Textbooks: Graber, TM., Orthodontics, 3rd Ed.

Moyers, R., Handbook of Orthodontics, 4th Ed.

Orthodontics
- the study of the relation of the teeth to the development of the face and the correction of arrested and
perverted development
- branch of dentistry concerned with the study of the growth of the craniofacial complex. the development of
occlusion and the treatment of dentofacial abnormalities (most common abnormality: cleft)
- study of growth and development of the jaws and face, particularly and the body generally
- study of action and reaction of internal and external influences on the development and prevention and
correction of arrested and perverted development

Purpose of Orthodontics
1. To improve and correct unfortunate dentofacial esthetics
2. To eliminate harmful oral habits
3 factors that cause malocclusion from harmful oral habits
- Intensity
- Duration
- Frequency
3. To eliminate impaired masticatory function and digestive problems
4. To correct impaired speech
Open bite:
Dental – tongue thrust, thumb sucking
Dento-alveolar Open Bite: lack of growth of maxilla or mandible (requires surgery)
5. To correct TMJ dysfunction
3 symptoms of TMD
- clicking
- popping
- grating
- *pain
6. To prevent susceptibility to dental caries (kissing caries)
7. To prevent susceptibility to periodontal diseases (which cause halitosis)
8. To guide development of occlusion
9. To improve muscle function (good tonicity for proper HMA function)
10. To aid in optimizing other treatment
Ex. Prosthodontics: 6’s early exo causes mesial drifting and tilting
11. To simplify oral hygiene procedures to improve oral health
12. To lower the risk of trauma due to protruded teeth
Reimplantation – successful if done within 15 mins
Soak tooth in a glass of milk
13. To prevent injury to the gums

Scopes of Orthodontics
A. Preventive
o During deciduous, early mixed dentition
o Maintenance of normal occlusion
o Indication of future orthodontic problems
o Treatment of caries as a preventive measure
o Critical period of tooth exchange
o Space control
o Occlusal equilibration (so there is no shifting) (less invasive restorations)
o Oral habits control
o Normal situations with abnormal influencing factors

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o Procedures that attempt to ward off untoward environmental attacks (threats) or anything that would
change the normal course of events
● Oral habits and dental caries cause threats
o Elimination of factors that may lead to a malocclusion in a normally developing dentition
o Measures taken to ensure that the normal situation is preserved and that nothing happens to disrupt
normal occlusion

8 Preventive Orthodontic measures

1. Education
a. Patient and parents
b. To increase dental awareness
● The need of regular dental visits
● Proper oral health care at home
● Importance of having a healthy mouth / teeth
● Benefits of different dental procedures
● Need for referral to diff specialists
● Traumatic flossing – causes black, triangular interdental spaces
2. Fluoride Treatment
a. The importance of Fluoride in tooth development
b. It strengthens the enamel to make it more resistant to carious attck
c. Systemic fluoride
d. Topical fluoride
3. Pits and Fissure Sealants
a. Importance of pit and fissure sealants
b. When to perform? As soon as tooth erupts, do not place after time of eruption due to
contamination
c. Which tooth? 1st molars
d. Age limit? Yes, not at 30 years
e. Is it forever? No, wear and tear
f. Use of flowable composite – to close off deep crevices
4. Proper Restorative Procedures
a. The need to restore the teeth, primary or permanent
b. Normal occlusal anatomy – premature contact
c. Normal mesio-distal width (affects total arch length)
d. Normal proximal contours (creating the “bulge” exerts pressure on periodontal ligaments)
5. Proper prosthetic rehabilitation
6. Stainless steel crown
a. Strip-off Crowns – preformed, composite
7. Space Control
a. Crown and Loop – abutment: carious tooth

b. Band and Loop – abutment: sound, non carious tooth

c. Distal shoe space maintainer – installed in contact with the

pre-eruptive molar
● Hardest to fabricate
● Indication: not enough support from adjacent
tooth
● To guide erupting tooth
● When opposing tooth is yet to erupt
● If used after extraction, the distal shoe is placed down the distal wall of the extracted
socket
● Healed edentulous space: an incision is made with a sterile scalpel

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 ● Position: determined by pre and post radiograph
● Prior to cementation, take a radiograph of the
appliance in the mouth to ensure proper fit

d. Lower Lingual Holding Arch

● Bilateral early loss of deciduous molars
● Anchorage: lower lingual incisors (prevents mesial tilting
● Only if the lower incisors are complete, fully and
nicely aligned

e. Nance Holding Arch

● Used for the maxillary arch
● Anchorage is not on maxillary anteriors but on the
palatal bone, at an angle
● Preventive phase, as part of a treatment may act as a
supporting appliance if there in movement needed
● Disadvantage: may cause inflammation if there is
debris buildup on the palate

f. Transpalatal Arch Space Maintainer (TPA)

● Fixed Removable Space Maintainer
● Maxillary Permanent First Molar – tends to
rotate mesiolingually
● Used to derotate upper 6
8. Supervision of the exfoliation of the primary teeth and eruption of
permanent teeth
a. Upper: 61245378
b. Lower: 61234578
c. Diastema between 2 upper central incisors is more than 2 mm, eruption of the permanent
canines will not cause total space closure and residual space may result
d. if the space present is greater than 2mm after the maxillary canines erupt, investigate case

Causes of Diastema and Gapped Teeth

1. Size and mismatch between teeth and jaws
2. Missing teeth
3. Abnormal jaw bone structure
4. Lip biting
5. Tongue thrusting
6. Oversized Labial frenum – wrongly placed
7. Thick Lingual Frenum

e. Mild Crowding of the Mandibular incisors

Ectopic Tooth Eruption
- tooth is erupting away from its normal path and causing abnormal resorption of the roots of
adjacent teeth
- usually affect the maxillary 6, especially if E is prematurely lost causing 6 to tip mesially
- Panoramic Radiograph is needed to confirm

Ankylosis
- union between the cementum of the root and alveolar bone
- resulting in incomplete eruption of the tooth
- common in primary molars

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 Congenital Missing of Permanent Teeth
- Primary teeth may be retained as long as there is no mobility and its size does not interfere with the
proper interdigitation

9. Prevention of Oral Habits

a. Thumb sucking (reflex for self gratification)
● Prolonged thumb sucking / digit-sucking may lead to
1. Anterior open bite
2. Labial flaring and spacing of the maxillary anteriors
3. Lingual tipping of the lower incisors
4. Posterior crossbite
● Ideally begin management at age 5
1. Conservative approach
a. Band aid around the finger
b. Painting a bad tasting substance on the thumb
c. Wearing cotton gloves during sleep
d. Pinning the pajama sleeves on pajama pants
2. Palatal crib with or without labial bow
a. Drawbacks: needs patient cooperation when a removable appliance is
used – Palatal / tongue crib
b. Tongue Thrusting
● May result to open bite
● Management: Palatal crib or a tongue reminder
● Result in:
1. Anterior Open bite – supra eruption of the posterior teeth
2. Posterior cross bite – imbalance of muscle forces between the tongue and
buccinators muscle
3. Labial Flaring and spacing of the lower anterior from tongue pressures
c. Mouth Breathing
● Management
1. Oral screen / oral shield
2. Vestibular Shield / screen
d. Lip sucking / Hyperactive Mentalis Muscle
● Lip sucking / lip biting
● May result in: Increased overjet resulting from labial flaring of the upper anteriors
and lingual tipping of the lower incisors
● Best time to start treatment is 5 years old
● Management:
1. Lip Bumper – fixed remover (lower arch)
2. T4K appliance

B. Interceptive
a. During late mixed dentition
b. Abnormal conditions already exist
c. With no visible malocclusion but with potential sign of malocclusion
d. Phase of science and art of orthodontics employed to recognize and eliminate potential irregularities
and malpositions in the developing dentofacial complex
i. Child – a lot of growth and development of craniofacial structure
e. Procedure to lessen the severity of malformation or to totally eliminate the cause
f. Interproximal splicing of teeth, serial extraction, arch expansion
i. Splicing – a selective procedure performed when there is not much growth anymore.
● Width: 0.2 – 0.5 mm of enamel: remove contact area
ii. Serial Extraction to simplify treatment in corrective phase (full bracket therapy)

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 ● A series of teeth are extracted over a period of time
● Order: C > D > 4
iii. Arch expansion – usage of mechanics to widen a narrow palate (maxilla) or mandible
● During interceptive phase there is growth and development
● V-shaped arch, overlapping anteriors, narrow intermolar distance
● Aim to initiate alveolar bone movement
● A key is used to “Widen” / expand appliance

● Expansion Screw Appliance / Schwarz Appliance – with a key

● Upper Arch – presence of diastema it means treatment is working
● Hyrax Appliance – Palatal Expansion

Orthodontic Headgears (Extra-oral Appliance)

– needs cephalometrics in order to determine design
1. Cervical Pull Headgear
2. Facemask of reverse pull headgear
3. High Pull Headgear – occipital anchorage

C. Corrective
a. During permanent dentition
b. Use of permanent brackets and elastics
c. Recognized the existence of malocclusion
d. Procedure done to reduce or eliminate the problem and its sequelae
e. Broader scope than the technique in interceptive orthodontics
f. Surgical Orthodontics / Orthognathic Surgery
i. Maxilla / Nasomaxillary Complex: Le Fort I, II, III
ii. Mandible:
1. IVRO – Intravertical Ramus Osteotomy
2. SSRO – Sagittal Split Ramus Osteotomy
iii. Chin: Genioplasty

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 Types of Corrective Orthodontic Procedures
1. Limited Corrective Orthodontic Procedure
a. General Practitioner
b. Pediatric Dentist
2. Extensive Corrective Orthodontic Procedure
a. Orthodontist

3 Tissue Systems involved in Human Dental Occlusion

1. Bone System (craniofacial structures)
2. Tooth System (Dentition)
3. Neuromuscular System
- Thorough knowledge of the bone system
- The vital and dynamic role of the nerve and muscular system
- Appreciation of facial esthetics – position of the dentition and its effect on the total profile and facial
balance

Speech Disorders in Relation to Dental Malocclusion

Speech Articulation Disorders
- involves mispronouncing speech sounds by omitting, distorting (lisping), substituting or adding
sounds which can make speech difficult to understand
- the tongue is considered the most important organ in articulation of speech due to its ability to
move and change its shape
- speech disorders occur when any abnormality prevents the tongue to articulate normally with the
related structures such as the lips, teeth, alveolar bones, hard palate and soft palate

Effects of Dental Malocclusion in Speech

1. Irregularities of the Anterior Teeth
- difficult to pronounce t and d
2. Anterior Open Bite
- Difficult to pronounce m, p, b
- Lisping – best known distortion
o refers to the specific substitution involving the letters s and z with th
o ex. Sing 🡪 thing
3. Increased overjet or decreased overbite
- More difficult to pronounce s (becomes an unvoiced s)
4. Skeletal Class III malocclusion
- Distortion and substitution of sounds like zh, ch, sh, z
- Difficult to pronounce f and v
5. Tongue tie
- Difficult to pronounce l
- Short tongue
- Frenectomy

History of Orthodontics
- crowded, irregular and protruding teeth have been a problem for some individuals since the antiquity
- attempts to correct the disorder go back to at least 1000 BC
- awareness of “crooked teeth” were mentioned in writings of Hippocrates (450-377 BC), Aristotle (384-322 BC) and
Celsus & Pliny (Contemporaries of Christ)
- Aurelius Cornelius Celsus (25 BC): first recorded treatment of teeth by finger pressure (method still used: thumb
used to push maxillary anteriors)
- Crude appliances were designed to regulate teeth have been found as archeologic artifacts in tombs of Ancient
Egypt, Greece and Mayans of Mexico
- Orthodontics came from two Greek works: orthos (to correct) and dons (tooth)

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- Oldest and largest specialty at present
- 300 BC – Ancient Greek Skull – used gold wires for alignment
- as dentistry developed in the 18th and 19th centuries, a number of devices for “Regulation” of teeth decreased by
various authors and apparently used sporadically by dentists of that era

18th Century
*Orthodontics probably has its roots in France

Pierre Fauchard – “Father of Modern Dentistry”

- widely known for his book The Surgeon Dentist
- described the bandelette now called the expansion arch 1728 Treatise on Dentistry
- Credited for the first comprehensive writing on crowded teeth
Etienne Bourdet – further perfected the bandeau
- first dentist on record to recommend Premolar Extraction to alleviate jaw crowding
- first to scientifically prove jaw growth

John Hunter – 1728 – 1793

- The National History of Human Teeth – 1771 – the first clear statement of orthodontic principles
- Termed: cuspids and bicuspids to describe jaw growth

Orthodontics as a science developed in the 1800s

19th Century
Norman William Kingsley 1829-1913
- noted sculptor, artist, influential dentist
- first Dean of the School of Dentistry in NYU
- A Treatise on Oral Deformities – first texts that systematically describe orthodontics
- first to use extra-oral force to correct protruding teeth
- pioneer in treatment of cleft palate and related problems
- Greatest Contribution: Obturator
- Ortho emphasis: alignment of teeth, correction of facial proportion and not on bite relation
J.N. Farrar 1800
- good brace appliance designer, recommended bodily movement of teeth (crown and root)
Delabarre
- introduced the wire crib
- marked the birth of contemporary orthodontics
J.S. Gunnel
- invented the occipital anchorage headgear
Friedrich Christopf Kneisel 1836
- first to recognize malocclusion with the use of plaster model
- first to use removable appliance (chin strap)
John Tomes
- first to demonstrate bone resorption and apposition
Joachim LeFoulon 1839
- first to use the term Orthodontia
J.J. Guilford 1889
- published the first textbook on orthodontics for students
Eugene Solomon Talbot 1847-1924
- suggested radiographs for Orthodontic diagnosis
- extraction for crowding in this era was to correct facial proportion. Little attention was given to how
teeth occlude
Edward H. Angle 1855-1930
- Father of Modern Orthodontics

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 - First dental specialist
- First publication in 1887: served to organize existing knowledge in orthodontia
- Developed concept of occlusion in natural dentition and the Edgewise Appliance (1928)
- Developed the Classification of Malocclusion (1890)
● 1st clear and simple definition of normal occlusion
● based on upper permanent first molar relationship
- Opposed extraction for orthodontic purpose
- Less attention given to facial proportion and esthetics so he abandoned the use of extra oral force
- Had creativity to develop new orthodontic appliances (the fixed appliance used in contemporary
orthodontics are based on Angle’s design from the early 20th Century

Angle’s E Arch
- Angle’s expansion arch
- Early 1900’s – ligatures from a heavy Labial arch were used to bring malposed teeth to the line of
occlusion and to expand arch

Angle’s Ribbon Arch Appliance 1910

- brass pins are inserted from the occlusal aspect into vertical slots of the brackets soldered into
bands to hold the archwire in place
- was well adapted to bring teeth into alignment but was too flexible to allow precise positioning of
roots
Angle’s Edgewise Appliance
- brackets soldered to the bands have horizontal slots

*Begg Appliance (Dr. Raymond Begg)

- modified ribbon arch appliance
- known for light wire technique
- bracket is upside down with the archwire inserted from the gingival aspects held in place by brass
pins
- Downside: flexible
- Australia
Calvin Case 1847-1923
- Major contribution: battle with Angle over extraction controversy
- Pioneer in mechanotherapy
- First to:
▪ Stress root movement
▪ Use rubber elastics in treatment (1892)
▪ Use small gauge , light resilient wires for tooth adjustment (1917)
▪ Use retainers to stabilize teeth - wrap around retainer to prevent relapse
- Outstanding in the prosthetic aspect of cleft palate rehab
William E. Magill 1817
- Introduced the plain band cemented to tooth
Aurelio Levrini & Lorenzo Favero
- Describe the details of invention and development of a revolutionary European approach to
treatment of malocclusion knows as Functional Jaw Orthopedics
Martin Dewey 1881-1933
- 1915 – Dr. C. V. Mosby - founded and editor of International Journal of Orthodontia (now: American
Journal of Orthodontics): most complete record of ortho lit in existence
- International Journal of Orthodontia and Dentofacial Orthopedics (IJO-DO)
- Dewey School of Orthodontia – 1911: post grad school like Angle
- Wrote Practical Orthodontics
- Stressed importance of the blend of biologic and mechanical aspects of Orthodontics
Albert Ketcham 1870-1935

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 - Instrumental in founding the American Board of Orthodontics and served as its first president
- Investigated the problem of root resorption due to mechanotherapy
- Awakened feeling of biologic sense
Milo Hellman 1872-1947
- 1 of 12 students of Angle
- Pioneer of Hand and wrist radiograph to determine the growth age and status of the patient

20th Century
- Extraction was reintroduced into Orthodontics in the 1930s
- Excellent occlusion unsatisfactory if it was achieved at the expense of proper facial proportion
Broadbent
- Created Cephalometric Radiography (Lateral Skull Radiograph)
- Developed and widely used after WWII to measure changes in tooth and jaw positions produced by
Growth and Treatment
- In Europe: studied more the role of the craniofacial skeleton in dentofacial anomalies and
malocclusion, functional jaw orthopedics was developed
Dr. Charles Hawley
- invented the Hawley’s retainer
- the Labial wire or Hawley Bow incorporates 2 omegas for adjustment
Dr. Martin Schwartz
- harbinger of today’s Twin Block
- inventor of appliance that corrects bilateral crossbite and anterior crowding
- removable appliance
Rolf Frankel
- recognized as an inventor of an appliance that corrects malocclusion with little or no contact with
dentition
- Functional Jaw Orthopedic Appliance
Phillip Adams
- Modified the arrowhead clasp made by Schwarz
- Used when there is no retentive area on abutment tooth
Dr. Earl Bergersen 1970
- Created passive Ortho-Tain Appliance – guides jaw growth and helps correct orthodontic problems
and malocclusion in children and adults
- Like T4K
Dr. Kraven Kurz (USA) & Prof. Kinya Fujita (Japan) 1975
- Lingual braces (invisible braces)
George Andreasen
- American orthodontis, inventor of Nitinol wire which was awarded a US patent in 1979
- Nickel Titanium – “memory wire”
Dwight H. Damon
- Developed the Damon Bracket: a passive self-ligating dental brace system that allows low friction
force treatment in aligning teeth more comfortably and in less time that precious procedures
- Faster
- Patient recall once in 2 months
21st Century
- Emphasis on dental, facial appearance (increase awareness of parents and patients because of
esthetics and psychosocial problems affecting quality of life)
- The advent of orthognathic surgery to correct facial dysproportions
- The development of computer imaging methods: to share facial concerns with patients
- Patients expect and are granted a greater degree in involvement in planning treatment
- Offered more frequently to older patients as part of multidisciplinary treatment plan involving other
dental and medical specialties

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 - Emphasis on skeletal and dental relationship is shifted toward greater consideration of the oral and
facial soft tissues
- Soft Tissues – are recognized as the major limitation to orthodontic treatment and major
consideration for success of treatment
Zia Chishti & Kelsey Wirth
- Applied 3D computer imaging graphics to the field of orthodontics and created alignment
technology and Invisalign method
- Invisalign braces were first made available to the public in May 2000
▪ a series of ALIGNERS that you switch out about every 2 weeks
▪ each aligner is individually manufactured with exact calculations to gradually shift your teeth in
place

*Angle’s Edgewise appliance 🡪 Straightwire

*Angle’s Ribbon arch appliance 🡪 Begg appliance.

GROWTH AND DEVELOPMENT

Growth
- quantitative aspect of biologic development measurable in inches / year, gm / day (units of increase
/ units of time)
- a result of biologic process in which living matter normally gets larger (in all directions, width, length
and height)
- an orderly process with an occurrence of spurts (sudden increase) at times

Development
- all the normal sequential series of events between fertilization of the ovum until adult state
- brings about a more advanced, effective or complex state as it progresses towards maturity
- According to Moyers: refers to all naturally occurring unidirectional changes in the life of an
individual from its existence as a single all to its elaboration as a multifunctional unit terminating in
death

Differentiation
- change from generalized cells / tissues to more specialized kinds during development
- a change in quality or kind

Maturation
- stabilization of the adult state
- the quantitative changes which occur with ripening or aging

Why study growth and development?

- recognition of significant deviations from normal growth
- planning of different treatment modalities to regulate the growing dentition and the jaw bones for
the benefit of the patient
- determination of the efficacy of therapy (retroactive study)

Factors affecting Growth and Development

1. Heredity
o Genetic influence on the size and parts, rate of growth and onset of growth

2. Nutrition
o Malnutrition may affect the size of parts, body proportions, quality and texture of tissues and onset of
growth events
3. Illness

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 o Prolonged and debilitating illness can have a marked effect on all aspects of growth
4. Race
o Although growth differences among races can be attributed to other nutritional and environmental
factors, some evidences show that race plays a role
5. Socioeconomic Factors
o Affluent and favorable socioeconomic conditions show earlier onset of growth events and grow to a
larger size
6. Exercise
o Contributes to certain aspects of growth such as development of some motor skills and increase in
muscle mass
7. Family Size and Birth Order
o The smaller the family size, the better will be the nutrition, studies have shown that first born babies,
tend to weigh less at birth, have smaller stature and higher IQ
8. Secular Trends
o Changes in size and maturation in a large population can be shown to occur with time due to changes in
socio-economic conditions and food habits
9. Psychological Disturbances
o If prolonged can markedly retard growth, children experiencing stressful conditions display inhibition of
growth hormone secretion
10. Climactic and Seasonal Effects
o Seasonal changes affect the adipose tissue content and the weight of newborn babies

Concepts of Growth
1. Concept of Normality
- In craniofacial growth, normality changes with age, what is expected for one age group may not
necessarily be normal for different age groups
2. Rhythm of Growth
- Most evident in stature or body height
▪ First wave of growth (Male and Female) – Birth 🡪 5th, 6th year
▪ Most rapid growth – first 2 years
▪ Slower increase, terminating in Boys at 12th year
● Girls not later than 10th year
▪ (M/F) Period of Accelerated Growth (adolescence)
● Completed (G) 14-16 y.o.
o (B)16-18 y.o.
▪ Final Period of Slow growth will end
● G – 18-20 y.o.
● B. – 25 y.o.
3. Growth Spurts
- Sudden increase in growth timing of Growth Spurts
a) Just before birth
b) 1 year after birth
c) mixed dentition growth spurt
B: 8-11 years old
G: 7-9 years
d) Pre-pubertal growth spurt
B: 14-16 years old
G: 11-13 years old
4. Differential Growth
- different organs grow at different rates, to a different amount at different times

2 Aspects of Differential Growth

1. Scammon’s Curve of Growth

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 4 Types of Body Tissue
- Lymphoid Tissue
- proliferates fast in late childhood
- at 18 years old – undergoes involution to reach adult size
- Neural Tissue
- Grows very rapidly and almost reaches adult size by 6-7 years old
- General / Visceral Tissue
- Consists of muscles, bones and other organs with rapid growth up to 2-3 years of age
- Slow Phase of Growth – 2-10 years
- After 10th Year – rapid phase of growth
- 18th-20th year – termination of growth
- Genital Tissue
- Reproductive organs have negligible growth until puberty, grow rapidly at puberty until
reaching adult size, after which growth ceases

2. Cephalo-caudal Gradient of Growth

- Growth extending from head towards the feet
a) Head
- takes 50 % of body length by 3rd month of intra uterine life
- at birth – trunk and limbs have grown more than head reducing to about 30% of body length.
- Overall growth patterns continues with a progressive reduction in relative size of head to
about 12 % in adulthood
b) Lower Limbs
- rudimentary by 2nd month of intra-uterine life
- later grow and represent 50 % of body length in adulthood
c) Cranium
- proportionally larger than face at time of birth
- Postnatally – face grows more than cranium

Development of the Orofacial Region

4th Week
– embryo
– flat disk that bends down at its anterior extremity as brain expands and enlarges, The action pushed the heart
beneath the brain until a pit is created at the midline and becomes the primitive oral cavity or stomodeum
5 Branchial / Pharyngeal Arches
– important in the development of Head and Neck
– development occurs from 4th – 7th embryonic week for facial organization
Enlarging Heart
– Positioned below the mandibular arch in the thorax and begins beating at the end of the 4th week
Forming Face
– grown away from brain and presses against the chest and heart

Development of the Oropharynx – 5th week

Oral Pit
- first appears in the 4th embryonic week
- gradually deepens between the forebrain and heart
- Deepening of the oral pocket appears between the forebrain and heart and eventually becomes the oral
cavity
- Deepest extent of the oral pit is the oropharyngeal membrane which ruptures on the 5th embryonic week
and opens the oral cavity to the tubular foregut and soon becomes the oropharynx

Development of the Pharyngeal Arches – 5th Week

Pharyngeal Arches

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 - termed because they bend around the sides of the pharynx as bars of tissues
- develop during the 5th week
- within Pharynx – grooves called PA pouches match the pharyngeal clefts on the external aspects of the neck

Fates of the Pharyngeal Arches and Pouches – 4th week

1st Pharyngeal Arch
- Mandibular Arch
- Mandible, muscles of mastication
2nd Pharyngeal Arch
- Hyoid Arch
- Facial Muscles, Hyoid Bone
3rd – 5th Pharyngeal Arch
- divided by the bulging heart at the midline

6th Week
- 1st Pharyngeal Groove – external auditory canal
- 1st Pharyngeal Pouch – Middle ear, eustachian tube
- 2nd Pharyngeal Pouch – Palatine Tonsils
- 3rd Pharyngeal Pouch - Inferior Parathyroids and Thymus
- 4th Pharyngeal Pouch – Superior Parathyroids
- 5th Pharyngeal Pouch – Ultimobranchial Body

Cartilaginous Skeletal Development

1st Arch
- Meckel’s Cartilage
- Malleus, Incus
2nd Arch
- Stapes
- Styloid
- Lesser Horns of Hyoid Arch
rd
3 Arch
- Greater Horn of Hyoid Arch
th
4 Arch
- Thyroid Cartilage
- Laryngeal Cartilage

Insights
- Initial Development (4th Week) – each pharyngeal arch has a specific cranial nerve associated with it
- Nerve and musculature of each arch emerge together and follow defined pathways to their functional
positions
- These events are closely regulated genetically during development and few errors occur

Development of the Face and Palate

Insights
- a professional must understand the variability that can occur in facial form
- we must be aware that the human face and palate are among the areas in the body most likely to develop
malformation
Facial Development
- human face develops from 4th-7th embryonic week
- palate closes at 8th week
▪ Frontal Process
▪ Mandibular Arch
▪ Hyoid Arch

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4th Embryonic Week
- critical period wherein environmental factors can affect facial development
th
5 Embryonic Week
- Frontal Process 🡪 Frontonasal Process
- Frontal Prominence decreases, face broadens
- Mandibular Arch Loses Constriction
6th Embryonic Week
- lateral parts of face expands broadening the face
- caused by the lateral growth of the brain
- Maxillary process and eyes – move to the front of the face
- Nasal pits – more centrally located and becomes limited making the face look more human
7th Embryonic Week
- Face: more human appearance
- Eyes approach front of face
- Nose represents less of face
- Upper Lip: fused; produces a medially located philtrum
- Nose / eyes: same horizontal plane
- Ears develop
- Ridge around eyes will form eyelids
- Danger of cleft has passed
Palatal Development 7th-9th Week
- Palate develops from an anterior wedge shaped medial part (primary palate) and 2 lateral palatine
processes
- Lateral Palatine Processes developed from the maxillary tissue laterally and grow towards the midline
- As the Palatine Shelf grows medially, they contact the tongue which grows upward into the nasal cavity at
7th week
- When the Palatine Shelf contacts the tongue, they grow downward on each side

Insights
- cleft lip and palate are among the most common congenital malformations
- they usually occur early in development (6th Week)
- the incidence in Asians is about 3 to 2000 births, 1 in 700 births in the USA

Etiology
- Heredity (40% cleft lip, 20% cleft palate)
- Environmental Factors
- Nutritional Deficiency
- Psychological, emotional, traumatic stress during pregnancy
- Defective vascular supply
- Mechanical obstruction due to enlarged tongue
- Steroid therapy during pregnancy
- Infections
- Alcohol, drugs, toxins

Classifications:
1. Unilateral Incomplete
2. Unilateral Complete
3. Bilateral Complete
4. Bilateral Incomplete

Tongue Development
- body of the tongue develops from the 1st Pharyngeal Arch
- base of the tongue develops from the 2nd and 3rd Pharyngeal Arches

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3 Mechanisms of Bone Growth
1. Cortical Drift
- produces generalized enlargement and relocation as a result of simultaneous deposition and resorption of
bone tissue in the different bones of the skull, movement is towards the depository surface
2. Displacement
- movement of the whole piece of bone as a unit, result of push or pull by different bones and their soft
tissues away from one another as they all continue to enlarge
- always takes place in the opposite direction to bone growth
a) Primary Displacement
● Bone displacement in conjunction with bone’s own growth
● Ex. Growth of maxilla at the tuberosity region results in pushing of the maxilla against the
cranial base resulting to displacement of maxilla
b) Secondary Displacement
● bone displacement in conjunction with growth of nearby adjacent but not immediate bones
and soft tissue
● ex. Maxilla, zygoma, anterior cranial base, forehead shift anteriorly due to growth of middle
cranial fossa and sphenoid bone

Primary Displacement and Bone Growth

1. Entire mandible displaced: downward, forward
a. Condyle: up, back
2. Away from articular joints by growth of its surrounding tissues
3. Translatory movements stimulates enlargement and remodeling of condyles and rami which take place
parallel to displacement
4. Bone Growth processes are directed upward and backward by an amount that equals the displacement of
the mandible
*Growth is faster in early post natal period than during adolescence

Remodeling
● process of reshaping or resizing as a result of progressive continuous relocation
● selective deposition and resorption of the whole bone due to change in regional shape in
order to conform to progressively new positions and change the dimensions and
proportions of each regional part

Changes Produced by Remodeling

1. Change in Size
2. Change in Shape
3. Change in Proportion
4. Change in Relationship of bone with adjacent structures

OSTEOGENESIS

Intramembranous Ossification
2 Types of Bone
1. Bundle Bone
● develops directly in uncalcified or fibrous connective tissue
● Adults: formed during rapid bone remodeling
● Preliminary type of ossification
● Reinforced by lamellar bone
2. Lamellar Bone
● takes place only in mineralized matrix (ex. Calcified cartilage or bundle bone speculae)
● mesh of bundle bone is filled to reinforce the matrix until compact bone is formed

15
 ● Osteoblast formations appear on the mineralized matrix, which the form circles and
surround the intracellular substance around a central vessel in several layers (Haversian
Canal System / Osteon) the arrangement of the apatite in concentric layers of fibrils meets
the functional requirements

Intramembranous Ossification
● subject to continual deposition and resorption which can be influenced by environmental
factors like orthodontic treatment
● More modifiable in context of dentofacial orthopedics / orthodontics

Endochondral Ossification
● has cartilaginous precursors
● found in bones associated with movable joints and some parts of the cranial base which
involve relatively high levels of compression and the condyle of the mandible
● less modifiable in context of dentofacial orthopedics

Reversal Line
– represents the interface between endosteally and periosteally produced bone layers

Individual Components of the Skull

1. Cranial Base
2. Spheno-occipital Complex
3. Nasomaxillary Complex
4. Mandible

Growth of Facial Components

Cranial Vault
– bone formation occurring primarily at periosteum lined contact areas, sutures
– remodeling: inner and outer surfaces of bone to allow for expansion of neurocranium

Cranial Base
– endochondral bone formation
– synchondrosis play a role in early growth
– spheno-occipital synchondrosis – considered principal growth cartilage of cranial base and only one
remaining active during childhood growth period
– A-P shape of face is determined after

Maxilla (Nasomaxillary Complex)

– intramembranous bone formation
– growth occurs through balanced apposition and resorption (remodeling, cortical drift, displacement)
– appositional growth predominates up and back against cranial base with growth expression projected
downward and forward “from under the cranial base”

Mandible
– endochondral at condyle
– intramembranous at body
– condyle fibrocartilage grows by apposition (similar to epiphyseal growth plates of long bones)
– appositional growth predominates along posterior border of ramus with remodeling resorption along
anterior border
– Up and back growth emphasis with expression downward and forward “from under the cranial base”

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Growth Center
– areas highly active growth fields – highly important
– Alveolar Bone area
– Spheno-occipital synchondrosis
– Maxillary tuberosity
– Condyle

Facial Growth Patterns

– facial growth: somatic growth pattern
– females reach skeletal maturity earlier than males by average of 2 years of age

Female Male
Start 10.5 – 11 years 12.5 – 13.5 years
Peak 12 – 13 years (14-18 mos) 14 – 15 years(18-24 mos)
Complete 13.5 – 14 years 17 – 18 years

2 Types of Facial Forms

Hyperdivergent / Dolichocephalic
– anterior vertical facial growth is greater than posterior condyle growth with clockwise rotation expressed as
steep mandibular plane with open bite tendency
– when treating patients with a long face – treatment should prevent further opening

Hypodivergent / Brachyfacial
– posterior facial height proportionately greater than anterior facial height with counter-clockwise rotation
expressed as flat mandibular plane and deep bite
– facial forms and growth patterns are maintained throughout the growth years
– stronger chin / jaw – strong musculature apply strong forces during treatment

Dimensional Facial Growth

Menton - lowest point of the bony chin

Soft Tissue Menton -

Dimensional Facial Growth

Facial Height (Nasion - menton)
- 70% complete by age 3
- 90% complete prior to adolescence
- growth spurt

Facial Width - shows least amount of change

- upper face width (bizygomatic width) - increased throughout childhood and adolescence, greatest rate
observed between 2-6
- lower face (bizygomatic width) - increased throughout childhood and adolescence, greatest rate observed
between 2-6

Facial Depth (Anteroposterior)

- longest growing facial dimension
- maybe divided into upper, middle and lower facial dimension with areas growing at different times and
rates (differential growth)
- greater mandibular increments allow profile to change from convex in childhood to straighter adult

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Craniofacial Growth Concept *Moyers

Genetic Concept (1940) - all skeletal tissues were under genetic control
Functional Concept (1960) - origin, growth and maintenance of all skeletal tissues and organs are always secondary

*Moss' Hypothesis - 1969 - Importance of Functional Matrix

__________________

Cephalometrics
- a technique employing oriented radiographs for the purpose of making head measurements
- study the craniofacial growth
- diagnose
- plan ortho treatment
- evaluation of treated cases

What to look for?

Patient is Class I Facial Profile
II - convex Protrusive
III - concave Retrusive
Straight
Type of Growth Pattern Profile Analysis
Skeletal Open Bite - dolichofacial Patient Concave - Class III
Deept Bite Orthognatic - straight
Normal growth pattern Convex - Class II - prognathic

Are maxilla and mandible: Cephalostat - patient at 90 degrees to xray beam

Proclined - flared, labioverted 60" away from beam
Retroclined - retruded, linguoverted 15" from film

Radiographic Landmarks / Cephalometric Landmarks

1. Sella Turcica (S) - located at geometric center of the pituitary (hypophyseal) fossa, part of the relatively stable
cranial base
2. Nasion (N) - most anterior point on the fronto-nasal suture
3. Porion (Po) - point is represented by the top of the cephalostat earposts (mechanical porion) or auditory meatus
(anatomic porion)
4. Orbitale (Or) - lowest point on the inferior margin of the orbit, midpoint beetween Right and Left images
5. Point A or Subspinale - the point at the deepest midline concavity on the maxilla between the ANS and prosthion
(most anterior superior point of the CEJ) or supradentale (the lowest and most anterior point on the alveolar
position of the premaxilla
6. Point B or Supramentale - the point at the deepest midline concavity on the mandibular symphysis between the
infradentale and pogonion
7. U1 (Upper Incisor) - the incisal tip of the most protruded maxillary central incisor
8. L1 (Lower Incisor) - incisal tip of the most protruded mandibular central incisor
9. Pogonion (Pg) - the most anterior point on the bony chin on the midline
10. Gnathion (Gn) - the most anterior inferior point on the bony chin, commonly used in the construction of Y-axis
11. Menton (Me) - most inferior point of the bony chin
12. Gonion (Go) - the constructed point of the intersection of the posterior border of the ramus and inferior border
of the mandible

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19
Frequently Used Planes:
1. Sella - Nasion Plane - cranial
2. Frankfurt Plane - Porion - Orbitale
3. Palatal Plane - PNS - ANS (Maxillary Plane)
4. Occlusal Plane - 1M - CI
5. Mandibular Plane - Gonion - Menton

Cephalometrics
● tool for diagnosis
● a radiographic technique for abstracting the human head into a geometric scheme
● tool for dealing with variations in craniofacial morphology
● manual or digitized
● assign values, compare with normal: degrees, mm, cephalogram

Cephalogram: radiographic image of the head

Cephalogram Analysis
● is derived from cephalogram in which anatomic structures are reduced to landmark points to indicate shapes and
relative locations of curves
● after: tracing of cephalogram
● Tracing paper: 1 side: dull, 1 side: glossy
● done in a dim room with a light box
20
History
16th Century

Dürer and Da Vinci - sketched series of human faces with straight lines joining homologous anatomic structures
Anthropologists - invented instrument known as CRANIOSTAT for orienting dry skulls which improved the act of
comparisons

Craniometry - science of determining facial morphology and growth changes in dried skulls

Several professions needed a method for studying serial changes (of face and head)

Cephalometry - study of morphology and growth of the head of living individuals

Cephalometric Roentgenography
head measuring in the living individual through the use of radiographs
this technique wad derived from ancient science of craniometry and cephalometry which used head measurements for
many centuries

Pacini (1922) - published first paper on "Cephalometrics"

Broadbent (1931) - standardized and popularized the procedure "radiographic cephalometrics"

Hofrath - published "Cephalometrics" in German

Simon's System of Gnathostatics (method for orienting orthodontic casts)

*Ideas from anthropometrics and gnathostatics naturally evolved and fused into new technology the "Radiographic
Cephalometrics"

Higley's Instrument - evolved the design of modern cephalometers

Purpose of Cephalometrics - a tool dealing with variations in craniofacial morphology, its purpose is always for
comparison

Reasons
1. To describe morphology or growth
2. To describe anomalies
3. To predict future relationships
4. To plan treatment
5. To evaluate results of growth or orthodontic treatment (due to good reproducibility and standard magnification)

Tools
1. Cephalometric Radiograph - Lateral, AP view
2. Panoramic
3. Diagnostic Cast
4. Photographs - intra-oral and extra-oral
5. Clinical Examination
6. History Taking

Purpose of Cephalometrics
1. Description
2. Diagnosis

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 3. Prediction
4. Treatment Planning
5. Evaluation of Treatment Results

Description
aid in specification, localization, understanding abnormalities

Three Kinds of Comparison

● Comparison with STANDARDS - compared with the normal or with the standard measures
o Standards - are objective measures statistically derived from populations
● Comparison with IDEALS -
o Ideals - arbitrary, subjective concepts of facial esthetics represented with numbers
● Comparison with SELF - involves notion of "norm" in sense of an ideal
o findings may be compared with norm for "amount" or direction of "growth"

Diagnosis
● determination of significant deviations from the normal
● its purpose is to analyze the nature of the problem and to classify it precisely

Prediction
● to observe certain quantities, assume they will behave in determinate ways and extrapolate the consequences
● a lot of growth potential

Treatment Planning
● applied prediction
● done after first cephalogram
● cephalogram is used to define expected changes resulting from growth and treatment and to plan appropriate
biomechanics

Evaluation of Treatment Results

● successive cephalograms are used to discern the progress of treatment changes to plan any changes in
treatment which may seem necessary

Obtaining the Cephalogram

Cephalometric Equipment
1. Cephalostat or Head Holder
2. x-ray source
3. cassette holder
4. lead apron for patient
5. Engaged in EAM (external auditory meatus)
6. head straight, look straight ahead, occlusal plane parallel to the floor

Types
1. Broadbent-Bolton Method
o utilizes 2 x-ray sources
o 2 film holders
o patient need not to be moved between lateral and PA exposure
o makes more precise 3-dimensional studies possible
o requires 2-xray sources and more space
o prevents oblique projections

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 2. Higley Method
o used in most modern cephalostat
o uses 1 x-ray source, 1 film holder with a cephalostat capable of being rotated
o patient is repositioned in the course of the various projections
o more versatile method, but care must be taken so head does not alter during positioning

Cephalogram Techniques

Lateral Projection
● midsagittal plane of subject's head is placed 60 in (152.4 cm) from the target of the x-ray tube with the left side
of the subject toward the film
● central beam of the x-ray coincides with the transmeatal axis, ear rods of the cephalostat
● under normal circumstances the distance from the midsagittal plant to film: 7 in / 18 cm
● Patient's head is placed with Frankfurt plane parallel to floor and subjects teeth together in their usual occlusal
postion or mandible in postural position

PA Project / Frontal / Posteroanterior Projection

● Head rotated 90 degrees, so central ray is perpendicular bisects transmeatal axis
● Frankfurt Plane: accurately horizontal or else all vertical displacements measurement will be altered
● check for midline symmetry
● Frankfurt: ear-eye line

Oblique
● Right and Left oblique ceph
● taken at 45 degrees, 135 degrees to lateral projection
● central ray entering behind one ramus to obviate superimposition of the halves of the mandible
● Frankfurt plan must stay horizontal
● useful in mixed dentition patients

Cephalometric Landmarks

Landmark - point serving as a guide for measurement

Ideal landmark:
● located reliably in the skull behaves consistently during growth
● reliability of the landmark is affected by:
● quality of cephalogram
● experience of the tracer
● confusion with other anatomic shadows
Types:
1. True Anatomic Points
2. Implants
3. Extremal Points
4. Intersection of Edges of Regression
5. Intersection of Constructed Lines

TRUE ANATOMIC POINTS

● small regions which might be located on the solid skull even better than in the cephalogram
● e.g. ANS (anterior nasal spine)
o Na (nasion)

IMPLANTS
artificially inserted radiopaque markers

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 ● usualy made of an inert metal
● maybe located more precisely than tradional points
● provides precise superimpositioning
● cannot be used to measure accurately

EXTREMAL POINTS
● points which are extrema of curvatures
● points whose coordinates are largest of smallest of all points on a specific outline
● e.g. A Point
o B Point
o Gnathion (Gn)
o Condylion (Co)
● have less precision of location than true anatomic points

● Maxillary: Point A - area a few mm anterior to apex of root of central incisor

● Mandibular: Point B - midpoint between infradentale (CEJ and Alveolar bone meet) and pogonion (anterior point
of bony chin)
● Gnathion - anterior, inferior point of bony chin (Subjective)
● Condylion - tip of condyle

● *Not a precise landmark; relies on identifying landmarks or referral points

INTERSECTION OF EDGES OF REGRESSION AS "POINTS"

● points identified as intersection of images are really lines looked at down their length
● not real points, or part of the skull
● exists only in projections and are dependent on subject positioning
● e.g.PTM (pterygomaxillary fissure)
o Ar (Articulare)

INTERSECTION OF CONSTRUCTED LINES

● eg. gonion is the intersection of ramal and mandibular lines
Techniques of Tracing Cephalograms
● Tracing Box or x-ray illuminator
● Frosted Acetate film: 0.003 in thick
● Lead Pencil 0.3 - 0.5 mm in thickness
● *Tape to secure

TIPS
● Tracing should be systematic (so as not to miss) L-->R; U-->D
● general inspection of the cephalogram
● locate and identify standard landmarks
● trace anatomic structures in a logical sequence
● construct derived landmarks

Geometric Methods
● curves
● points
● landmarks
● lines
● angles

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Numeric Methods
● Measurements:
o size and growth
o pattern
o morphology
o deformation
o displacement

Cephalometric Analysis
● Collection of numbers extended to compress much of the information from the cephalogram into a usable form
● provides info about sizes and shapes of craniofacial components and their relative positions and orientation
● Used for:
o Diagnosis
o Treatment Planning
o Assessment of Treatment Effects

Basic Morphologic Analysis

Diagnosis and screening

Vertical Analysis
Localize and quantify any vertical skeletal problem

Profile Analysis
Evaluating the craniofacial skeletal dentoalveolar profiles
Localize the regions contributing to Imbalance

Analysis of Symmetry
PA / Frontal Projection

Prediction of Morphology
Amount of remaining growth of the individual
Timing of important growth events: spurts
Growth vectors and changes
Specific orthodontic treatment on craniofacial growth

Analysis of Growth
To assess patient’s growth by comparison with appropriate standards

Skeletal Assessment

Angle Description Normal Value

SNA Measures protrusiveness of base of alveolar bone that contains the 82°± 2°
central incisor

Higher value: maxilla is protruded

Lower value: maxilla is retruded / receded
SNB Measures the protrusiveness of the base of the mandibular alveorlar 80°± 2°
ridge that contains the central incisor

Higher Value: mandible is protruded

Lower Value: mandible is retruded or receded
ANB Establishes the difference between SNA and SNB (SNB – SNA) 2°± 2°

25
 It relates the protrusion of the maxillary denture base with
mandibular denture base
Angle formed between NA and NB
Position of maxilla and mandible in relation to one another
FH / NP Aka Facial Angle 88°± 2°
Relates the protrusiveness of the mandible compared to the cranial
base

Higher Value: mandible is protruded

Lower Value: mandible is retruded
U1 / SN Describes the protrusive relation of central incisor within the 104°± 2°
maxillary bone

Higher Value: Maxillary central incisors are protruded

Lower Value: Maxillary central incisors are retruded
U1 / L1 Interincisal angle 130°± 2°

Smaller Value: Central incisors are more protrusive

Larger Value: less protrusive and more vertical the teeth are in
relation to each other
IMPA Incisor Mandibular Plane Angle 90°± 2°
Measures the axis of the most protruded mandibular central incisor to
the mandibular plane

Higher Value: Lower Incisors are more protruded

Lower Value: Lower incisors are more retruded / lingual
FMIA Frankfurt Mandibular Incisor Angle 65°± 2°
Relate the axis of the most protruded mandibular central incisor to
the cranial base

Higher Value: Lower incisors are more upright / retroclined

Lower value: Lower incisors are more proclined
FMA Frankfurt Mandibular Plane Angle 25°± 2°
Relates the steepness of the mandibular plane when compared to
cranial base

Higher Value: Steeper mandible

Lower value: flat mandibular plane
Y-axis Measures direction of growth of the mandibular plane 65°± 2°

Higher Value: downward growth of the mandible

Lower Value: forward / horizontal growth of mandible
E-plane Esthetic Plane 0 mm ± 2 mm
Distance between (Pronasale – Pog’) and lip -2 ± 2 mm

Cecille Steiner – Steiner’s Analysis – SNA, SNB, ANB

Tweed’s Triangle: FMIA + IMPA + FMA = 180°

NORMAL OCCLUSION
● A mouth in which all of the teeth are present and occluding in a healthy, stable and pleasing manner but with
variations in position within measurable normal limits
● Non-carious teeth
26
● According to Angle, in normal occlusion the MBC of the upper 6 occludes with the groove between the MBu and the
Middle Bu cusp of the lower 6, the DBC of the upper 6 contacts the MBC of the lower 7

IDEAL OCCLUSION
● An evenly placed row of teeth arranged in a graceful curve with harmony in between the upper and lower arches
● Ideal intercuspation
● Maximum intercuspation

6 Keys to Occlusion
1. Correct Molar Relationship
2. Correct Crown Angulation – MD tip, G3 of crown
3. Correct Inclination (Labio or Bucco-lingual inclination)
4. No Rotations
5. No Spaces
6. Flat Occlusal Plane

Development of the Concept of Occlusion

1. Fictional
2. Hypothetical
3. Factual

FICTIONAL
● Orthodontists were primarily concerned with tooth alignment or “regulation” or if each arch were a thing in
itself
● LISCHER made efforts to establish the concept of:
o Mesiocclusion: Class III
o Distocclusion: Class II
o Neutrocclusion: Class I
In likes of Angle’s Class I, Class II, Class III as descriptions of jaw relationship
● The standard of normality of the dental arch – curved line expanding as it approaches the ends and all teeth
standing on that line

HYPOTHETICAL
● Edward H. Angle: 1899 – “Occlusion is the basis of the Science of Orthodontia”
o The shapes of cusps, crowns and roots and even the very structural material of the teeth and
attachment are all designed for the purpose of making occlusion the one grand object. We shall define
occlusion as being the normal relationship of the occlusal inclined planes of teeth when the jaws are
closed
● Old Glory – Angle’s model of Ideal Occlusion – the description of this concept on the occlusion with the arch
having a graceful curve and all teeth are arranged with harmony on a prognathic set of jaws

● Key to Occlusion – the permanent first molars are the most especially the maxillary first molars

● Matthew Cryer and Calvin Case – raised concepts antagonizing Angle’s work with the “Old Glory” which cannot
fit in a straight profile of Apollo Belvedere (Angle’s Paragon of a Profile)

● Simon tried to broaden the concept of occlusion by relating the teeth to the rest of the face and cranium using
orbita, Frankfurt and medial sagittal plane for orientation (gnathostatics)

● Allan G. Brodie further broadened the concepts of occlusion by recognizing the contributions of the teeth to the
entire kinetic chain of head posture

27
 ● Milo Hellman emphasized facial growth and development
o Warned that the first molar (key to occlusion) is prone to rotation upper first molar rotate Mesio-bucally

FACTUAL PERIOD
1930 – static concept of occlusion gave way to one that is more dynamic

B. Holly Broadbent – introduced an accurate technique of roentgenographic cephalometry in relation to occlusion

Planer of Vienna – researched in depth or tooth and jaw movement

● “mere occlusion contact of the teeth isn’t enough”
● the start of the 3rd element of occlusion: the TMJ

Lawrence F. Andrews – presented the 6 characteristics he considered to be present in normal occlusion. These 6 keys
led directly to the straight wire appliance

Ronald H. Roth – suggested that orthodontists should embrace the principles of gnathology that had long been held by
eminent Prosthodontic and Restorative dentists to establish a retruded, Postero-superior “seated” Centric Relation
position when the interdigitating occlusion was in Centric Occlusion
● 1970s – goals of ideal functional occlusion included condyles seated in
o centric relation
o 4 mm of vertical overbite
o 2-3 mm overjet
o canine lift

Mouth of the Neonate

1. The Gum Pads
2. Neonatal Jaw Relationships
3. Previously Erupted Primary Teeth

GUM PADS
● at birth – alveolar processes are covered by gum pads: Pink
● maxillary arch – horseshoe shaped
● mandibular arch – posterior to the maxillary arch when gum pads contact

Leighton
● state of maturity of infant at birth
● size at birth – expressed by birth weight
● size of developing primary teeth
● purely genetic factors

NEONATAL JAW RELATIONSHIPS

● no was is “precise bite” or jaw relationship yet seen
● neonatal relationship can’t be used as a diagnostic criterion for reliable prediction of subsequent occlusion
in the Primary Dentition

Samsung and Cheung – only 2% of all neonates have an anterior open bite gum pad relationship
● mouth of the neonate – richly endowed with sensory guidance system providing input for many vital
neuromuscular functions
PREVIOUSLY ERUPTED PRIMARY TEETH
Natal: present at birth
Neonatal: within 30 days of birth
Pre-erupted teeth are almost always lower incisors which frequently display enamel hypoplasia

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Characteristics of Primary Dentition
Generalized Spacing
Primate Spaces (M / D space – canine)
Overjet and overbite: 2 mm
Tight contact between molars

Primary Deciduous Teeth: Age of Eruption in SEQUENCE:

Months Uppe A B D C E
ARCH A B C D E r
Uppe 7. 9 1 1 2 Lowe A B D C E
r 5 8 4 4 r
Lowe 6 7 1 1 2
r 6 2 0

Primary Dentition occlusal relationship established by 36 months with minimal subsequent dimensional changes: Arch
Length, Width and perimeter, occurring until permanent dentition eruption

PRIMARY DENTITION OCCLUSION

Spaced vs. non-spaced arches approximate 2/3 of Primary Dentition show:
Baume Type I – generalized spacing
Baume Type II – 1/3 are non-spaced
Related to basal arch size rather than tooth material difference

Generalized Spacing (Anteriors)

● 40% of children have spacing in their primary dentition
● allows for adequate space for permanent dentition

Primary Spacing Affects Crowding Outcome (Predictors into the Mixed Dentition)
1. Spacing 3-6mm – no transitional crowding
2. Spacing less than 3 mm – 20% of incisor crowding
3. No spacing – 50% with incisor crowding
4. Crowded Primary Teeth – 100% with incisor crowding

Arch Length Prediction from Alignment of Primary Teeth

Primary Alignment Permanent Outcome
Crowding Almost certain extraction
No Spacing Possible extraction
Fair Spacing Mild to Moderate crowding
Good Spacing No or mild crowding
Excess Spacing No crowding / excess space

Primate Spaces
● Upper: Mesial to Canine = 1.7mm
● Lower: Distal to Canine = 1.5 mm
● A pattern of spacing of primary dentition
● Seen in Primary Dentition only
● Incidence of 70% in the maxillary and 63% in mandibular
● Congenital rather than developmental
● Primate spaces are present in both Baume type arch forms
Incisor Relationship
Overbite: 2 mm – 30-50% overlap
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 Overjet: 0-3 mm

Canine Relationship
Best predictor of sagittal relationship into permanent dentition

1. Mesial Step Canine / Mesio cuspid – Class I relationship

2. Distal Step Canine / End-on Canines / Disto cuspid – Class II
3. Excessive Mesial Step (with Incisor crossbite) – Class III

*Neutro cuspid
*Mesio cuspid
*Disto cuspid
Determinants of Permanent Dentition
1. Flush Terminal Plane
2. Mesial Step
3. Distal Step

Molar Terminal Plane Relationship

Mesial Step Class I
Flush Terminal Class II (Majority)
Plane Full Class II (those that stay end
on)
Distal Step Full Class II (usually)
Class III (some)

Posterior Occlusal Relationship

Posterior Cuspal Relationship
Cusp of lower, more anterior to cusp of upper
Lingual Cusp of upper on the central fossa of lower

Ideal Primary Dentition Occlusion 1. Anterior Generalized Spacing

30
 2. Presence of Primate Spaces Normal Signs of Primary Dentition
3. Tight Proximal contact on the posterior ● Presence of Spaced Anteriors
4. Horseshoe / ovoid shaped arch form ● Presence of Primate Spaces
5. Good interdental or primate spacing ● Shallow Overbite, Overjet
6. Flush Terminal Plane or Mesial Step molars ● Class I Cuspid Relationship
7. Neutro cuspid ● Flush Terminal Plane / Mesial Step
8. Shallow Overbite and Overjet ● Almost Vertical Inclination of Anterior Teeth
● Ovoid Arch Form

Management of Primary Dentition

Premature Loss of Primary Teeth (Space Maintenance)

1. Primary Incisors
● space loss is unlikely is primary canines erupted into occlusion
● replacement of primary incisors – for esthetic purposes and not for space control

2. Primary Canines
● Usually lost due to ectopic eruption of Permanent Laterals
● Indicates significant tooth mass discrepancy – beyond simple space
maintenance
● If canine loss is due to caries or trauma – no space maintenance indicated
except to maintain midline symmetry
● Use of 2x4 Appliance

3. Primary First Molars

● Space maintenance needed if 6’s have not erupted or in active eruption, usually unilateral fixed appliance
used, E’s as abutments and C’s where the wire rests on the distal
● Once 6’s have erupted into occlusion, space loss is negligible if Ds are lost during mixed dentition and the Es
remain to buttress the 6’s position
4. Primary Second Molars
● Regardless of timing of loss, space maintenance is indicated as space loss will occur in the primary and mixed
dentition
● Dimensional loss is greater in the maxillary arch, without Es the maxillary 6s will move forwards bodily and
rotate around the palatal root, the mandibular 6’s will undergo Mesial and Distal tipping
● Space loss in both arches are most dramatic during the eruptive timing of the 6’s
● If 6’s not erupted or inactive eruption – Distal Shoe Space Maintainer from the Ds to Guide the 6s to erupt into
position

Mandibular arch – LLHA once lower incisors are erupted

Maxillary arch – Transpalatal Arch Expander or Nance Holding Arch

Distal Shoe Space Maintainer – provides support when opposing tooth is yet to erupt
● After exo – DSSP is placed down the distal wall of the extracted socket
● Healed edentulous space incisor with sterile scalpel
● Position of incision – determine position with radiograph
● Prior to cementation – take a radiograph of the appliance in mouth to insure proper fit

Lower Lingual Holding Arch

● Dental anchorage is placed on the Middle 3rd

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TAD – Temporary Anchorage Device

Anterior Crossbite in the Primary Dentition

True vs. Pseudo Class III – anterior crossbites typically involving the full anterior segment

Pseudo Class III – incisal and canine interferences produces anterior shift of the mandible on closure
Tx – fixed or removable maxillary appliance with finger springs to advance the incisors

True Class III – in primary dentition, it presents classic skeletal and dental patterns with retruded maxilla,
prognathic mandible, adult concave profile, retroclined lower incisors
Tx – reverse pull headgear / facemask, chin cup directed at dentofacial orthopedic changes to convert
skeletal malocclusion

Bilateral Posterior Crossbite

● Represents true maxillary skeletal constriction with bilateral Buccal segment crossbite
● 2-3% of posterior crossbites in children are often associated with dolichofacial skeletal vertical growth, openbite
malocclusion, compromised airways and mouth breathing patterns
● Treatment – maxillary expansion appliances with emphasis toward sutural expansion indicated for significant
transverse discrepancies

Non-nutritive Digit Sucking Habits (NNS)

● Normal at an early age, 50% of children with NNS stops by 24-48 months
● Digit habits can last longer than pacifier habits
● May result in anterior openbites distorted incisor eruption, procline maxillary incisor, retroclined lower incisors,
posterior crossbite with constricted maxilla, possible Class II relations
● Treatment – consider intervention prior to eruption of permanent anterior teeth approximately 5-6 years if NNS
persists, use gentle persuasion and behavior modification, if still unsuccessful, fixed appliance such as palatal
crib can help child quit

Airway Compromised / Mouth Breathing

● May impact on facial growth with tendency to increase vertical orientation (skeletal openbite)
● Similar occlusal changes as seen with deleterious extraoral habits
● If determined to be airway , refer to an ENT for possible allergy management, tonsillectomy, adenoidectomy,
palatal expansion
● Tx – oral shield / screen, vestibular shield / screen

MIXED DENTITION ● Ugly duckling stage – diastema between 11/21

● Aka Transitional Period / ugly duckling ● Primary roots resorb due to eruption of
● Numerous changes and major characteristics permanent dentition
are transient ● Elongation of permanent root and eruption of
permanent crown
● Growth of alveolar process
Stages: ● 3 year period of turn over from primary to
Early Stage: 6-9 years old permanent
Middle Stage: 10-12 years old
Late Stage: 11-14 years old ● Favorable sequence:
Upper: 6124537
Lower: 6123457 (1 and 6 maybe interchanged)
EARLY STAGE *upper canine longer root takes time to form
● 6-9 years old

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 Characteristics ● Increase arch perimeter
Anterior
1. Distal Flaring of Maxillary Incisor LATE STAGE
● Due to active growth of maxilla 1. Leeway Space
● Transient space – for canine ● Bigger in mandible that in maxilla
eruption because the lower primary second
2. Transient Crowding of Mandibular Incisor molars are bigger than their maxillary
● Due to slower growth of the counterparts
mandible
Early Mesial Drift
Posteriors ● occurs when there is a spaced arch
1. Cusp to cusp / end to end relationship (primate spaces, anterior generalized
● Due to normal distal relationship of spacing)
primary second molars
● Developing Class I Occlusion – FTP / Late Mesial Drift
M Step ● occurs when there are no available
anterior primate spaces
● change in molar relationship will occur
as Leeway space or changes become
available (then it moves into its final
molar relationship)
MIDDLE STAGE Late Mesial Shift
Characteristics ● Mesial movement of the permanent molars
1. Distal Flaring resolution to occupy the Leeway Space
● Due to eruption of canine ● Longer molar shift in the mandible due to
2. Easement of Transient Crowding the longer Leeway Space
● Due to growth of the mandible together ● Will proceed as Normal Class I Occlusion
with the eruption of canine

Maxillary teeth
Central Lateral First Second
Primary teeth
incisor incisor Canine molar molar
Initial calcification 14 wk I.U. 16 wk I.U. 17 wk I.U. 15.5 wk I.U. 19 wk I.U.
Crown completed 1.5 mo 2.5 mo 9 mo 6 mo 11 mo
Root completed 1.5 yr 2 yr 3.25 yr 2.5 yr 3 yr
Mandibular teeth
Initial calcification 14 wk I.U. 16 wk I.U. 17 wk I.U. 15.5 wk I.U. 18 wk I.U.
Crown completed 2.5 mo 3 mo 9 mo 5.5 mo 10 mo
Root completed 1.5 yr 1.5 yr 3.25 yr 2.5 yr 3 yr

Maxillary teeth
Central Lateral First Second First Second Third
Permanent teeth
incisor incisor Canine premolar premolar molar molar molar
Initial calcification 3–4 mo 10–12 mo 4–5 mo 1.5–1.75 yr 2–2.25 yr at birth 2.5–3 yr 7–9 yr
Crown completed 4–5 yr 4–5 yr 6–7 yr 5–6 yr 6–7 yr 2.5–3 yr 7–8 yr 12–16 yr

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 Root completed 10 yr 11 yr 13–15 yr 12–13 yr 12–14 yr 9–10 yr 14–16 yr 18–25 yr

Mandibular teeth
Initial calcification 3–4 mo 3–4 mo 4–5 mo 1.5–2 yr 2.25–2.5 yr at birth 2.5–3 yr 8–10 yr
Crown completed 4–5 yr 4–5 yr 6–7 yr 5–6 yr 6–7 yr 2.5–3 yr 7–8 yr 12–16 yr
Root completed 9 yr 10 yr 12–14 yr 12–13 yr 13–14 yr 9–10 yr 14–15 yr 18–25 yr

Eruption times for primary and permanent teeth [35]

Primary teeth
Central Lateral First Second First Second Third
incisor incisor Canine premolar premolar molar molar molar
Maxillary teeth 10 mo 11 mo 19 mo 16 mo 29 mo
Mandibular teeth 8 mo 13 mo 20 mo 16 mo 27 mo
Permanent teeth
Central Lateral First Second First Second Third
incisor incisor Canine premolar premolar molar molar molar
Maxillary teeth 7–8 yr 8–9 yr 11–12 yr 10–11 yr 10–12 yr 6–7 yr 12–13 yr 17–21 yr
Mandibular teeth 6–7 yr 7–8 yr 9–10 yr 10–12 yr 11–12 yr 6–7 yr 11–13 yr 17–21 yr

Nolla’s Stages of Calcification (For Permanent Dentition)

0 – Absence of Crypt – no developing tooth

1 – Presence of Crypt - unsure
2 – Initial Calcification - 1st clinical evidence of a developing tooth
3 – 1/3 of Crown Completed
4 – 2/3 of Crown Completed
5 – Crown almost Completed
6 – Crown Completed – start of active eruption of crown / tooth, cervical area of tooth is open
7 – 1/3 of Root Completed
8 – 2/3 of Root Completed
9 – Root almost Completed / Calcified, open Apex – tooth is already in occlusion
10 – Apical End of Root Completed – closing of root apex
Exo of Primary – done when permanent is at stage 6-8 to prevent ectopic eruption
Interrelation Between Calcification and Eruption

Eruption – developmental process that moves a tooth from its crypt position through the alveolar process into the oral
cavity and to occlusion with its antagonist

Calcification and Eruption

● Teeth do not begin eruptive movements until after the crown is completed (stage 6)
● Pass through the crest of the alveolar process at varying stages of root development

Posterior Teeth
● 2-5 years – to reach the alveolar crest
● 12-20 months – to reach occlusion

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Root formation – completed a few months after occlusion is attained

Time of Eruption – emergence of tooth into oral cavity

Development Process that Occurs Simultaneously with eruption of Permanent Teeth

Developmental Process during Eruption

1. Elongation of Permanent Rooth
2. Resorption of Primary Predecessor
3. Movement of the Permanent Tooth Occlusally
4. Growth of the Alveolar Process
5. Less growth activity on the Inferior Border of the Mandible

Stages of Eruption of Permanent Teeth and Factors ▪ Tendency of the tooth to drift
Affecting Each Stage mesially even before they
1. Pre-eruptive appear in the oral Cavity
2. Intra-alveolar ▪ DSSM – guide to eruption
3. Intra-oral / Pre-occlusal
4. Occlusal INTRA-ORAL / PRE-OCCLUSION
● Tooth pierces soft tissue
PRE-ERUPTIVE ● Oral cavity has been entered
● Crown starting to develop ● Almost complete formation of root
● Factors affecting tooth position at this stage ● Factors
o position of tooth germ o Lip
o Cheek
INTRA-ALVEOLAR o Tongue Muscles
● Crown start to develop o Extraneous objects brought into the
● Root starting to form mouth
● Factors affecting tooth position at this stage o Caries and extractions
o Presence / absence of adjacent teeth
o Rate of resorption of the primary teeth OCCLUSAL
/ predecessor ● Teeth occlude with those of the opposite dental
o Early loss of primary teeth arch
o Localized pathologic conditions ● Factors
o Any factors that alter the growth or o Muscles of mastication; M. Pterygoid, L.
conformation of the alveolar process Pterygoid; Temporalis, Masseter
o Mesial Drifting Tendency o Anterior Component of Force

*Teeth Position changes throughout life

CLASSIFICATION OF MALOCCLUSION Skeletal

Malocclusion
● Refers to misalignment of teeth and / or income
relation between teeth of the maxillary and
mandibular arches
● Can cause abnormality in oral function
TYPES:
Dental Malocclusion – teeth not lined up properly
● Occurs when the upper and lower jaws don’t
line up correctly
● Headgears
● Underbite – negative overbite
Other common malocclusion:
1. Upper protrusion – Class II
2. Misplaced Midline – Glabella, nose, chin point
3. Open bite – Anterior not touching

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 4. Crossbite – Lower teeth more buccal, labial ● ease of reference – retroanalysis
5. Rotation ● facilitate comparison – compare treatment and
6. Transposition – changes in position give suggestion
● ease in communicating
Classification System
● Grouping of clinical cases of similar appearance System of Classification
for ease in handling and discussion 1. Lischer – Individual Tooth Malposition
Purpose of Classification 2. Simon System
1. For Traditional Reasons 3. Angle
● people in same profession will have their own 4. Dewey-Anderson’s Malocclusion
language 5. Ackermann – Proffit Classification

LISCHER o Lingual Crossbite – 1 or more maxillary

Naming malpositioning Individual Teeth and Groups of
Teeth
1. Individual Teeth
2. Vertical Variations of a Group of Teeth
3. Transverse Relationship of Groups of Teeth
Individual Teeth – “- version”
Lischer’s nomenclature:
● Mesioversion
● Distoversion
● Linguoversion
● Labioversion / Buccoversion
● Infraversion
● Superversion
● Axiversion
● Torsiversion
● Transversion
Vertical Variations of Groups of Teeth
● Excessive vertical overlap of incisors –
Deep bite, deep overbite
● Localized absence of occlusion while
remaining teeth are in occlusion – open
bite
● Dental Open Bite – can be resolved
● Skeletal – Le Fort surgery
Transverse Variations of Groups of Teeth
● Abnormal buccolingual / labiolingual
relationship of the teeth
o Bu crossbite
o Li crossbite
o Complete Lingual Crossbite
● Underdeveloped maxilla –
Thumbsucking etc.
o Upper teeth are more Lingual
teeth are in crossbite towards the
midline
o Buccal Crossbite – Lingual cusps of
maxillary posterior teeth occlude
completely buccally of the buccal cusps
of lower teeth
SIMON SYSTEM
● Related to 3 anthropologic planes based on
craniofacial landmark
o Orbital Plane
o Sagittal Plane
o Frankfurt Plane
● Principal Contribution
o Emphasis on orientation of the dental
arches to facial skeleton
o Separates carefully by means of its
terminology, problems in malpositions
of the teeth from the osseous dysplasia
o Capable of more precision than Angle
system and its is 3-dimensional
o Not used, confusing at times, difficult to
communicate
Orbital Plane (Antero-posterior Relationship)
Protraction – dental arch is more
anterior with respect to orbital
Retraction – dental arch is more
Posterior placed than normal with respect to orbital
plane
Midsagittal Plane (Mediolateral Relationship)
Contraction – when dental arch or part
is nearer to MSP than the normal
Distraction – when the dental arch or
part of it is farther to the midsagittal
plane than normal

Vertical Plane (Frankfurt Plane)

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 Attraction – when the dental arch or Class I Type 1
part of it is nearer to the FP than normal ● Class I + crowding
Abstraction – when the dental arch or ● Crowding
part of it is farther away from the FP than normal ● Dental misalignment caused by inadequate
anterior spaces
ANGLE’S CLASSIFICATION OF MALOCCLUSION
Based on the position of maxillary first molar Class I Type 2
● Pseudo Class II
Class I Malocclusion ● Labioversion of Maxillary Incisors
- Molar relationship is normal but other
teeth have problems such as crowding, Class I Type 3
spacing, over or under eruption ● Anterior Crossbite
- Normal molar relationship but the incorrect ● Pseudo class III
line of occlusion
Class I Type 4
Class II ● Posterior Crossbite
- Upper molars are placed not in the
mesiobuccal groove but anteriorly to it. Class 5
Usually in the mesiobuccal cusp rests in ● Drifted Molars no good space control
between the first mandibular molars and ● Early loss of E
2nd premolars
ACKERMANN AND PROFFIT
Class II Division 1 5 Characteristics and their interrelationships are
● Anterior teeth protruded assessed has been developed
● Large overjet 1. Alignment – crowded spaces, mutilated
● Deep overbite 2. Profile – convex, concave
● Abnormal lip seal 3. Type – crossbite, bilateral, unilateral,
skeletal, dental
4. Class – Angle’s Classification, skeletal or
Class II Division 2 dental
● Central incisors are retroclined 5. Bite Depth – Open bite, deep overbite,
while lateral incisors are closed
overlapping the CI
● Minimal overjet Group 1 – Intra-arch alignment / symmetry
● Look at cusp of molars and Ideal
canine Crowding
Spacing
Class III
- Molars are in Class III Group 2 – Profile
- Anterior Teeth: edge to edge or crossbite Convex
relationship / lingual crossbite Concave
- Upper or both jaws could be abnormal in Straight
relationship
- Tight Group 3 – Transverse Deviation – Crossbites
- No overjet Buccal
Palatal
DEWEY ANDERSON’S MODIFICATION Group 4 – Sagittal Deviation – Angle’s Classification
● Angle’s classification addresses only the sagittal I – regardless of spacing or crowding – molars
dimension / AP and not vertical / transverse II
dimension III
● It does not take the facial profile of the patient
Group 5 – Vertical Deviation

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 Bite depth – open bite Limitations of Classifications Systems
Deep bite ● None are truly inclusive
Collapsed bite – not enough space due ● Omit entire regions, dimensions, syndromes
to late construction of prosthesis ● All are static in concept
● Allowance not made for future changes –
Group 6 – Trans-sagittal maximum interdigitaion
Group 7 – Sagitto-vertical ● Most are narrow in focus and perspective
Group 8 – Vertico-transverse ● There is tradition of misuse and misapplication
Group 9 – Trans-sagitto – vertical – most complicated

Jaw Positions ● Maximal contact of inclined planes of the

opposing teeth
Physiologic Rest Position ● Bilaterally symmetrical in activity
● Habitual postural position of the mandible ● Balanced and unstrained TMJ
when at rest in the upright position and the Factors that mitigate against the establishment
condyles are in the neutral unstrained position of Centric Occlusion
in the mandibular fossa o Premature contacts
● “postural position” o Loss of teeth
Factors o Over eruption of teeth
● Sleep o Overextension of artificial
● Psychic factors influencing muscle tonicity restoration
● Pain o Malposition of individual teeth
● Proprioception from the dentition and
muscles Most Retruded Position (Terminal Hinge Position)
● Occlusal changes (e.g. attrition) Can be retruded in a mm or 2
● Muscle disease and muscle spasm
● TMJ disease

Centric Relation
● Unrestrained, neutral position of the mandible Habitual Occlusal Relation
in which the anterosuperior surfaces of the Intercuspal Position
mandibular condyles are in contact with Dentist’s Goal: to make sure that habitual
concavities of articular disks as the approximate occlusal position and centric occlusal position
the postero-inferior third of their respective are in harmony with centric relation
articular eminence
Buccinator Mechanism
Initial Contact ● Major factor in environmental balance is the
● From physiologic rest position to centric musculature
relation ● Muscles are a potent force, whether they are
● Incline planes are brought together actively in function or at rest
simultaneously ● From a study of the laws of muscle action
Factors: ● A resting muscle still is performing a
● Premature contact function that of maintaining posture and a
● Malocclusion relationship of contiguous parts
● Teeth and supporting structures
Centric Occlusion ● Always interdependent with muscles
● State of balance ● Integrity of arches and relations of teeth to each
● The habitual occlusion, not necessarily other within each arch are results of
centric morphogenic pattern
● Maximum intercuspation
● Only possible if no malocclusion present

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 ● Stability dependent on sum total of elements –
genetic, epigenetic, environmental,
morphologic, physiologic
Buccinator
● Lateral wall of oral cavity
● Pulls back the angle of the mouth laterally
Orbicularis Oris
● Sphincter muscle around the mouth
● Controls and shapes the size of the mouth
opening
Tongue
● Intrinsic
o Longitudinal
o Transverse and vertical
SOLDERING AND SPOT WELDING
Solder
- fusible alloy used to unite by heating
metals and alloys which are less fusible
- Comes in alloy of silver (61%), copper, zinc
in the forms of wires which are most
convenient for ortho use
Flux
- Used as a reducing agent
- Absorbs the metallic oxides as they are
formed
- Removed by boiling in alum solution
Soldering is done with precious alloys which comes in
disks, bars, and fine wires of various gauges and karats
(gold, platinum, palladium group) which have good
strength, high fusing points, not affected by the fluids of
the mouth, don’t affect the tooth or tissues
2 Ways
1. Gas Soldering – uses orthodontic torch or
orthodontic soldering burner (butane gas)
2. Electric Soldering – adjuncts to spot welders
A true solder joint is formed by the intimate mechanical
union of stainless steel and solder
3 Types of Flame
1. Outer dark blue oxidizing flame
2. Middle light blue reducing flame
3. Inner colorless cone of unburned gas
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o Manipulates food for chewing and
swallowing
o Organ for taste
● Extrinsic
o Attaches tongue to some other
parts
Unconscious
● Infantile (absence of teeth) swallow / visceral
swallow
Mature Swallow / Somatic Swallow
● Teeth are together
● Minimal contraction of lips
Clinical Significance
● Single most important occlusal stabilizing
feature
● May lead to malocclusion
- A good flame for soldering should be at
least 1-1.5 inches high with well defined
point (at the apex of the middle flame or
the light blue reducing cone)
- Flame should be on the thicker of the 2
pieces of metal to be joined
- If 2 soldering operations are in close
proximity, first should be done with higher
karat solder than second
- Solder’s temperature should not be raised
excessively above the melting point
- Solder should be kept at minimum
- When soldering 2 objects, the heavier
should be heated first
- After solder has melted and joint has been
made, components must be removed from
the flame before overheating and without
jarring them before solder has solidified
- Soldering should be done with no
appreciable alteration of the qualities of
metals to be joined
- Soldering precious alloys – flux used with
borax or boric acid
- Soldering stainless steel – fluoride flux (1
part KFl + 1 part boric acid + water)
Spot Welding
- the joining of 2 metals by heating caused by a flow
of electric current through the portions of the
pieces in juxta position
- uses spot welders or electric spot welding machine - alloys used are stainless steel only
where electrodes hold 2 parts together - a true weld is formed, no flux or solder is used

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