (Fig.
15.5).
Figure 15.5: Flame used for soldering
Temperature
The temperature used should be the minimum
required to complete the brazing operation.
Prior to the placement of the solder, the parent
metal is heated till it is not enough to melt
the filler metal as soon as it touches. A lower
temperature will not allow the filler to wet the
parent metal. Higher temperature increases
the possibility of diffusion between parent
and filler metal.
Time
The flame should be kept in place until the
filler metal has flowed completely into the
connection and a moment longer to allow the
flux of oxide to separate from the fluid solder.
Shorter time increases chances of incomplete
filling of joint and possibility of flux inclusion
in the joint. Longer times increase possibility of
diffusion. Both conditions cause a weaker joint.
Hydrosoldering Units
A recent development in orthodontic soldering
is a hydrogen soldering unit which consists
of a unit with hydrogen gas producing unit
and a flame controlling unit used to produce
reducing flame of hydrogen gas which can
effectively solder stainless steel without
oxidizing the components.
Antiflux
There are times when the operator desires
that the solder should not flow into a specific
area. The flow can be prevented by use of an
antiflux material. It is applied to the surface
before the flux or solder is applied. Solder will
not flow into an area where antiflux has been
applied. Examples of antiflux are graphite (soft
lead pencil), rouge (iron oxide) or whiting
(calcium carbonate) in an alcohol and water
suspension.

Pitted Solder Joints
Pits or porosities are the solder joint often
becomes evident during finishing and
polishing. They are due to:
i. Volatilization of the lower melting
com­ponents due to heating at higher
temper­atures and for longer times.
ii. Improperly melted or excess flux that
is trapped in the solder joint. To avoid
such pitting, less flux is applied and the
leating should be discontinued as soon
as the flux and solder are well melted
and flowed into position.
Welding
The term welding is used if two pieces of
similar metal are joined together without the
addition of another metal. It is used to join flat
structures such as bands and brackets.
Indications
1. In orthodontics to join flat structures like
bands and brackets.
2. In pedodontics to weld bands and other
appliances.
3. In prosthodontics, to join wrought wire
clasps and repair of broken metal partial
dentures.
Technical Considerations
Welding is done by passing an electric current
through the pieces to be joined. These pieces
are also simultaneously pressed together. The
resistance of the metal to flow of current causes
intense localized heating and fusion of the
metal. The combined heat and pressure fuses
the metals into a single piece.
Welding is done in an electric spot welding
apparatus called as spot welder. The wires or
the band to be welded is placed between the
two copper electrodes of the welder. A flexible
spring attached to the electrode helps to apply
Materials Used in Orthodontics 533
Figure 15.6: Spot welder
pressure on the metals. A hand controlled
switch is used to operate the welder. On
pressing the switch a large current passes
through the wires or bands beween the coper
electrodes. The combined heat and pressure
fuses the metal pieces at that point and joins
them. This kind of welding may also be referred
to as ‘spot welding’ (Fig. 15.6).
Prosthodontic appliances are welded in a
larger machine. The parts to be joined are held
together using a special clamp. A hand or foot
controlled switch controls the current.
Weld joints are susceptible to corrosion
because of precipitation of chromium carbide
and consequent loss of passivation.
Laser and Plasma Welding
Laser welding units are now available. The
laser used as usually a pulsed high power
neodymium laser with a very high power
density.
Commercial Names
1. Dental laser DL 2002 (Dentarum, Germany)
2. Haas laser LKS (Haas Laser GmbH,
Germany)
534 Essentials of Orthodontics

3. Heraeus Hass laser 44P (Heraeus Kulzer, material in the mouth and allowing that
GmbH, Germany). material to set. Those impression materials
The unit consists of a small box that most frequently used in orthodontics are
contains the laser tip, an argon gas source and elastic in nature so that they can be removed
a stereo microscope with lens crosshairs for easily from the mouth. From this negative
correct alignment of the laser beam with the form of the teeth and surrounding structure,
components. The maximum depth the laser a positive reproduction or cast is made. These
can penetrate is 2.5 mm. The heat generated materials are called impression materials.
is small, so the parts can be hand held during
welding and it can be done close to the ceramic Ideal Requirements of an Impression
or even resin facings without damaging it. Material
1. Accuracy in duplication of the tissues
Indications 2. Exactness of the hard and soft tissues
Laser welding is used mainly to join titanium including the undercuts
components. This is because the commercially 3. Nonirritating to the oral tissues (Biocom­
pure titanium (cpTi) used in dentistry for brid­ patible)
ges and partial denture frameworks are highly 4. Pleasant color, taste and appearance
reactive in air. Ordinary soldering procedures 5. Sufficient strength
result in weak joint because of the formation of 6. Resistance to distortion and fracture
thick layer of titanium oxide (especially when 7. Easy to manipulate
heated above 850°C). Laser welding or plasma 8. Dimensional stable
selding can be done at lower temperatures. 9. Adequate shelf-life
10. Cheap and easily available.
Advantages of Laser Welding
i. Lower heat generation. Classification
ii. No oxide formation because of the inert According to the set structure they can be
argon atmosphere. classified as:
iii. Joint made of the same pure titanium as I. Rigid or inelastic
the components, thus reducing the risk 1. Impression plaster
of galvanic corrosion. 2. Zinc oxide eugenol
3. Impression compound
4. Impression wax.
OTHER DENTAL MATERIALS II. Elastic:
1. Alginate hydrocolloids
These materials are regular dental materials 2. Nonaqueous elastomers
used in orthodontics and in other specialities. a. Polysulphide polymers
b. Polyether.
Impression Materials c. Silicone
An impression is a record of the negative form i. Condensation polymerization
of the hard and soft tissues of the oral cavity. ii. Addition polymerization
It is made by placing some soft semifluid 3. Agar hydrocolloids.

Uses
In orthodontics, alginates are most commonly
used as impression materials, elastomeric
materials, zinc oxide and waxes are used
for bite registration. Impression compound
material is sometimes used in cases of cleft lip
and palate cases. Agar and alginate materials
are used for duplication of casts.
Alginate Impression Materials
Alginate impression materials are irreversible
hydrocolloids which set by chemical change
called gellations and are elastic.
Alginate is obtained from sea weeds. In
1940 an English Chemist William Wilding
is first to use ‘Algin’ sea weed as a dental
impression material. Alginate was produced
as a substitute for agar impression material
during World War II.
Composition
Alginate is supplied in powder form to be
moxed with water for impression taking, the
power contains.
Pottasium alginate: 18% linear polymer of
pottasium salt of b D Mannuronic acid (Hydro
gel former).
Calcium sulphate 16% reactor, increases
shelf life and dimensional stability (Calcium
ion provider).
Pottasium titanium fluoride, or pottasium
zinc fluoride 3% ensures hard stone casts and
accelerates setting of stone.
Diatomaceous earth or zinc oxide or
silicate powder 55 to 60% filler increases
strength and stiffness form smooth and firm
enhances solution.
• Sodium phosphate 2% retarder
• Glycols trace—to make alginates dust free
• Pigments—to provide color
• Pepperment—to provide pleasant taste
• Disinfectants like chlorhexidine—to help
in disinfecting the impression
Materials Used in Orthodontics 535
• Sodium silico fluoride—controls the pH.
Some alginates are modified with water
without calcium to form a sol. This is mixed
with plaster of paris which acts as a reactor.
In some other alginates the ractor is calcium
itself.
Chemistry
Alginic acid is insolvable in waters but salts
of the alginic acid are soluble salts, with polar
carboxyl group such as sodium or pottasium
are insolvable and are used.
When alginate powder is mixed with
water it form a sol with increased molecular
weight and increased viscosity of the sol,
sodium phosphate reacts with calcium as all
the sodium phosphate reactor gets reacted
with calcium sulphate the calcium sulphate
reacts with potassium alginate to form calcium
alginate gel.
2Na3PO4 + 3CaSO4→ Ca3(PO4)2 + 3Na2SO4
K-Alg + n/2CaSO4→ n/2K2SO4 + Ca n/2 Alg
Alginates w ill deter iorate at high
temperatures, storing of alginates in high
temperatures are avoided they are to be stored
in cool and dry place, lid must be tightly closed
to reduce the contamination, and they should
not be stored for more than 1 year period.
Hydrocolloid
Hydrocolloid impression materials are solids
supersaturated in liquids, they are lyophilic
(liquid loving) sols. If gelatin or Agar is
dissolved in water, the gelatin particles attract
the water molecules and swell in size thus
forming a hydrocolloid. If the concentration
of the dispersed phase in the hydrocolloid is
of the proper amount, the sol may be changed
to a semisolid material known as a gel, when
the temperature is decreased the temperature
at which this change occurs is known as
gelation temperature for alginate it is about 18
to 20%, In alginate gel if formed from a sol by a
536 Essentials of Orthodontics
chemical reaction, the fibrils of the gel formed
chemically are primarily bonded and are not
effected by temperature changes. They can be
returned to sol only by a reversal of the original
chemical reaction and not by heat. So they are
called irreversible hydrocolloids.
Sol → Gel
Alginate is a linear polymer of the sodium
salt of b D Mannuronic acid, thus acts as
irreversible hydrocolloid.
Gel Structure
Fibrils in an alginate gel are assumed to be held
together by primary bonds rather than inter­
molecular forces. Final structure is brush heap
of calcium alginate fibril network enclosing
sodium alginate sol, with excess water and
filler particles and reaction byproducts.
Manipulation
Parabolic plastic bowl and stiff bladed spatula
are used for mixing water to powder ratio
is about ½ water measuring and 1 powder
measuring spon (W:P ratio of 1:2). The spatula is
stropped against the bowl in 8 shape mixing time
is about 45 sec. One min time from mixing to the
end of the gelation within which the impression
is to be taken, Gel­ation time is about 3 to 4 min.
ADA specification No. 18 for specifies:
• Type I (fast setting) 1 to 2 min
• Type II (normal setting) 3 to 5 min.
This gelation time is regulated by addition
of retarder altering W:P ration or altering
temperature of water compressive strength is
about 49.8 Psi surface reproduction of Alginate
is about 0.075 mm. Impression is disinfected
by iodophor or glutaraldehyde.
Imbibition and Syneresis
The gel may lose water by exudation from its
surface or by the exuding of fluid by a process
called syneresis.
Absorption of water it lacks water content
and causing swelling of gel structure is called
imbibition.
Advantages
1. Easy to manipulate
2. Does not require elaborate equipment
3. Comfortable for the patient
4. No special trays are required
5. Clean and pleasant, modified in form of
pleasant taste such as Cardamom or orange
is available, one product can change color
on mixing and setting is indicated by the
othe color.
6. Inexpensive
7. They are hydrophilic and can displace
saliva and blood.
Disadvantages
1. Cast must be poured immediately as they
are dimensionally unstable.
2. Cannot be stored for longer time.
3. They may tear easily.
4. They can be used only once for pouring
casts.
5. Not compatible with epoxy resins.
Uses
1. Impression for fabrication of appliances
and study models.
2. Impression for cleft lip and palate cases.
3. Bite registration for functional appliances.
4. Duplicating casts.
5. Impression of face.
6. For record purposes.
Impression Trays
Impression trays are used for loading
impression materials and carrying into the
mouth for the purpose of impressions.
Classification: Impression trays are classified
as:

1. Stock trays and special trays
2. Rim lock trays and nonrim lock trays
3. Perforated and non-perforated
4. Dentulous and edentulous
5. Complete and partial
6. Metal, plastic and resin
7. Maxillary and mandibular
8. Different sizes.
Impression Tray Selection
Generally stock trays are used for orthodontic
impression. Special trays are used with cleft
lip and palate cases. Rimlock trays are used
for agar impression materials. Perforated trays
are preferred over non-perforated trays since
they can prevent tearing of alginates, so that
impression materials are retained in the trays
through the pores such that it can be easily
drawn from mouth. Complete trays are used
resin trays may be required for cleft lip and
palate and facial impres­sions. Stock trays must
be selected such that there is a clearance of
about 3 to 4 mm for impression throughout and
the borders of the tray are correctly positioned
in the sulcus and covering up to retromolar
area.
Impression Technique in
Orthodontics
After proper tray selection, the patient is
placed upright with involved arch parallel
to the floor to avoid air entrapment during
mixing and placing tray. Alginate is wiped into
the tray with spatula from posterior region
forward so that only minimal material is left
in the posterior areas, because the excess
alginate may be forced to the throat and cause
gagging. The tray is seated first in the posterior
region and displaced anteriorly in the patients
mouth. Small amounts of impression material
may be placed in the critical areas such as
palatal vaults and lingual sulcus to prevent air
Materials Used in Orthodontics 537
Figure 15.7: Alginate impression
entrapment. Material should have developed
sufficient body so that it does not flow out of
the tray and choke the patient (Fig. 15.7).
Press middle and front of tray against
tissue to produce uniform layer of material.
Hold tray in place until alginate is set, as
determined by probing with finger. Impression
can be removed after ensuring the full set of the
material with a sudden snap or jerk to prevent
distortion.
Impression Technique for Cleft Lip
and Palate Cases
An intraoral examination is done prior
to impression taking it will reveal the
nature of unrepaired cleft in it repaired
those perforation that can result from tissue
breakdown one should look particularly the
anterior mucolabial fold for minute oronasal
perforation actions after the repair of clefts,
and also the mid palatal area.
Impression compound, alginate and
elasto­mers are commonly used for cleft lip
and palate cases. Impression compound can
only be used if no tissue undercuts are present.
Alginate is the common material.
The problems incident to impression are
divided into two groups are unrepaired cleft
presenting rare situation and the repaired
cleft another when using alginate the posterior
portion of the tray should be modified with
boxing or utility wax to prevent material from
538 Essentials of Orthodontics
flowing down the patients throat. In addition
the use of alginates adjacent to the cleft or
perforation should be prevented from entering
the nasal cavity. To prevent this tray should
be under loaded in the area of cleft. The tooth
bearing section of the tray is completely filled
with alginate, but the area corresponding
to the cleft is loaded to the height of only
2 to 3 mm thus when the tray is seated the
material is out likely to be forced upward into
the cleft in sufficient quantity to lock cleft
palates previously treated present slightly
different problems. The palate repair result
itself may look adequate and yet an oronasal
perforation may exist in the mucobuccal fold.
Since impression material would be forced
into similar perforations under more pressure
it is best to pack perforations with cotton or
petroleum jelly gauze found or impression
material small enough to be dislodged by
blowing the nose should not be of concern.
In young patients with cleft without
tooth and undercuts, impression compound
is extended and impression is taken, the
impression is repeated after softening for 4
to 5 times until required impression form is
obtained.
Facial Impression Techniques
Impressions of face are required for the
purpose of fabrication of chin cups, facial
reconstructions, cleft lip corrections,
maxillofacial prosthesis constructions, and
record purposes.
Facial impressions are also called “Mask
impressions” and are commonly taken with
alginate, agar hydrocolloids or elastomers.
Facial borders are built by modeling wax or
plate, according to the contour of face. Nose
is protected by cotton or gauze with tubing
for respiration. Eyes are closed and the mixed
impression is directly poured over the face and
removed as one piece one variation of this is
mask type of tray is used and impression is
taken similarly.
Duplicating Materials
Agar and alginate hydrocolloids can be used
as duplicating materials for dental casts.
Reversible hydrocolloids are more commonly
used as dental duplicating materials, as they
are kept in liquid form at constant temperature
and are cheap. Resin duplicating materials are
also available but they are expensive. ADA
specification No. 20 refers to dental duplicating
materials. These reversible agar hydrocolloids
duplicating materials contain more water and
less agar which influence the compressive
strength and setting characters.
Elastomeric Impression Materials
Nonaqueous elastomeric dental impression
materials are that set by chemical change and
are elastic and irreversible.
They are large molecules with some
weak bonds in between them so that when
stretching they elongate and when released
return to their original contour. They are also
called rubber impression materials.
Advantages of elastomeric impression
materials include no special equipments
required, good reproduction of details,
superior strength and can be electropolished,
pouring of casts can be delayed and poured
more than once, and it has good shelf life.
Disadvantages of elastomers include, the
impression can be distorted easily, extremely
hydrophobic and very expensive.
Bite Registration Waxes
Impression waxes are thermoplastic impre­
ssion materials which set by temperature
change, rigid and reversible.
The difference between impression wax
and modeling plastic is that the impression
waxes have the ability to flow as long as they are

in the mouth and there by permit equalization
of pressure and prevent over displacement,
whereas the modeling plastics flow only in
proportion to the amount of flaming and
tempering that can be done out of mouth, and
this does not continue after the plastic has
approached mouth tempera­ture.
Composition
Impression waxes contain various natural
waxes such as paraffin, ceresin, car nauba and
bees wax. Synthetic waxes such as Acrawax
and Durawax and additives such as stearic
acid, glycerol tristearate, turpentine oil,
natural resin, copal, damover, shellac, rosin
and synthetic resins such as polyethylene
polystyrene are also present.
Bite registration waxes exhibits high flow
and ductility, it will distort readily when with­
drawn from undercut areas. The use of waxes
therefore, has been limited to the non undercut
edentulous portions of mouth and they are
generally used in combination with impression
materials such as polysulphide rubber, zinc
oxide, and eugenol or impression compound.
Waxes expand when subjected to a rise
in temperature and contracts as temperature
decreased. The elastic modulus, proportional
limit and compressive strength of waxes
are low. Ductility of the wax increases as
temperature increases.
Bite registration wax is used to articulate
certain models of opposing quadrants the
wax bite registration must provide proximal
and occlusal relations. Bite registration
are frequently made from 28 range casting
wax sheets or from base plate wax, but
waxes identified as bite waxes appear s to be
formulated from bees wax or hydrocarbon
waxes such as paraffin or ceresine. Certain
bite waxes contain aluminum copper particles.
There are no ADA specifications for bite waxes.
Materials Used in Orthodontics 539
The flow is measured by penetration at 37°
ranges from 2.5 to 22% indicating that these
waxes are susceptible to distortion on removal
from mouth these bite registration waxes
are used for bite registration in fabrication
of functional appliances such as activator,
bionator and Frankel appliance.
Gypsum Products
Gypsum is a mineral, chemically it is nearly
pure calcium sulfate dehydrate (CaSO4.2H2O)
These materials are the results of the
calcining of gypsum. Commercially the gypsum
is ground and subjected to temperatures of
110 to 120°C to drive off part of the water of
crystallization. As the temperature is further
raised the remaining water of crystallization is
removed and products formed are hexagonal
anhydrate and orthorhombic anhydrate.
CaSO4.2H2O→(CaSO4)2.H2O→CaSO4→CaSO4
The principal constituent of the dental
plasters and stones is the calcium sulfate
hemihydrate (CaSO4)2.H2O or CaSO4.½H2O.
Depending upon the method of calcinations,
different forms of the hemihydrate can be
obtained. These forms will be referred to as a
or b Hemihydrate.
Plaster of Paris
If gypsum is heated to the temperatures of 110
to 120° C in a kettle, vat or rotary kiln open
to air, a crystalline form of the hemihydrate
results known as b-hemihydrate, which is
also known as plaster of paris. These crystals
are characterized by their sponginess and
irregular shape.
Dental Stone
When gypsum is heated with special procedure
a-hemihydrate is obtained, which is the dental
stone. The product is denser and which have a
prismatic shape.
540 Essentials of Orthodontics
Types
According to ADA specification No. 25 for
gypsum products the following five types have
been classified:
Type I (Impression plaster): These plasters are
plasters of paris to which modifiers have been
added in order to regulate the setting time
and the setting expansion. These materials
are rarely used now and are restricted to final
impression for complete dentures.
Type II (Model plaster, plaster of Paris): They
are the b form of hemihydrate of gypsum
commonly known as plaster of paris. Their
strength is low. They are commonly marketed
white in color are are used as casts for working
models, fabrication of soldered components
and for articulating of models in fabrication
of functional appliances and surgical splints.
Type III (Dental stone): These are a forms
of hymihydrate of gypsum. They are mainly
intended for construction of casts in the
fabrication of appliances and study models.
They have adequate strength. They are most
commonly used in orthodontics as Kalstone,
Orthokal and Densite, for construction of study
models.
Type IV (Dental stone high strength): This type
of hemihydrate has high strength and the
particles are cuboidal in shape.
Type V (Dental stone high strength high
expansion): These products have higher
strength than Type IV and they also have
high setting expansion used commonly as
investments for casting.
Proportioning
Since the strength of stone is indirectly
proportional to the W:P ratio, is it most
important to keep the amount of water as low
as possible. The water and powder should be
measured by using a scoop. Normal W:P ratio
for dental stone used in orthodontics is 0.28
to 0.30.
Mixing
When mixing with hand the bowl should
be parabolic in shape smooth and resistant
to abrasion. The spatula should have a stiff
blade and a handle that is convenient to hold.
Trapping of air in the mix must be avoided in
orer to avoid porosity leading to weak spots
and surface inaccuracies. The use of automatic
vibrator of high frequency but of low amplitude
is useful.
Water is taken in the bowl, the powder is
then added to the bowl the mixture is then
vigorously stirred, with the periodic wiping of
the inside of the bowl with the spatula to suture
the weting of all of the powder and breaking
up of any agglomerates, or lumps. The mixing
should continue until a smooth mix is obtained,
usually within a minute. Longer spatulation will
drastically reduce the working time.
The guess work of repeatedly adding water
and powder in order to achieve the proper
consistency must be avoided. It will result in
an uneven set within the mass, resulting in low
strength and distortion, one of the main causes
of inaccuracy in the use of gypsum products.
Mixing Time
This is the time from the adition of the powder
to the water until mixing is completed.
Mechanical mixing of stones and plasters
is usually completed in 20 to 30 sec. Hand
spatulation generally requires at least 1 minute
to obtain a smooth mix.
Working Time
This is the time available to use a workable mix,
one that maintains even consistency that may
be manipulated. Generally 3 minutes working
time is adequate.
Setting Time
The time that elapses from the beginning of
mixing until the material hardens is known as

the setting time. It is normally measured by
penetration tests.
Loss of gloss: As the reaction proceeds some
of the excess water is taken up in forming the
dihydrate so that the mix losses its gloss and it
takes about 9 minutes.
Initial Gillmore: Gillmore needles are used
and the time at which it no longer leaves an
impression is called initial set.
Vicat setting time: Another instrument used to
determine the setting time.
Fina Gillmore: Heavier gillmore needle is used.
The elapsed time when it leaves only a barely
perceptible mark on the surface is called the
final setting time.
Ready for use: It is considered as the time when
the compressive strength is at least 80% of that
attained at 1 hour. Most of orthodontic plasters
are ready to use by 30 minutes.
Accelerators and Retarders
Accelerators are added to gypsum to reduce
the setting time, and retarders are added to
prolong the setting time.
Pottasium sulphates, Sodium sulphate,
powdered gypsum, are common accelerators.
Increase in time and speed of mixing also
accelerate setting.
The citrates, acetates and borates generally
retard the reaction.
Setting Reactions
When hemihydrate is mixed with water,
a suspension is formed that is fluid and
workable. The hemihydrate dissolves until
it forms a saturated solution. This saturated
solution of the hemihydrate is supersaturated
with respect to the dihydrate, so the latter
precipitates out. As the dehydrate precipitates,
the solution is no longer saturated with the
hemihydrate so it continues to dissolve.
Thus the process continues solution of the
Materials Used in Orthodontics 541
hemihydrate and precipitation of the dihydrate
whether new crystals or further growth on
those already present. The reaction is con­
tinuous and repetitious until exhausted.
The reaction rate can be followed by the
exothermic heat evolved. Initially there is
very little reaction and thus, little or no rise
in temperature. That time is referred to as the
induction period. This is accompanied by a
slight thickening of the mass, which permits
the mix to be poured into an impression or tray.
As the amount of gypsum forming increases,
the mass thickness and then hardens into
needle like clusters called spher­ulites, finally
the intermeshing and entangling of crystals of
gypsum lead to a strong, solid structure.
Compressive strength of commonly used
orthodontic plasters after 1 hour is about 210
kg/cm2 (3000 psi).
Care of the Cast
If the surface of the cast is not hard and smooth
when it is removed from the impression,
its accuracy is questionable. The cast is
supposedly an accurate reproduction of the
mouth tissues, and any departure from the
expected accuracy will probably result in a
poorly fitting appliance. Therefore the casts
should be handled carefully.
Storage of set plaster or stone at room tem­
perature produces no significant dimensional
changes. If the storage temperature is raised
above 55°C dimensional changes like shrinkage
occurs and strength is lost.
For ease of trimming orthodontic plasters
have longer working time and are normally
polished with soap for an added sheen and
good appearance.
Infection Control
Disinfecting solutions can be used that will
not adversely affect the quality of the gypsum
542 Essentials of Orthodontics
cast, overnight gas sterilization with ethylene
oxide can be used.
ACRYLIC MATERIALS
Synthetic resins are nonmetallic compounds
synthetically produced that can be moulded
into various forms and than hardened for use.
The most common synthetic resin used in
dentistry is based on acrylic resin, poly methyl
methacrylate.
IDEAL REQUIREMENTS FOR
DENTAL RESIN
1. The material should exhibit a trans­
lucence or transparency such that it can
be made to duplicate esthetically the
oral tissues it is to replace. It should be
capable of being tinted or pigmented to
the end.
2. There should be no change in color or
appearance of the material subsequent
to its fabrication.
3. It should not expand, contract, or warp
during processing or during subsequent
use by the patient.
4. It should possess adequate strength,
resilience, and abrasion resistance.
5. It should be impermeable to the oral
fluids.
6. It should be completely insoluable in
the oral fluids.
7. The resin should be tasteless, odorless,
non-toxic, and non-irritating to the oral
tissues.
8. It should have low specific gravity.
9. Its softening temperature should be well
above the temperature of any hot foods
or liquids taken during mouth.
10. In case of unavoidable breakage, it
should be possible to repair the resin
easily and efficiently.
11. The fabrication of the resin into a dental
appliance should be easily effected with
simple equipment.
ACRYLIC RESINS
Acrylic resins are derivatives of ethylene
and contain a vinyl group in their structural
formula.
Methyl methacrylate is a liquid monomer
which is mixed with poly methyl methacrylate
polymer which is in powder form. The
monomer partially dissolves the polymer to
form plastic dough. This dough is packed into
the mould, and the monomer is polymerized
by one of the three methods chemical, heat or
light curing.
Methyl methacrylate is a clear, transparent
liquid at room temperature with the following
physical properties: melting point of –48°C,
boiling point of 100.8°C, density of 0.945 gm/
ml at 20°C, and heat polymerization of 12.9
kcal/mol. It exhibits high vapor pressure and
is an excellent organic solvent. The conditions
for the polymerization of methyl methacrylate
are not critical, proviced that the reaction is
not carried out at a too rapid rate. The degree
of polymerization varies with the conditions
of polymerization, such as the temperature,
method of activation, type of inititator used
and its concentration, and purity of chemicals.
A volume shrinkage of 21% occurs during
the poly-merization of the pure methyl
methacrylate monomer.
Poly methyl methacrylate is a transparent
resin or remarkable clarity. It transmits light into
the ultraviolet range to a wavelength of 0.25 µm.
It is a hard resin with Knoop hardness number of
18 to 20. Its tensile strength is approximately
59MPa (8500 psi) and its specific gravity is
1.19. Its modulus of elasticity is approximately
2400 MPa (350,000 psi). The resin is extremely

stable; it will not discolor in light. It is stable
at heat and softens at 125°C and it can be
moulded as a thermoplastic material. The
typical methacrylate polymers increase by
0.5% of weight when placed in water for one
week. The polymers are soluble in chloform
and acetone.
Uses of Acrylic Resins in
Orthodontics
1. Fabrication of removable appliances like
Hawleys appliance, etc.
2. Fabrication of functional appliances like
activator, bionator, etc.
3. Fabrication of retention appliances like
hawleys retainer, Begg retainers, etc.
4. Fabrication of orthognathic surgical splints
and occlusal splints.
5. Fabrication of special trays for special
impressions.
6. Fabrication of special study models for
demonstration and research purposes.
7. Fabrication of chin cups.
8. Fabrication of appliances for cleft lip and
palate therapy.
Self-cure Acrylic Resins
Composition
The monomer is generally pure methyl metha­
crylate with a slight amount of hydroquinone
(0.006%) which aids in the inhibition of
poly­merization during storage. Crosslinking
agent is added in the monomer at 1 to 2%.
The polymer usually consists of a powder
composed of small spherical particles.
Plasticizers such as dibutyl phthalate are
added in 8 to 10%, to prevent deterioration
in oral fluids. An initiator benzoyl peroxide is
always included in polymer. Coloring pigments
are also added.
The fundamental difference between them
and other resin is that the method of activation
Materials Used in Orthodontics 543
of the benzoyl peroxide. Tertiary amines are
added to the monomer before monomer
and polymer are mixed so that the reaction
takes place at room temperature. As a general
rule the degree of polymerization by use of
a chemical activator is not as high as that by
activation by heat.
The type and concentration of both the
activator and the initiator influence the
rate and degree of polymerization. There
appears to be a maximal useful concentration
of the amine at approximately 0.75%; the
maximal concentration for the peroxide is
2%. As with the heat curing resing, the rate of
polymerization is influenced by the particle
size of the polymer. The smaller the particle
size, the more rapid is the polymerization.
Properties
Self-cure resins have lower maximal strength
and stiffness because of lower degree of poly-
merization attained and residual monomer
retained. The tensile strength and modulus of
elasticity of self-curing are also less than that
of heat cured resins. Hardness of self-curing
resin is 16-18 Knoop hardness number and
that of heat cure resin is 20 KHN. Color stability
is also less for self-cure resin than for heat
cured resins.
Heat Cure Acrylic Resins
Composition
The monomer is generally pure methyl meth­
acrylate with a slight amount of hydro-quinone
(0.006%) which aids in the inhibition of
polymeri­zation during storage. Crosslinking
agent is added in the monomer at 1 to 2%.
The polymer usually consists of a powder
composed of small spherical particles.
Plasticizers such as dibutyl phthalate are
added in 8 to 10%, to prevent deterioration
in oral fluids. An initiator benzoyl peroxide is
544 Essentials of Orthodontics
always included in polymer. Coloring pigments
are also added.
Usually monomer and polymer are
combined immediately before fabrication of
appliances. However, some recent materials
are available in sheets and gel forms which can
be heated and compressed in Biostar machine
to get the appliance.
Polymerization
Heat cure acrylic resin is generally processed
for 9 hours at 74°C or 20 minutes to 2 hours at
100°C for rapid curing. Long low temperature
curing will result in good curing and strong
appliance.
Storage
The container of the liquid monomer must be
kept tightly sealed at all times to guard against
evaporation of the most volatile ingredients
and an imbalance in the chemistry of the
liquid.
Self-cure and heat cure materials are
formulated to endure high temperatures
over extended periods of time. The finer
sized particle of polymer tends to migrate to
the bottom of container and cause different
polymer monomer ratios; therefore, it is
adviced to shake the polymer powder before
use.
Separating Media
During fabrication of acrylic resins they
must be carefully protected from the gypsum
surfaces of the casts. Seperating media like tin
foil, Cellulose lacquers, sodium alginates, soap,
sodium silicate, and starches all have been
used as paint on the models.
However, the most popular separating
agents are water soluble alginates that
produce a very thin water and organic solvent
insoluable calcium alginate film on the
gypsum surfaces.
Light Cure Acrylic Resins
A visible light activated resin is available
for several years. They can be described
as composite, having a matrix of urethane
dimethacrylate, microfine silica, and high
molecular weight acrylic resin monomers.
Acrylic resin beads are present as organic
filler. The camphoroquinone photoinitiator
is readily activated by the same visible light
source and frequency of 400 to 480 nm. For
final polymerization, a special higher energy
light source is recommended.
Orthodontic Appliance Cleaners
A wide variety of agents are used by patients for
cleaning removable orthodontic appliances.
They include dentifrices, proprietary denture
cleaners, soap and water, salt and soda,
household cleaners, bleaches and vinegar.
Either immersion in the agent or more
generally brushing of the appliance with the
cleaner is employed.
The most common commercial appliance
cleaners are the immersion type; they are
usually marketed as a powder or tablet. Their
com­positions include alkaline compounds,
detergents, flavoring agents and sodium
perborate. When the powder is dissolved in
water, the perborate decomposes to liberate
oxygen. The oxygen bubbles supposedly then
acts mechanically to loosen the debris.
The household bleaches containing
chlorine are not to be used with stainless steel
components because they remove the surface
chromium oxide layer of stainless steel and
thereby corrode the steels.
Infection Control
Orthodontic appliances are disinfected by
ethylene oxide gas. Since the polymeric
materials can absorb liquids, toxic agents
such as phenolics or glutaraldehydes should
not be used.

Silicone Rubber Materials
These silicone rubber materials are used in
orthodontics in fabrication of soft splints
for TMJ disorders, tooth positioners and as
preorthodontic trainers.
They are transparent or opaque, dry earth
pigments are added for the color. They can
be self- curing or heat curing. Heat curing
materials have better properties. They are
supplied in sheets or gel form and require
milling, packing under pressure and 30
minutes curing at 180°C.
FINISHING AND POLISHING
MATERIALS
Before any appliance is placed in mouth it
should be finished and polished. Finishing and
polishing are done to prevent irritation, food
debris acc­umul­ation, and to prevent tarnish
and corr­osion.
Abrasion occurs when a hard, rough
surface slides along a softer surface and cuts or
plows a series of grooves. The abrasives used in
dentistry are applied to the work by means of a
number of abrasive tools like burs, brushes and
disks. Abrasives can also be mixed with water,
glycerine, or some other medium to produce
pastes and they are used in finishing and
polishing irregular surfaces such as removable
orthodontic appliances, and for prophylaxis
before bonding and banding.
COMMONLY USED ABRASIVES
Emery: Emery consists primarily of a natural
oxide of aluminum, called corundum. There
are various impurities present, such as iron
oxide, which may also acts as abrasives. They
are commonly supplied in sheets or disks.
Aluminum oxide: Pure aluminum oxide is
Materials Used in Orthodontics 545
manufactured from bauxite. Extremely fine
particles of aluminum oxide can be obtained
by a water flotation process and is known as
levigated alumina. It is particularly useful in
polishing metals.
Garnet: The mineral comprise the silicates
of any combination of aluminum, cobalt,
magnesium, iron and manganese. Garnet is
usually coated on paper or cloth with glue
or a similar binder. It is one of the common
abrasives used in denture abrasive disks,
acrylic trimmers and burs that are operated
with the dental handpiece.
Pumice: Pumice is a highly siliceous material
of volcanic origin, and it is suitable for use
either as an abrasive or as a polishing agent,
according to its particle size. It is used in
orthodontics for the polishing of removable
appliances and polishing of teeth in mouth
before bonding.
Rouge: Rouge is a fine red powder composed of
iron oxide. It is used empregnated on paper or
cloth, known as crocus cloth; it is an excellent
polishing agent for noble metal alloys and
stainless steel.
Tin oxide: Tin oxide is rarely used for polishing
metallic parts of the fixed appliances.
Chromic oxide: Chromic oxide (Cr 2O 3) is
relatively hard abrasive that is capable of
polishing variety of metals. It is often used as
a polishing agent for stainless steel.
Sand: Sand as well as other forms of quartz
is used as an abrasive agent. It is used in
sandpaper is common example. It is used as
powder in sandblasting equipment.
Carbides: Various carbides such as silicon
carbide, boron carbide and titanium carbide
are employed effectively as abrading agents.
Both of these products are manufactured by
heating silicon, boron and titanium at a very
high temperature to effect their union with
the carbon. The silicon carbide is sintered, or
546 Essentials of Orthodontics
pressed with a binder, into grinding wheels
or disks; Most of the steel burs employed the
cutting tooth are made of silicon carbide.
Titanium carbide burs are used in orthodontics
after debonding ro remove the resin tags over
the enamel.
Diamond: The hardest and most effective
abrasive for tooth enamel is composed of
diamond chips. The chips are impregnated
in a binder or plated onto a metal shank to
form the diamond burs, stones and disks used
for tooth cutting and proximal stripping in
orthodontics.
Zirconium silicate: This material is ground into
various particle sizes and used as a polishing
agent. Zirconium silicate is frequently used
as a constituent of dental prophylactic pastes
and in abrasive impregnated polishing strips
and disks.
IMPLANT MATERIALS IN
ORTHODONTICS
HISTORY
Dental implant history dates back thousands
of years and includes civilization such as
the ancient Chinese, who 4000 years ago
inserted bamboo into the jaw bone for fixed
tooth replace­ments. The Egyptians and, later,
physicians from Europe used ferrous and
precious metals for implants over 2000 years
ago, and the Incas used precious of sea shells,
inserted into the jaw bones to replace missing
teeth. The United States began its involvement
in implant dentistry with Greenfield and his
iridoplatinum cage in 1909.
Today, oral implantology has changed the
entire discipline of dentistry. Dr A Norman
Cranin introduced the “orthodontic appliance”
to oral implantology. For 50 years he has placed
the correct amount of pressure in the right
areas in order to help move the profession
toward an intellectual and predictable method
to incorporate implants into clinical practice.
In 1936, Venable and Stuck from their
investigation determined conclusively that
vitallium was the only metal which produced
no electrolytic action when it was buried in
the tissues. In the same year this metal was
embedded in human tissues for the first time
in the form of screws for stabilizing fragments
in a fractured bone. The results were highly
successful. They also observed that the screws
and plates were bright and untarnished, and
the tissues surrounding them were normal and
healthy. Pearse in 1941 employed this metal
as an implant in the soft tissues. He reported
vitallium to be the best tolerated of any metal
in the tissues. The constituent elements (cobalt
65%, chromium 30%, molybdenum 5% and
minor constituents such as manganese, silica
and carbon) are so combined in the metal that
there is no interaction between them in the
presence of moisture and body fluids.
The progress in the medical field gave an
impetus to implant dentistry. Goldberg and
Gerschkoff in 1949, were the first to think of
using this alloy to construct a prosthesis in
the form of a framework designed to fit on the
osseous surface of the jaw and to support posts
which emerging from the mucous membrane
were capable of supporting and retaining
a dental prosthesis. Their initial works on
implants opened a new field in dentistry
and stimulated the other research workers to
attempt on a restoration of this kind.
METALS AND ALLOYS
The major groups of implantable materials for
dentistry are titanium alloys, cobalt chromium
alloys, austenitic Fe-Cr-Ni-Mo steels, tantalum,

niobium and zirconium alloys, precious
metals, ceramics, and polymeric materials.
Titanium and Titanium-6
Aluminum-4 Vanadium (Ti-6Al-4V)
This reactive group of metals and alloys
(with primary elements from reactive group
metallic substances) form tenacious oxides
in air or oxygenated solutions. Titanium
(Ti) oxidizes (passivates) upon contact with
room temperature air and normal tissue
fluids. This reactivity is favorable for dental
implant devices. In the absence of interfacial
motion or adverse environment conditions,
this passivated (oxidized) surface condition
minimizes biocorrosion phenomena. In
situations where the implant is placed within
a closely fitting receptor site in bone, areas
scratched or abraded during placement
would repassivate in vivo. This characteristic
is one important property related to the use
of titanium for dental implants. Some reports
show that the oxide layer tends to increase in
thickness under corrosion testing and that
breakdown of this layer is unlikely in aerated
solutions.
Cobalt-Chromium-Molybdenum-
based Alloy
The cobalt-based alloys are most often used
in a Cast or cast-and-annealed metallurgic
condition. This permits the fabrication
of implants as custom designs such
as subperiosteal frames. The elemental
composition of this alloy includes cobalt,
chromium, and molybdenum as the major
elements. Cobalt provides the continuous
phase for basic properties; secondary phases
based on cobalt, chromium, molybdenum,
nickel, and carbon provide strength (4 times
that of compact bone) and surface abrasion
resistance, chromium provides corrosion
Materials Used in Orthodontics 547
resistance through the oxide surface while
molybdenum provides strength and bulk
corrosion resistance.
Iron-Chromium-Nickel-based Alloys
The surgical stainless steel alloys (e.g. 316
low carbons) have a long history of use for
orthopedic and dental implant devices. This
alloy, as with titanium systems, is used most
often in wrought and heat-treated metallurgic
condition, which results in a high-strength and
high-ductility alloy. The ramus blade, ramus
frame, stabilizer pins (old), and some mucosal
insert systems have been made from the iron-
based alloy.
OTHER METALS AND ALLOYS
Many other metals and alloys have been used
for dental implant device fabrication. Early
spirals and cages included tantalum, platinum,
iridium, gold, palladium, and alloys of these
metals. More recently, devices made from
zirconium, hafnium, and tungsten have been
evaluated.
Gold, platinum, and palladium are metals
of relatively low-strength, which places limits
on implant design.
Ceramics and Carbon
Ceramics are inorganic, nonmetallic, nonpoly-
metric materials manufactured by compacting
and sintering at elevated temperatures. They
can be divided into metallic oxides or other
compounds. Oxide ceramics were introduced
for surgical implant devices because of their
inertness to biodegradation, high strength,
physical characteristics such as color and
minimal thermal and electrical conductivity,
and a wide range of material specific elastic
properties. In many cases, however, the low
548 Essentials of Orthodontics
ductility or inherent brittleness has resulted
in limitations. Ceramics have been used in
bulk forms and more recently as coatings on
metals and alloys.
The aluminum oxides are fully oxide
materials, bulk, and surface, thereby affording
advantages related to tissue interface related
investigation. Also, studies have included
the polycrystalline (alumina) and single
crystalline (sapphire) forms of the oxide
structure. Direct relationships have been
established between the interfacial events
of tissue integration for metallic surface
oxides of titanium and chromium and the
aluminum oxide systems. Ceramic coatings
(Al2 O3) have been shown to enhance the
corrosion resistance and biocompatibility of
metal implants, in particular surgical stainless
steel and Ni -Cr, Cr- Co alloys.
However, studies in orthopedics, caution
that the (Al 2 O 3 ) coating may cause a
demineralization phenomenon caused by
high local concentration of substrate ions in
the presence of metabolic bone disease.
Polymers and Composites
• Polymethylmethacrylate
• Polytetrafluoroethylene
• Polymethylene
• Polysulfone
• Silicone rubber
• Polypropylene.
In general, the polymers have low strength
and elastic moduli and high elongation to
fracture, compared with other classes of
biomaterials. They are thermal and electrical
insulators and when constituted as a high
molecular weight system without plasticizers,
they are relatively resistant to biodegradation.
Compared with bone, most polymers have low
elastic moduli with magnitudes closer to soft
tissues.
Bone Augmentation and
Replacement
The calcium phosphate (CaPO 4) ceramics
used in dental reconstructive surgery include
a wide range of implant types and thereby
a wide range of clinical applications. Early
investigations emphasized solid and porous
particulates with nominal compositions that
were relatively similar to the mineral phase
of bone (Ca5[PO4]3OH). Micro-structural and
chemical properties of these particulates were
controlled to provide forms that would remain
intact for structural purposes after implan­tation.
ENDOSTEAL AND
SUBPERIOSTEAL IMPLANTS
The first series of structural forms for dental
implants included rods and cones for filling
tooth root extraction sites (ridge retainers)
and in some cases, load-bearing endosteal
implants. Limitations in mechanical property
characteristics soon resulted in internal
reinforcement of CaPO 4 ceramic implants
through mechanical (central metallic rods)
or physicochemical (coating over another
substrate) techniques.
The coatings of metallic surfaces using
flame or plasma spraying (or other techniques)
increased rapidly for the CaPO4 ceramics. The
coatings have been applied to a wide range of
endosteal and subperiosteal dental implant
designs with an overall intent of improving
implant surface biocompatibility profiles and
implant longevities.
Advantages and Disadvantages
The recognized advantages associated with
CaPO4 ceramic biomaterials are:
1. Chemical compositions of high purity
and of substances that are similar to
 Materials Used in Orthodontics 549

constituents of normal biologic tissue ORTHODONTIC INSTRUMENTS

(calcium, phosphorus, oxygen, and hydro­
gen). ADAM’S PLIERS
2. Excellent biocompatibility profiles within (UNIVERSAL PLIERS)
a variety of tissues, when used as intended.
3. Opportunities to provide attachments Adams pliers are heavy wire pliers with sharply
between selected CaPO4 ceramics and hard tapered beaks forming a four-sided pyramid
and soft tissues. when closed. Used for bending heavy-gauge
4. Minimal thermal and electrical conductivity wires and adjusting removable appliances.
plus capabilities to provide a physical and
chemical barrier to ion transport (e.g. metal
ions). ARCH-FORMING PLIERS
5. Moduli of elasticity more similar to bone (ARCH-CONTOURING PLIERS, DE
than many other implant materials used LA ROSSA PLIERS) (FIG. 15.8)
for load-bearing implants.
6. Color similar to bone, dentin and enamel. Pliers with straight, thick, parallel beaks;
7. An evolving and extensive base of inform­ the concave beak fits around the opposing
ation related to science, technology, and cylindrical one. The cylindrical beak may
application. have grooves of varying sizes or may be non-
Some of the possible disadvantages grooved. Used to form and contour arch
associated with these types of biomaterials are: wires, either round or rectangular, as well as
1. Variations in chemical and structural to incorporate (reverse) curve of Spee into an
chara­cteristics for some currently available arch wire.
implant products.
2. Relatively low mechanical tensile and
shear strengths under condition of fatigue BAND BURNISHER (BEAVER-TAIL
loading. BURNISHER) (FIG. 15.9)
3. Relatively low attachment strengths for
some coating tosubstrate interfaces. Stainless steel instrument with a heavy, hollow
4. Variable solubility depending on the handle for palm grip, similar to a Mershon
product and the clinical application. The
structural and mechanical stabilities
of coatings under in vivo load-bearing
conditions (especially tension and shear)
may be variable as a function of the quality
of the coating.
5. Alterations of substrate chemical and
structural properties related to some
available coating technologies.
6. Expansion of applications that sometimes
exceed the evolving scientific information
on properties. Figure 15.8: Arch forming pliers
550 Essentials of Orthodontics
Figure 15.9: Band burnishers
Figure 15.10: Band-contouring pliers
band pusher. The shank ends in an angled
beaver-tail-shaped tip that can be smooth or
serrated and flattened for easier access to band
margins under buccal tubes or bracket wings.
Used for burnishing and adapting margins of
bands to the tooth contour.
BAND-CONTOURING PLIERS
(FIG. 15.10)
Pliers with two long, tapering and slightly
bowed beaks. The convex tip at the end of the
one beak fits into the opposing concave tip in
a ball- and-socket manner. The diameter and
shape of the tips vary with the manufacturer.
Used for adaptation and contouring of stainless
steel orthodontic bands.
BAND PUSHER (MERSHON BAND
PUSHER) (FIG. 15.11)
Stainless steel instrument with a large, tapering
handle for palm grip and a long shank with an
angled tip. The tip is rectangular and serrated
Figure 15.11: Band pusher pliers
Figure 15.12: Band-removing pliers—anterior
to prevent slippage of the instrument during
use. Used for positioning and seating the band
properly, as well as for burnishing or adapting
the edges of the band around the tooth.
BAND-REMOVING (DEBANDING)
PLIERS, ANTERIOR (FIG. 15.12)
Pliers with a longer, flat-sided curved beak
placed on the incisal edge of teeth, opposing
a shorter, sharper beak positioned under the
gingival aspect of the band or attachment. The
longer incisal beak may have a replaceable
plastic or rubber tip to prevent fractures of the
incisal edge of the teeth. The beaks generally
do not make contact when the handles are
closed fully. They are used to remove bands
from anterior teeth.
BAND-REMOVING (DEBANDING)
PLIERS, POSTERIOR (FIG. 15.13)
Pliers with two beaks, one longer than the other.
The longer beak, which carries a replaceable
 Materials Used in Orthodontics 551

Figure 15.13: Band-removing plier—posterior

Figure 15.15: Bird-beak pliers

Figure 15.14: Band seater

plastic cap, is placed on the occlusal surface

of a tooth, while the shorter, sharpened beak
engages and lifts the gingival margin of the
band. Anterior and posterior band removing
pliers can be combined in a “Universal” design.
Figure 15.16: Bracket-positioning instrument

BAND SEATER (BAND BITER) BIRD-BEAK (NO. 139) PLIERS

(FIG. 15.14) (FIG. 15.15)

Plastic or metal instrument consisting of a
handle and a bite stick that makes use of the
patient’s biting force to aid the clinician in
seating a band. The tip of the bite stick has two
sides. The one that is placed on the occlusal
margin of the band is made of stainless steel
and is available in several sizes and shapes. As
well, it usually is serrated to minimize slippage
of the instrument during use. The opposite
side of the tip, which comes in contact with the
patient’s teeth during biting, usually consists
of a plastic bite shelf.
Pliers with two short beaks (one of which is
conical and the other pyramidal in shape) used
for bending small wires and springs.
BRACKET-POSITIONING
INSTRUMENT (BRACKET-HEIGHT
GAUGE, BOONE’S GAUGE)
(FIG. 15.16)
Device of various designs used to facilitate the
placement of brackets at standard distances
552 Essentials of Orthodontics
from the incisal edges or occlusal surfaces of
specific teeth. It usually has a ledge that rests
on the incisal edge (occlusal surface) of the
tooth, while a shorter arm is inserted into the
bracket slot.
BRACKET-REMOVING
PLIERS (DEBONDING PLIERS)
(FIG. 15.17)
Pliers used to remove brackets bonded to teeth.
There are various designs depending on the
type of bracket (e.g. stainless steel, ceramic,
plastic). The standard design for stainless steel
brackets has two mirror-image jaws with the
sharp cutting tips formed around a cylindrical
opening. The cutting tips generally do not
make contact when the handles are closed
fully. The bracket is removed by peel and shear
forces by placing the cutting tips at the bracket-
adhesive junction and squeezing.
CONVERSION INSTRUMENT
Conversion instrument is an orthodontic
instru­ment that is inserted into the mesial
opening of a convertible tube and functions
in a “can-opener” fashion to remove its
convertible cap and thus turn it into a bracket.
Figure 15.17: Bracket-removing pliers
COON LIGATURE-TYING PLIERS
(FIG. 15.18)
Reverse-action pliers (squeezing the handles
increases the separation of the tips), consisting
of two opposing mirror-image parts (handle,
shank and tip, all one piece) joined just below
the shank by a round metal cylinder with a
channel. The opposing handles are attached
by a spring that holds them apart, causing the
tips to touch when the instrument is passive. It
is used for tying metal ligatures. The opposing
tips are blunted and forked to facilitate
retention of the ligature wire. As the handles
are compressed, spreading the tips, the
channel locks the ligature wire automatically.
Because of the reverse action, the initial twist
and the pressure are exerted at the bracket-
arch wire junction and then twisted away from
the bracket. This gives the ligature a tighter
fit around the bracket, forcing the arch wire
further into the slot.
DISTAL-END CUTTER (FIG. 15.19)
A special wire cutter with the juxtaposed
cutting edges set at right angles to the long
axis of the instrument to facilitate cutting of
the distal end of the arch wire, intraorally.
May have a safety hold mechanism provided
Figure 15.18: Coon ligature-tying pliers
 Materials Used in Orthodontics 553

Figure 15.20: Separator placing pliers

Figure 15.19: Distal-end cutter

either by a thick wire running parallel to the

cutting edges, or by a rectangular shoulder
immediately below the cutting edges. This
mechanism serves to grip the loose end of the
cut arch wire and prevent it from being lost in
the mouth, so that it can be discarded easily.
It can be used to cut round wires up to 0.020
inch or 0.51 mm in diameter and rectangular
wires up to 0.022 x 0.028 inch or 0.56 x 0.70 mm.
Figure 15.21: Facebow-adjusting pliers

ELASTIC SEPARATOR PLIERS
(SEPARATOR PLIERS)
(FIG. 15.20)
Reverse-action pliers (squeezing the handles
increases the separation of the beaks) with two
long beaks that are angled for better access.
The beaks are connected with a circular hinge
and carry tapered, grooved, blunted tips, which
can retain elastic separators (modules). They
are used to stretch, hold and place elastic
separators.
when the pliers are closed. Each beak has
a rounded notch at a right angle to the beak
near the tip on the opposing surfaces. Used
for adjusting the inner and outer arches of
facebows, or for contouring wires of large
diameter (up to 0.062 inch or 1.55 mm).
HARD WIRE CUTTER
Cutter of design similar to a pin and ligature
wire cutter, only larger, and capable of cutting
full-dimension arch wires.

FACEBOW-ADJUSTING PLIERS
(FIG. 15.21)
Heavy-duty pliers with a box-jointed pivot
con­struction, having two parallel beaks and
an opposing one that fits between the former
HEMOSTAT (MOSQUITO PLIERS)
(FIG. 15.22)
Small and light pliers with scissor-like
design, provided with a mechanical locking
554 Essentials of Orthodontics
Figure 15.22: Mosquito pliers
mechanism located between the handles. The
handles are available in various lengths. The
serrated beaks can be either straight or curved
and they may be notched to aid in retention of
elastomeric ligatures. Used for placement of
elastomeric ligatures (donuts).
HOWES UTILITY PLIERS
(FIG. 15.23)
Pliers with two long, round beaks tapered to
a pyramid shape and bowed, terminating in
juxtaposed flat round serrated pads. The pads
are positioned at right angles to the long axis
of the beaks; their diameter varies with the
manufacturer. The beaks may be straight or
offset at a 45° angle. They are used mainly for
gripping and handling arch wires and stainless
steel ligatures during placement in the mouth.
LIGATURE DIRECTOR
(PITCHFORK INSTRUMENT, TIE
IN TUCKER) (FIG. 15.24)
It is a stainless steel instrument carrying a
straight or angled tip with a notch capable of
Figure 15.23: Howes utility pliers
Figure 15.24: Ligature director
engaging wires. They are available in double-
ended versions or in combination with
amalgam-pluggers, scalers or other tips. Used
to tuck and direct stainless steel ligatures under
the arch wire or bracket wings, or to push arch
wires or auxiliaries into position.
LIGHT-WIRE PLIERS (FIG. 15.25)
These pliers are essentially identical to bird-
beak pliers, only with longer and more slender
beaks. Some designs have one or more grooves
at the tip of the pyramidal beak to aid in making
repro­ducible loops and helices. Used mainly to
form various loop designs in Begg orthodontic
wires (generally light, round wires), to make
minor adjustment bends in arch wires or to
place metal spring separators.

Figure 15.25: Light-wire plier
Figure 15.26: Mathieu ligature-tying pliers
MATHIEU-STYLE LIGATURE-
TYING PLIERS (FIG. 15.26)
Pliers with long, thin handles equipped with a
positive-locking ratchet and spring for instant
opening and closing. The opposing tips are
serrated and may have tungsten carbide
inserts for longer instrument life. The tips
vary in length and taper by the manufacturer.
The pliers are available in various sizes. Used
mainly for tying stainless steel ligatures as well
as for placing elastomeric ligatures (donuts).
PARALLEL-ACTION PLIERS WITH
CUTTER (SARGENT’S HEAVY-
DUTY PLIERS) (FIG. 15.27)
Heavy-duty pliers with parallel, flat, serrated
opposing beaks. One of the beaks carries a wire
cutter on its non-serrated side. Used mainly
Materials Used in Orthodontics 555
Figure 15.27: Parallel-action pliers with cutter
Figure 15.28: Pin and ligature wire cutter
for bending, cutting or holding large-diameter
wires in laboratory procedures.
PIN AND LIGATURE WIRE CUTTER
(FIG. 15.28)
Cutter with two tapered and pointed opposing
beaks, terminating in delicate and sharp cutting
edges. The cutting edges may have carbide
inserts that can be sharpened or replaced when
dull or damaged, without replacing the entire
instrument. It is available in various angles,
the straight and 15° to the long axis being the
most common. The tape and size of the tips
vary with the manu­facturer. They are used to
cut soft ligature wires (generally up to 0.016
inch or 0.41 mm) and arch-retaining lock pins.
556 Essentials of Orthodontics
SERRATED BAND PLUGGER
(SERRATED AMALGAM PLUGGER)
(FIG. 15.29)
It is a single-ended or double-ended (in
combin­ation with a ligature director or other
tip) stainless steel instrument, sometimes
used to seat and position bands or to tuck steel
ligatures. The tip is available in various lengths,
angles and diameters and usually is serrated
for better control in pushing motion.
STEINER LIGATURE-TYING
PLIERS (FIG. 15.30)
They are identical to the Coon ligature-tying
pliers, differing only in that the round metal
cylinder at the shank of the instrument does
not carry the special channel to engage the end
Figure 15.29: Serrated band plugger
Figure 15.30: Steiner ligature-tying pliers
of the ligature wire. The ligature wire is retained
on the instrument by manually wrapping its
free ends around the round metal cylinder.
TORQUING KEY (FIG. 15.31)
Torquing keys are usually a cross-shaped
stainless steel instrument, each of the four
ends of which carries a milled slot to engage
the wire for placement of torque. Each slot is
a different size to accommodate various gauge
wires. They are used to place torque in an arch
wire or to assist full engagement of a wire into
a bracket slot. Various other kinds of torquing
keys are used in combination with special
pliers to place torque for an individual tooth.
TRIPLE-BEAKED PLIERS (THREE
PRONG PLIERS, THREE JAW
PLIERS, CLASP-ADJUSTING
PLIERS) (FIG. 15.32)
These pliers are similar to but smaller than the
facebow-adjusting pliers, with a box-jointed
Figure 15.31: Torquing key
 Materials Used in Orthodontics 557

TWEED ARCH-ADJUSTING
(NO. 142) PLIERS (FIG. 15.34)

Pliers used exclusively for handling or adjusting

square or rectangular wires. The beaks are
symmetrically flattened blades that are parallel
at a separation of 0.020 inch (0.51 mm).

TWEED LOOP-FORMING PLIERS

(OMEGA PLIERS, OPTICAL
Figure 15.32: Triple-beaked pliers PLIERS) (FIG. 15.35)

Pliers with two opposed parallel beaks, one

with concave and one with round cross-
section. The round beak generally is stepped,
having three sections of different diameters

Figure 15.33: Turret

pivot construction. The double-sectioned

beak is opposed by a single beak, so that a
squeezing motion can produce a sharp bend in
the wire. Used for adjusting wires, particularly Figure 15.34: Tweed arch-adjusting
labial bows or clasps on retainers, activation
of quadhelix, as well as for placing a curve
on flexible or heavier wires, or stainless steel
tubing.

TURRET (FIG. 15.33)

Turret is a tubular metal device of various

circum­ferences carrying grooves of various
calibrated sizes, used to shape straight lengths
of orthodontic wire into an arch form. Some
turrets are equipped with angulated grooves
to place torque into rectangular wire during
shaping of the arch form. Figure 15.35: Tweed loop-forming pliers
558 Essentials of Orthodontics

(most commonly 0.045, 0.060, and 0.075 inch

or 1.12, 1.50 and 1.90 mm). The tip of the round
beak may be replaceable. They are used to
form various loops or short curved sections in
orthodontic wire.

WEINGART UTILITY PLIERS

(FIG. 15.36)

Figure 15.36: Weingart utility pliers

These are pliers with two long, slender beaks
with opposing serrated tips. The tips are oblong
and pointed and can be straight or curved from
the long axis of the pliers to provide a better
working angle for intraoral adjustments. Used
for holding or gripping the arch wire to place
it and remove it from the mouth or to make
adjustment bends, cinching and activating
the loops.
 Community Orthodontics 559

Bibliography

1. Chaconas. Principles of Orthodontics.

2. Dickson, Heatley. Atlas of Removable Orthodontic Appliances.
3. Don Ranly. Synopsis of Craniofacial Growth.
4. Enlow. Handbook of Facial Growth, 3rd edn.
5. Graber, Newmann. Removable Orthodontic Appliances, 2nd edn.
6. Graber, Swain. Orthodontics—Principles and Techniques.
7. Graber, Vanarsdall. Orthodontics—Current Principles and Techniques, 3rd edn.
8. Graber TM. Principles and Techniques of Orthodontics, 3rd edn.
9. Graber, Rakosi, Petrovich. Functional Appliances with Dentofacial Orthopedics, 2nd edn.
10. Houston, Tulley. Textbook of Orthodontics.
11. Issacson, Houston. Removable Orthodontic Appliances.
12. Mills. Practice of Orthodontics.
13. Moyers. Handbook of Orthodontics, 4th edn.
14. Philip C Adams. Design, Construction and Uses of Removable Orthodontic Appliances,
6th edn.
15. Proffit WR. Contemporary Orthodontics, 3rd edn.
16. Rakosi. Orthodontic Diagnosis.
17. Salzmann. Practice of Orthodontics.
18. Samir E Bishara. Textbook of Orthodontics.
19. Walters. Orthodontic Notes.
20. White, Gardiner. Orthodontics for Dental Students, 4th edn.

Page numbers followed by f and t refer to figure and table, respectively
A with soldered buccal
Aberrant developmental
position of teeth 56
Abnormal
eruptive path 133
frenal attachments 272
labial frenum 128, 132
suckling 128
swallowing habits 126
Accidental and nonaccidental
oral trauma 494
Achondroplasia 433
Acid etching 368
Acidic primers 525
Acidulated phosphate fluoride 295
Ackerman-Proffit classification
99, 100f
Acrylic
partial dentures 330
resins 519, 542
splints 259
Action of functional
appliances 394
Adam’s
clasp 347-350, 354, 361
fabrication 349f
on incisors and
premolars 350
with distal extention 350
with incorporated helix 350
with J hook 350
Index
tube 350
pliers 549
Adjunctive orthodontic
treatment 452
Adolescent growth 79
Adult orthodontics 448
Advantages of
fixed
appliances 364
space maintainers 331
functional appliances 393
LASER welding 534
osseous implants 324
proximal stripping 254
removable
appliances 345
space maintainers 330
serial extractions 335
Air abrasion 525
Alginate impression 537f
materials 535
Alignment of arch 436
Alpha titanium 507, 517
Altered mandibular
movements 466
Aluminum oxide 545
Alveolar
bone 257, 314
process 41
Index 561
American
Association of Orthodontics 1
Cleft Palate Association
classification 476
Heart Association 486
Anatomy of hand-wrist 221f
Anchorage planning 319
Angle of
convexity 213
mandible 40
Angle’s
classification 93, 96
of malocclusion 97
concept of normal
occlusion 87, 87f
Ankylosed teeth 319
Ankylosis 128, 133, 465
Anomalies of tooth
shape 128, 132
size 132
Anterior
bite plane 280f
centric contacts 86
crossbite 276
maxillary
osteotomy 260, 434
segmental osteotomy 437
nasal spine 209
nonocclusion 93
openbite 274
part of body of sphenoid 31
562 Essentials of Orthodontics
Anthropology 120, 117
Appliance
design 397, 410
selection 251
Application of
external influences 446
implants in orthodontics 432
primer 368
Arachnoid granulation
impressions 201
Arch
contouring pliers 549
expansion using fixed
appliances 262
forming pliers 549f
index 119
length 270
tooth material
discrepancy 263
perimeter analysis 189, 254
wire 369
materials 507
Arrow pin clasp 347, 352f
Arrowhead clasp 347
Arthritides 465
Articulation of models 400
Ashley Howe’s analysis 189
Augmentation genioplasty 434
Austenitic stainless steel 512
Australian wire 513
Auxiliary
force delivery systems 509
springs 357
B Blue grass appliance 142
Backward path of closure 182
Baker’s anchorage 316, 317f
Balancing extractions 267
Ball end clasp 347, 351, 351f
Ballard’s classification 98
Ballista springs 284
Band
and bar
space maintainer 333f
type space maintainer 333
and spur appliance 416
burnisher 549, 550f
contouring pliers 550, 550f
pusher 550
pliers 550f
removing pliers 550, 551
Banded canine-to-canine Bone
retainer 416, 419 adaptation 422
Barrel shaped lateral incisors 119 augmentation and
Basal replacement 548
bone 319, 383 bending piezoelectric
metabolic rate 230 theory 308
Basion-Nasion plane 211 deposition 311
and resorption 22
Beaver-tail burnisher 549
remodeling theory 54
Begg’s
resorption 311
appliance 376f
Boone’s gauge 551
concept of normal occlusion 88 Bracket
retainer 416, 418, 418f and attachment
technique 376 materials 508, 517
Benjamin’s theory 138 height gauge 551
Bennett’s classification 98 positioning
Bilateral instrument 551, 551f
facial asymmetry 219 removing pliers 552, 552f
sagittal split osteotomy 434, 440 Branches of orthodontics 2
Bimaxillary protrusion 162 Branchial arches 28, 28f
Biometric tests 19 Brass wire separators 372
Bird-beak pliers 551f British standard classification of
Bisecting angle technique 196 incisor relationship 98
Bite Broadbent registration point 210
Buccal
opening 425
and lingual cervical
planes 392
undercuts 347
registration 399, 4078, 408 canine retractor 360f
waxes 538 displacement 91
wing radiographs 197 implants 325f
Bjork, Grave and Brown inclination 91
method 223 nonocclusion 276
Blade implants 321 object rule 282
Blood flow theory 308 self-supporting canine
retractor 360
Bodily movement 300, 365 tubes 374
Body Bud stage 45
centered cubic 512, 516 Burstone’s cephalometrics for
of mandible 40 orthognathic surgery 435
Butler’s theory 164
Bolton’s
Button pull exercise 341
analysis 191, 254
index 191f C
plane 211 Calcium carbonate 532
point 209 Canine
tooth size ratio 180 classification 99
Bondable brackets 373 guided occlusion 86
Bonded lingual retainers 419, 419f loops 405
Bonding retractors 359
materials 508, 518 Cantilever spring 284
systems 519 Cap stage 45

Carabelli’s trait 119
Care of
cast 541
deciduous dentition 327
Carey’s analysis 189, 190
Caries 364
Cartilaginous theory 23, 23f
Cast
cap splints 259
retainers 416
Catalan’s appliance 277, 338f
Catenary’s curve 57, 57f
Causes of
anterior
cross bite 134
open bite 134
crowding 133
deep bite 134
localized spacing 134
midline diastema 134, 272
posterior
cross bite 134
open bite 134, 275
Cementation of band 367
Center of
resistance 299, 299f
rotation 299
Central processing unit 237
Centric
contacts 85
holding cusps 84
Cephalic index 118, 174, 174f
Cephalocaudal gradient
growth 13, 13f
Cephalogram 200f
Cephalometric
analysis 212
landmarks 208, 209f
radiographs 172, 198
superimpositions 218
tracing technique 211
Cephalometry 20
Ceramic brackets 373, 518
Cerebral palsy 129
Cervical
pull headgear 385, 387f
spine 205
vertebrae 228f
Chapman method 222
Characters of mature swallow 61
Index 563
Chemical methods 141 Complex tongue thrust 145
Chin cup 390f Components of
therapy 390 computer system 237
Chondrocranial ossification 30 extraoral appliance 382
Chrome cobalt 507 fixed orthodontic
alloys 514 appliances 368
Chromic oxide 545 Frankel appliance 405
removable appliances 346
Chromium 512
servosystem 27
Chromosome 159, 160
Composite
Circumferential clasp 347, 348f
coated arch wires 508
Circumoral muscles 341 resins 519
Citric acid 508 Computed tomography 233, 283
Clark’s rule 282 Computerized cephalometric
Classic Freudian theory 138 systems 240
Classification of Conditioning and crystal growth
active components 355 systems 508, 525
clasps 347 Condylar
cleft lip and palate 474 hyperplasia 433
crossbite 275 process 35
habits 135 Cone shift technique 172
implants 432 Congenital
malocclusion 90 and developmental
orthodontic bone disorders 465
muscle disorders 465
appliances 344, 507
heart disease 485
retainers 415
micrognathia 147
tongue thrust 144
syphilis 129
Cleft lip and palate 129, 162, Congenitally missing
473, 476f incisors 112, 113
Cleidocranial teeth 113
dysostosis 129 Conservative management of
dysplasia 162 malocclusion 455
Clockwise rotation 42f Construction
Closed coil spring 371, 371f bite 398, 403
Coffin spring 261, 261f, 278, 359 of Adams’ clasp 349
Cognitive theory 71 Continuation of growth
Coil springs 284 pattern 249
Collagen hydroxyapatite Continuous positive airway
interface 309 pressure 482
Combination Contraindications of
removable space
of retrognathic maxilla and
maintainers 330
prognathic mandible 289
RME 259
pull headgear 385, 387f
Conventional
Command method 181
brackets 373
Competent lips 177 nipple 137
Complete tomography 233
maxillary osteotomy 437 Conversion instrument 552
overbite 279 Coon ligature-tying pliers 552f
564 Essentials of Orthodontics

Coordination of arch 436, 445 Delivery of removable Dewel’s method 336

Copper NiTi alloy 516 appliance 363 Dewey’s classification 97
Correction of Delta clasp 354, 354f Dewey-Anderson’s
crossbite 316f Density of bone 251 modification 97
crowding 247 Dental Diabetes mellitus 489
deep bite and crossbite 287 anterior openbite 274 Diameter of wire 357
developing crossbite 333 arch 58f Digital
mandibular deficiency 286 caries 128, 133 cephalometric radiographs 435
maxillary prognathism 286 crossbite 276 subtraction radiography 235
proclination 247 deep bite 279 Diploic vein channels 201
sagittal interarch distraction 446 Direct
relationship 263 device 447 bonding 368
skeletal malocclusion 383 drift 427 extraoral method 182
Corrective orthodontics 2 health component of index 115 intraoral method 182
Cosmetic parameters 213 Direction of
dentistry 455 stone 539 growth 22
surgeries 441 high strength 540 tooth movement 358
Cotton test 184 system 90 Disadvantages of
Cranial Dentoalveolar anterior fixed
base bones 20 crossbite 338 appliances 365
vault bones 20 Dentofacial space maintainers 331
Craniofacial microsomia 443 deformities 433 intraoral periapical
Craniosynostosis syndrome 433 orthopedic growth radiographs 197
Cranium 200 modification 3 proximal stripping 254
Crossbite 275 Dentomaxillofacial complex 206 removable
elastics 278, 370 Dentoskeletal analyses 212 appliances 346
Crown and loop appliance 332 Deoxyribonucleic acid 159 space maintainers 330
Crozat clasp 347, 354, 354f Derotation of posterior Disinfecting impression 187
Crystal growth systems 525 teeth 269, 269f Distal
CSF procedure 431 Design of anchorage system 389 displacement 91
Curve of Determination of end
Monson 85, 85f anterior ratio 192 cutter 553f
Spee 84, 90, 181f arch length 190 of long bones of
Wilson 84, 84f discrepancy 191 forearm 221
Cusp force magnitude 384 shoe space
embrasure occlusion 84 overall ratio 191 maintainer 332, 333f
fossa occlusion 84 tooth material 191 Distraction osteogenesis 442
Cusp-to-cusp occlusion 84 Development of Dizygotic twins 163
Custom made bands 366 autonomy 69 Double cantilever spring 277
basic trust 69 Down’s
D branchial arches 28 analysis 212, 213f
Davis cranial structures 29 syndrome 162
and Ritchie classification 474 dentition 47 Drawbacks of
rules 335 and occlusion 44 Angle’s classification 96
De La Rossa pliers 549 intimacy 70 Simon’s classification 98
Deciduous dentition period 46, 48 Development of Dual
Deep maxillary sinus 33 cured systems 508
bite 49, 278 nasal pits 29 energy X-ray
breath exercise 184 palate 32 absorptiometry 229
Delayed eruption of permanent perioral region 29 Dunlap’s beta hypothesis 141
teeth 128, 133 tongue 33 Duplex steels 514
 Index 565

Dural sinuses 202 Eruptive tooth movement 303 F

Duration of tooth movement 320 Esthetic harmony 2 Fabrication of
Duyzing clasp 347, 352, 352f Ethmoid bone 31
acrylic portion 400
Evaluation of
E facial proportions 176
activator 399
Edgewise Adams’ clasp 349
path of closure 182
appliance 375f surgical hooks 445
space adequacy 430
brackets 373 Face
swallowing 185
Edward H angle 4f bow 385f
Examination of
Ehlers-Danlos syndrome 483 adjusting pliers 553f
facial proportions 171
Elastic centered cubic 512
frenal attachments 178
chains 370, 370f Facial
gingiva and periodontium 178
modules 370, 371f angle 212
lips 171, 177
Elastic axis 211
nose 176
ring separators 372f bone 318
palate 178
separator pliers 553 symmetry 171 clefting syndrome 433
thread 284, 370 temporomandibular joint 184 divergence 219
Elastomeric tongue 177 impression techniques 538
chain 284 index 118
tonsils and adenoids 178
impression materials 538 plane 211
Exchange of incisors 51
Electrogalvanic stimulation symmetry 174
Exercises for
therapy 470 Ferritic stainless steels 512
lips 341
Electromyography 172, 230 Fetal alcohol syndrome 433
masseter muscles 342
Eliminating occlusal Fibonacci numbers 167
temporalis muscle 341
interference 327 Finger
Exercises of pterygoid muscles 342
Elongation of synchondrosis 37 nail biting 153
Extension of base plate 363
Elsahy’s modification of spring 358, 358f
External rotation 42
Kernahan’s striped “Y” sucking 127, 128, 137
Extraction of
classification 475
canines 265 Fishman’s
Endochondral bone formation
first method 226f
20, 21, 35
molars 266 skeletal maturity
Endocrine
premolars 265 indicators 225
disorders 127, 488
lower incisors 264 Fitted labial bow 355, 357
imbalance 128, 130
Endocrine tests 172 second Fixed
Endodontic stabilizers 322 permanent molars 266 appliance 142, 258, 278, 344,
Endosteal premolars 265 364, 416
and subperiosteal supernumerary retainers 419
implants 548 impacted and ankylosed techniques 375
implants 321 teeth 430 therapy 280
Enlow’s counterpart principle 27 teeth 327 functional appliances 391
Envelope of discrepancy 435, 435f third molars 267 retainers 416, 418
Epithelial coils 54 upper incisors 264 space maintainers 331
Epoxy resins 519 Extraoral tongue guard 146f
Eric Johnson and Brent Larson distraction appliance 445f Fixing orthodontic
classification of non-nutritive methods 268 attachments 431
sucking 136 radiographs 197 Flexible spiral wire 461
Erikson’s vertical osteotomy 434 Flexure of cranial base 31
eight ages of man 69 Extrusion of teeth 401 Fluid dynamic theory 308
theory 69 Eyelet clasp 347, 351, 352f Fluoridated etchants 508
566 Essentials of Orthodontics

Fluoride 530 General Hass appliance 258f

application 255 adaptation syndrome 468 Hawley’s
releasing systems 508 properties of orthodontic appliance 416
Flush terminal plane 48-50 wires 509 with fitted labial bow 417
Fluxes 513, 530 Genioplasty 434, 441, 441f retainer 273, 345, 353, 416, 416f
Fogh-Andersen’s Genital stage 68 Head strap 386f
classification 474 Gerber space regainer 339 Heat cure acrylic resins 543
Force Gingival and periodontal Height chart 14f
application 392 diseases 127 Helical canine retractor 360
delivery Glass ionomer cements 521, 522 Hemifacial microsomy 433
systems 508 Glutaraldehyde 187 Herbst appliance 409, 409f
unit 382 Gnathion 209 Herren’s modification of
elimination 392 Gold activator 402
generating unit 383 alloys 510 Hertwig’s epithelial root sheath 46
of mastication 55 solders 529 High
Forensic Goldenhar’s syndrome 433 arched palate 162
dentistry 493 Graber’s classification 128 labial bow 355, 356
odontology 493 Grain growth 512 pull headgear 385, 386f
orthodontics 493 Grayson analysis 218 Hixon and Oldfather’s
science 493 Graz implant supported analysis 189
Forward path of closure 182 system 322, 324, 433 Holography 16
Frankel Greulich and Pyle method 222 Homeostatic dysfunction 468
appliance 403, 405f Grewe’s method 337 Horizontal planes 210
philosophy 403 Growth Hotz modification 396
Frankel’s classification 72 axis 213 Howe’s utility pliers 554, 554f
Frankfort disorders 465 Howship’s lacunae 305, 306
horizontal plane 97, 176, 210, in height 13 Huckaba’s analysis 189
210f, 216 in weight 14 Human chromosomes 161f
mandibular modification 286 Hunter-Enlow growth
incisor angle 216 of root 54 equivalents concept 27
plane angle 216 spurts 11, 12f Hyalinization 307
Free hand soldering 531 Grummon’s analysis 218 Hydrofluoric acid 508
Freeway space 425 Guiding cusps 84 Hydrogen 531
Freud’s theory 69 Gum pads 46 Hydroxyapatite 309
Frontal cephalogram 198 Gypsum products 539 Hyperplasia 465
Frontonasal buttress 66 Hypertrophy 465
Function H Hypodontia 56
of flux 530 Hagg and Taranger method 227f Hypoplasia 465
regulator 403 Hammock ligament 54 Hypothesis testing 106
Functional Hand wrought roach clasp 353 Hypotrophy 465
crossbite 276 Handicapping Hyrax appliance 259f
cusps 84 labiolingual deviation
matrix index 110 I
and skeletal units 24 malocclusion assessment 114 Ideal requirements of
matrix theory 24, 24f Hard dental solder 529
Fusion temperature 530 solders 529 impression material 534
wire cutter 553 orthodontic
G Hardening heat treatment 512 appliance 345
Gag reflex 177 Harnessing natural growth study model 186
Gait 173 forces 250 spring 357
Gardner’s syndrome 162, 204 Haryettatal’s theory 138 Ideal tooth relationship index 116

Impacted teeth 281
Impression
plaster 534
technique in orthodontics 537
tray 536
selection 537
Improper dental restorations 133
Incisor
classification 98, 98f
mandibular plane
angle 214, 216
occlusal plane angle 214
retraction intramaxillary osteotomy 434
anchorage 317f
Inclination of tooth 319, 383
Incompetent lips 177
Incomplete overbite 279
Indications for
adult orthodontic
treatment 450
hand-wrist radiographs 221
proximal stripping 254
removable
appliances 345
space maintainers 330
serial extractions 335
use of
extraoral force 383
headgear for cervical
pull 385
Indices of
malocclusion 109
maturity 15
Indirect
bonding 368
extraoral method 182
Infantile swallow 60, 145f
Infectious diseases 128, 130
Interarch malocclusions 91
Interception of habit 150, 338
Interceptive orthodontics 2, 333
Interdental implants 324
Interincisor angle 215
Interracial mixing 434
Interrupted force 302
Intersphenoidal synchondrosis 38
Intertransitional period 52
Intra-arch malocclusions 91
Intractable sucking 139
Intramatrix rotation 42, 42f
Index 567
Intramaxillary anchorage 317 L
Intramembranous bone Labial
formation 21 bow 405
Intramucosal inserts 322 support wires 406
Intraoccipital synchondrosis 38 Labiolingual
Intraoral crown inclinations 89
distraction appliance 445f technique 377
methods 268 Lahshal classification 475
periapical Laminated brackets 508
radiographs 255, 435 Lampshire’s classification 72
radiographs 196
Laser
vertical
etching 525
holography 235
ramus osteotomy 441
Lateral
Intrauterine fetal posture 285
cephalogram 198
Intrusion of teeth 400, 436
functional occlusion 86
Invisible retainers 418, 419f
maxillary osteotomy 260
Iron-chromium-nickel-based
path of closure 183
alloys 547
Law of tension stress 442
Irregularity index 114
Leeway space 52f
J of Nance 52
LeFort osteotomy 439f
Jack screw 261, 362f
Leone implant 433
expanders 261f
Leptorrhine 176
Jackson’s
clasp 348, 348f Lesser wing 31
triad 2 Leveling curve of Spee 247
Jasper jumper 410, 410f Ligat director 554f
Joint Ligature
sounds 466 director 554
system 463 wire 284, 374
Juvenile Light
period 79 activated system 520
periodontitis 462 cure acrylic resins 544
rheumatoid arthritis 491 cured system 508
wire pliers 554, 555f
K Limitations of
Karwetzky modification 402 muscle exercises 342
Katz classification 100 osseous implants 324
Kernahan serial extractions 336
and Stark’s classification 475 Linderharth’s analysis 190
striped “Y” classification 474 Lingual
Kesling’s appliance 378
separator 372 arch space maintainer 332
spring separators 372f crossover 406
tooth positioner 418 displacement 91
Kilroy springs 284 inclination 91
Kingsley classification 136 nonocclusion 276
Klinefelter’s syndrome 161 stabilizing bow 405
Korkhau’s analysis 190, 439 tipping 91
Küfner osteotomy 439 tuberosity 40
568 Essentials of Orthodontics

Lip cleft lip and palate 477 Mental region 35

and nail biting 128 deaf child 485 Mentolabial sulcus 176, 176f
biting and lip sucking 151 thumb sucking 140 Mershon band pusher 550
bumper 396, 396f tongue thrust 146 Mesial
exercises 150 Mandibular inclination 91
index 119 canines 47 step terminal plane 51
pads 405 condyle 28 tipping 91
plumber 396 first premolars 47 Mesiobuccal rotation 91
sucking 127 plane 211f Mesiodistal crown angulations 89
Lischer’s classification 96 angle 213, 215 Metabolic disturbances 128, 130
Little’s index 114 prognathism 113, 129, 434 Metal injection moulding 518
Local protraction 404 Metallic brackets 373
adaptation syndrome 468 retrognathism 113, 434 Methods of
diseases 127 rotation 42 examination of swallowing 185
Location of tooth 430 second premolars 47 gaining space 253
Lock pins 374, 375f surgeries 440 gathering growth data 18
Long Mandibulofacial orthodontic attachment 284
axis dysostosis 162, 433 retention 415
of upper and lower Manner of force application 384 studying
incisors 211 Marfan’s syndrome 162 growth 19
rotation 301 Martensitic stainless steels 512 role of genes 163
labial bow 355 Mastery of skills 70 Micrognathia 162
Loss of periodontal support 461 Maternal rubella 129 Microimplants 324
Lower Mathieu ligature-tying pliers 555f Microstructure of soldered
incisor 215 Matrix rotation 42 joints 530
crowding 267 Mature swallow 61f Midarch analysis 193
lingual Maxillary Midface hypoplasia 443
arch 315f, 332f anterior teeth 257 Midline diastema 134f, 272
bar 416 canines 47 Midpalatal osteotomy 434
springs 405 collapse syndrome 112, 113 Millard’s modification of
Lysosomal acid protease 311 expansion syndrome 112, 113 Kernahan striped “Y”
first premolars 47 classification 475
M median diastema 113 Mills retractor 355, 356, 361, 361f
Macrognathia 162 posterior teeth 257 Mineral acids 525
Magnetic prognathism 434 Minor tooth movements 345
appliances 528 retrognathism 434 Mirror test 184
resonance imaging 232 surgeries 438f Missing
of TMJ 233f Maxilloalveolar index 119 muscles 433
Magnitude of force 384 Maxillothorax myotherapy 150 teeth 131
Maher’s theory 69 Maximum mouth opening 184f Mixed dentition 90, 252
Malalignment index 110 McCallins classification 100 analysis 192
Malar-zygomatic buttress 66 McNamara analysis 217 model analysis 189
Maleic acid 508 Measurement of arch period 46, 50
Malocclusion severity circumference 190f Mock surgery 436
estimate 113 Meckel’s cartilage 34 Mode of
Management of Medial pterygoid plate 31 action of
abnormal Frenal Median sagittal plane 97 clasps 347
attachments 328 Membranous bone formation 21 Frankel appliance 404
ankylosed teeth 327 Meningeal genetic transmission 160
appliance 400 calcifications 202 Modification of Adams’ clasp 350f
blind child 485 vessel grooves 201 Modified Adams’ clasp 354
 Index 569

Moire topography 16 Nasopharyngeal diseases 127 Optimum orthodontic force 306

Moisture resistant primers 525 Neck strap 386f Orbicularis oris 62
Molar Neonatal skeleton 36 Orbital plane 97
clasp 347 Neoplasia 465 Organic acids 525
displacement 425 Neuroepithelial trophism 27 Orthodontic
distalization 383 Neuromuscular system 90, 127 appliance cleaners 544
Molybdenum 517 Neurotrophic process in arch wire materials 509
Monocrystalline 508 orofacial growth 26 cements 508, 520
Monosomy 161 Neurovascular dysfunction 467 in India 5
Monozygotic twins 163 Newer interdental systems 325 indices 110
Mosquito pliers 553, 554f Newton’s laws of motion 298 management of
Mouth Nickel ankylosed teeth 456
breathing 147, 339 hypersensitivity 381 cleft lip and palate 472
mirror test 184 titanium 507 cleidocranial dysplasia 480
Movement of posterior teeth in alloys 514 obstructive sleep apnea
sagittal plane 401 NiTi syndrome 482
Moyer’s arch wires 284 TMJ and occlusal
classification 127 load deflection curve 516t disorders 462
mixed dentition Nitric acid 508 minianchor system 325
analysis 189, 192 Nonfluoridated etchants 508 root resorption 312
theory 281 Nonfluoride releasing study models 185, 186f
Multidisciplinary systems 508 therapy 275
orthodontics 448 Nonfunctional tooth movement 3, 310
Multiple-piece maxillary treatment
cusps 84
planning 246
osteotomy 440, 440f occlusion 86
priority index 113
Muscle Non-nutritive
triangle 75f
contracture 465 digital sucking 138
Orthognathic surgery 433, 434
exercises 328, 333, 341 sucking 137
and stabilization 436
function adaptation 404 Nonsupporting cusps 84
Orthopedic
Muscular
O appliances 382
dysfunction 467
dysfunction 466
forces 422 Obstructive sleep apnea 482
traction 408
Myodynamic appliances 391 Occipital
Orthosystem implant systems 433
Myofascial pain dysfunction bone 30
Osseous implants 323
syndrome 297 pull headgear 387f
Ossification of palate 33
Myofunctional Occlusal Osteoarthritis 465
appliances 280, 344 equilibration 421 Osteoarthrosis 465
therapy 275,421 index 110, 113 Osteogenesis 20
Myotherapeutic exercises 146 plane 210f imperfecta 162
Myotonic appliances 391 angle 215 Overbite 112, 113
therapy 153
N Oligodontia 252 P
Nager’s syndrome 443 Omas system 433 Palatal
Nail biting 127 Open bow 405
Nance bite 92, 112, 113 canine retractor 360, 360f
Carey’s analysis 189 appliance 407 implants 325f
method 337 coil springs 371, 371f index 119
palatal arch 332f eruption 284 osteotomy 260
Nasolabial angle 177, 177f spaces during mixed plane 210
Nasomaxillary complex 80 dentition 144 vault 178
570 Essentials of Orthodontics

Panoramic radiographs 197, 283 Polymethylmethacrylate 548 Preventing Milwaukee brace

Parallel-action pliers with Polypropylene 548 damage 328
cutter 555, 555f Polysulfone 548 Primary dentition 90, 252
Paralleling technique 196 Polysulfide polymers 534 Principles of retention 346
Paranasal sinuses 203 Polytetrafluoroethylene 548 Procedure of proximal
Parental anxiety 76 Pont’s analysis 189 reduction 255
Passive Position of tooth in dental Process of sucking 138
maxillary obturator 478 arch 319, 383 Proclination of anterior teeth 269
muscle function 64 Posterior Prognathic mandibles 289
Payne technique 146 centric contacts 85 Prolonged retention of
Peck and Peck index 189 cross bite 92, 113, 276 deciduous teeth 132
Peer assessment rating index 114 facial height 425 Properties of dental solders 530
Pendulum appliance 268, 268 nasal spine 210 Protraction
Pentagon analysis 168 open bite 113, 275 face mask therapy 388
Period of part of body of sphenoid 31 headgear 386
embryo 28 Posteroanterior cephalometric Protrusion of incisors 401
fetus 28 analysis 218 Protrusive functional occlusion 86
occlusal development 46 Posteruptive tooth Proximal stripping 254f
ovum 28 movement 303 Psychoanalytical theory 67
Periodontal ligament 54, 313, 451 Postnatal growth of Psychological
traction 422 cranial development 11, 66
Permanent dentition 90, 252 base 36 methods 140
model analysis 189 vault 36 Psychosocial theory 69
period 46, 53 mandible 40 Pterygoid buttress 66
Persistence of supernumerary Pulp 313
maxilla 38
teeth 56 growth theory 54
TMJ 43
Petrovic’s servosystem theory 27
Postsurgical orthodontics 441 Q
Phases of
Pottasium
development of thumb Quad Helix 261
alginate 535
sucking 139 appliance 142, 261f, 278
titanium fluoride 535 Qualitative methods of
orthodontic treatment 252
Preadjusted edgewise recording malocclusion 94
tooth movement 309, 310f
appliance 378f
Phonetic method 181
Pierre Robin syndrome 443
Pre-eruptive tooth movement 303 R
Premature loss of deciduous Rabey’s morphanalysis 16
Pillowing habits 154
Pin and ligature wire tooth 132 Ramus 40
cutter 555, 555f Prenatal blade 322
Pinching of band 367 development of frame 322
Pineal gland 202 mandible 34 vertical osteotomy 434
Pitted solder joints 533 maxilla 32 Random access memory 238
Placement of brass separators 372f growth of temporomandibu- Rapid maxillary
Plaster of Paris 539 lar joint 35 expansion 255, 278, 389
Plastic brackets 373, 374 Preorthodontic trainer 146, 340 Rare facial clefts 476
Polyacid-modified Preparation of Read only memory 238
composite resins 523 cast 349 Rectangular wire 369f
Polyalkenoic acids 522 wire elements 400 Reduction genioplasty 434
Polyarthritides 465 Preprosthetic alignment 455 Reinforce intraoral anchorage 383
Polycarbonate 508, 518 Pressure tension theory 308 Reinforced anchorage 315
Polycrystalline 508 Presurgical Removable
Polymeric acids 525 orthodontics 436 appliances 142, 257, 280,
Polymethylene 548 orthopedics 478 344, 345

distal shoe space
maintainer 331
partial denture 416
plates 278
prosthesis 480
retainers 416
space maintainers 329
Removal of dental
compensations 445
Resin-modified cements 522
Respiratory disturbance index 482
Resta clasp 350
Retained infantile swallow 145
Retention of rotations 274
Retrognathic maxilla 289
Retrusion of incisors 401
Reverse
labial bow 355, 356, 361, 361f
pull headgear 385, 389f
Rheumatic fever 485
Rheumatoid arthritis 465
Rhythm of growth 11
Ribbon arch brackets 373
Rigid labial bow 316
Ring
chromosomes 161
separators 372
Robert’s retractor 356, 361, 361f
Role of
apical foramen 251
cosmetic restorations 273
extraction 287, 290
functional appliances 288
growth 251
occlusion 422
orthodontist 78, 487, 494
third molars 422
Root
formation 46
length 318, 383
Roth’s concept of functional
occlusion 88
Round wire 369f
S 323, 433
Sagittal
appliance 268
deviation 99
plane malocclusions 92
procedures 434
split osteotomy 434
Index 571
Salzmann’s classification 128 parameters 212
Sargent’s heavy-duty pliers 555 system 90
Sassouni Smart clasp 354, 354f
analysis 216 Soft tissue
physioprints 16 analysis 215
Scammon’s growth curve 12, 12f irritation 364
Schuchardt and Pfeiffer’s Soldered grate appliance 142
symbolic classification 474 Southend clasp 347, 351, 351f
Schwarz clasp 352, 352f Space
Scissors bite 92, 92f regainer 340f
Sealants and adhesion regaining 333, 339
promoters 508, 524 Speech therapy 147
Second transitional period 52 Sphenoethmoidal
Selection of magnitude of synchondrosis 38
extraoral force 388 Sphenoid bone 31
Self-cure acrylic resins 543 Sphenooccipital synchondrosis 37
Self-ligating brackets 373 Spider screw 433
Self-supported springs 357 Split labial bow 355, 356
Semifixed appliance 344 Spot welder 533f
Separation of teeth 366 Spring retainer 416, 420, 420f
Sequence of Square wire 369f
color code in cephalometric Stamp cusps 84
superimposition 212 Statistical test 106
treatment in orthodontics 455 Status of dentition 47
Steiner ligature-tying
Serial extractions 334, 430
pliers 556, 556f
Serrated
Steiner’s analysis 214
amalgam plugger 556
Step index 119
band plugger 556
Steps in
Short labial bow 355
banding 366, 368
Shovel shaped incisors 119
construction of
Silicone rubber materials 545
Adam’s clasp 350
Silver solders 529
orthodontic study
Simon’s
models 187
classification 97
soldering procedure 531
law of cuspid 98 Sterilization in orthodontics 243
system 97 Straight wire appliance 378
Simple Strang’s steps for proper
anchorage 315f classification 91
tongue thrust 144 Streptococcus
Singer’s method of mutans 379
assessment 224 viridans 291
Skeletal Stress-strain curve 510f
anchorage system 322, Stretched periodontal
ligament 249
anterior open bite 274 Structural disorders 161
cross bite 276 Stylomandibular ligament
deep bite 279 inflammation 465
jaw malrelations 264 Subapical osteotomy 434
malocclusions 91, 93, 93f Submucosal implants 321
maturity indicators 220 Subperiosteal implants 322, 323
572 Essentials of Orthodontics
Sucking reflex 137
Supernumerary teeth 131
Surface
remodeling of mandible and
maxilla 40f
tension of solder 530
Surgical
exposure of impacted
teeth 430
lip closure 478
orthodontics 2, 429
palate closure 479
Sutural theory 23
of growth 23f
Svanholt and Solow analysis 218
Synchondroses 37f
Systemic diseases 127
T bands 366
Tanaka Johnston analysis 189
Tanner and Whitehouse
method 222
Taranger method 222
Technique of soldering 531
Telescoping bite 92f
Temporal bone 31
Temporary anchorage device 321
Temporomandibular
joint 35, 81, 184, 314
tomography 233f
Theories of
constant proportions 62
deglutition 62
expulsion 62
growth 23
integral function 62
negative pressure 62
retention 414
tooth movement 308
Therapeutic
extractions 429
occlusion 83
Thickness of base plate 363
Third finger
distal phalanx 227
middle phalanx 226
Three alarm system 142
Thumb sucking 127, 128, 137, 339
Tip edge technique 378
Titanium 517, 518
molybdenum alloys 516
niobium 508, 517
Tongue
blade therapy 338f
sucking 154
thrusting 127, 142, 339
Tooth
brushing 380
crown index 119
displacement 113
eruption 302
germ 47
mobility 305, 364
width index 119
Torquing springs 371f
Total
dentition space analysis 193
finger ridge count 495
space analysis 189
Trajectories of
force 65
mandible 66
maxilla 66
Transcutaneous electrical nerve
stimulation 470
Transient malocclusion 272
Transoral vertical ramus
osteotomy 441
Transosteal implants 322
Transpalatal arch 315f, 332
Trans-sagittal deviation 99
Transverse
deviation 99
plane malocclusions 92
Traumatic
occlusion 83
ulcerations 380
Treacher Collins syndrome 443
Treatment of
anterior
crossbite 277, 290
openbite 275
bony defects 460
deep bite 280
posterior crossbite 278, 290
skeletal anterior crossbites
during growth period 277
Treatment planning in
mixed dentition 252
permanent dentition 253
postpermanent dentition 253
primary dentition 252
Triangular
clasp 347, 351, 351f
force concept 62
Triple-beaked pliers 556, 557f
T-spring 359f
Tube shift technique 282, 282f
Turner’s syndrome 161
Tweed
loop-forming pliers 557, 557f
method 337
triangle 216f
Twin block appliance 408, 408f
Types of
bonding 367
cephalograms 198
cusps 84
device 446
force 301, 301f
function regulators 404
growth data 17
Herbst appliance 409
malocclusion 91
solders 529
teeth 248
tooth movement 248, 299, 300f
U
U loop canine retractor 359, 359f
Ugly duckling stage 52f
Unerupted central incisors 113
Unfavorable sequelae of
malocclusion 2
Upper
incisor 215
lingual arch 142
Use of
acrylic resins in
orthodontics 543
base plate 362
cephalograms 199
computer in orthodontics 238
crowns and prosthesis 271
fixed appliances 270, 271, 274

lip bumper 396
open coil springs 268
removable
appliance 270, 271, 273
tongue blade 277
V White and Gardiner’s
Van der Linden’s
retainer 417, 417f
Van Limbourgh’s theory 25
Various indices of occlusion 111
Vasoactive intestinal
polypeptide 311
Veau’s classification 474
Vertical
plane malocclusions 92
pull chin cup 390
Vestibular arena of
operation 403
Visick clasp 347, 353, 353f
Index 573
W Z
Zinc
Wassmund technique 437
oxide eugenol 534
Water test 184
phosphate cements 521
Weingart utility pliers 558, 558f
polycarboxylate cements 521
Weldable brackets 373
silicophosphate 521
classification 128 Zirconium 517
Wilkinson extraction 266 silicate 546
William James classification 135 Z-spring 358f
Zygoma anchorage
Wilson’s
system 322, 324, 433
classification 72
W arch appliance 262, 262f
Wolff’s law of transformation
of bone 66
Wright’s classification 73
Wunderer’s
modification 401
technique 437
Wylie analysis 217