1.

Learning objectives: by the end of the lectures every student must be able to:
a. Understand the different terminology of malocclusion. b. Understand the different ways to describe malocclusion. c. Understand the classification of malocclusion. d. Understand the purpose of classification. e. Diagnosis different type of malocclusion.

2. Learning materials:
a. Lecture notes b. Contemporary orthodontics by Proffit & Ackerman. Chapter 6 c. Hand book of orthodontics by Robert E. Moyers Chapter 9

3. Teaching methodology:
a. Lecture using PowerPoint presentation (2 h)

4. Detailed outline:
I. Prevalence of normal occlusion in Egypt, II. Terminology of malposition of individual teeth, III. Terminology of malrelation of the dental arches, IV. Terminology of malrelation of the apical bases maxilla & mandible, V. Different classification of malocclusion. VI. Reliability, validity, advantages and disadvantages of classification.

Definition:
Malocclusion may be defined as A condition where there is departure form the normal relation of the teeth to other teeth in the same dental arch and/or to teeth in the opposing arch.

Prevalence of normal occlusion in Egypt:

Published research has shown that prevalence of normal occlusion among adult Egyptian is 34.3%. It is significantly more common in females (36.7%) than males (31.6%). The prevalence of normal occlusion among Egyptians is lower than that of the Indians however; it is higher than that of the Americans, Swedish and Danes.

Malocclusion is associated with one or more of the following conditions:

1. Malposition of individual teeth, 2. Malrelation of the dental arches, 3. Malrelation of the apical bases Maxilla and mandible.

Malposition of individual teeth:

In normal occlusion, the line of occlusion passes through i. The central fossae and along the cingulae of the maxillary teeth. ii. The buccal cusps and incisal edges of the mandibular teeth. The direction of the deviation of a tooth from the line of normal occlusion is identified by adding the suffix version (described by Lischer) to the direction of deviation, as follows: 1- Mesioversion: Mesial to the normal position. A tooth in Mesioversion may be: Mesially inclined: The crown of the tooth is tipped mesillay. Mesially displaced: The whole tooth is displaced mesially. 2- Distoversion: Distal to the normal position. 3- Labioversion: Towards the lipMaxillary and Mandibular anterior teeth. 4- Buccoversion: Towards the cheeks Maxillary and Mandibular posterior teeth. 5- Palatoversion: Towards the PalateMaxillary teeth. 3

6- Linguoversion: Towards the tongueMandibular teeth. 7- Supraversion: Erupted past the line of occlusionOvererupted. 8- Infraversion: Short of the line of occlusionSubmerged. 9- Torsiversion: Rotated on its long axis. e.g. The tooth is rotated mesiolingually when its mesial surface is turned toward the tongue. What is the difference between mesiolinguoversion and mesiolingual rotation? A tooth is in mesiolinguoversion when it is both mesial and lingual to its normal position. A tooth is rotated mesiolingually when its mesial surface is turned lingually. 10- Transversion: Wrong order in the archTranspositon. Imbrications: Teeth are irregularly placed in the arch due to the lack of space, especially lower incisors. The American Heritage Dictionary of the English Languague: Imbrication: Having regularly arranged, overlapping edges, as roof tiles or fish scales. An Imbricated Roof 4

Malrelation of the dental arches:

Malrelation of the upper and lower dental arch is analyzed in the three planes of space: I. Antero-posterior II. Vertical III. Transverse

Anteroposterior
Incisor anteroposterior malrelation (overjet): It is the distance between the labial aspect of the lower incisors and the palatal aspect of the upper incisors when the teeth are in centric occlusion. It is normally 1 to 3 mm. Abnormal overjet may be: i. Increased overjet: Overjet is more than 3 mm. ii. Edge to Edge bite: No overjet. iii. Reversed overjet/ anterior cross bite: Overjet is negative. Posterior anteroposterior malrelation: Normally when the teeth are in centric occlusion and condyle are in the glenoid fossae, the lower dental arch is normal anteroposter relation to the upper dental arch. "This is manifested in Class I molar and Class I canine relationships". 5

Postnormal Occlusion: When the teeth are in centric occlusion and the condyle are in the glenoid fossae, the lower dental arch is distal to the upper dental arch. "This is manifested in Class II molar and Class II canine relationships". Prenormal Occlusion: When the teeth are in centric occlusion and the condyle are in the glenoid fossae, the lower dental arch is mesial to the upper dental arch. "This is manifested in Class III molar and Class III canine relationships".

Transverse:
Anterior transverse malrelation: Deviations of the midline: The upper and lower midlines may be: Coincident: normal Incoincident: This may be due to deviation of the upper midline, lower midline or both. The midline may be deviated to the right or to the left. Posterior transverse malrelation: Posterior Cross bite: A cross bite in which one or more posterior teeth occlude in an abnormal buccolingual relation with their antagonist. It is either unilateral or bilateral: i. Bilateral Crossbite: The etiology is usually skeletalA narrow maxilla and a wide mandible. ii. Unilateral Crossbite: The etiology is usually abnormal soft tissue behavior, and sometimes a slight skeletal discrepancy.

occlude in the central fossae of the mandibular teeth. 6

It is either buccal or lingual/palatal; i. Buccal Crossbite: due to buccal displacement of the affected tooth/teeth from their ideal position. ii. Lingual Crossbite: due to lingual displacement of the mandibular tooth/teeth from their ideal position. iii. Palatal Crossbite: due to palatal displacement of the maxillary tooth/teeth from their ideal position.

mandibular arch. This is a Complete Crossbite. It may be buccal or lingual/palatal. Special types of Complete Crossbite: Telescopic Bite: This is a complete maxillary palatal or mandibular buccal cross bite, i.e. small maxilla and a large mandible. Brodie Syndrome: This is a complete maxillary buccal cross bite, in which the maxillary dental arch is wide and buccal to the mandibular arch. This rare situation is seen in extreme Class II anomalies with maxillary hyperplasia. A scissors bite: This is a Unilateral Complete Crossbite. It may be either buccal or lingual/palatal.

Vertical:
Anterior vertical malrelation: Overbite In the normal overbite the palatal surfaces of the upper incisors overlap the incisal third of the labial surfaces of the lower incisors. Variation in the degree of the overbite: i. Deep overbite: if the overbite is excessive, it is called deep overbite or closed bite. This abnormality may be due to:

ii. Open bite: if the overbite is negative, it is called open bite. 7

This term is applied when there is no vertical overlap of the upper and lower incisors Open bite is associated by abnormal soft tissue behavior patterns preventing the dentoalveolar structures from closing the intermaxillary space, e.g. thumb, lip and/or tongue. This abnormality may be due to:

Posterior vertical malrelation: occlusion in the buccal segments. This is usually associated with a lateral tongue thrust habit.

Malrelation of the apical bases:

Malrelation of the upper and lower apical bases is due to: a. Abnormal size; b. Abnormal shape; c. Abnormal relation to the skull; d. Abnormal relation to each other. Malrelation of the upper and lower apical bases is analyzed in three planes, similar to malrelation of the dental arches: I. Anteroposterior II. Vertical III. Transverse Assessment of the malrelation of the apical bases in the anteroposterior and vertical planes is done through the analysis of Lateral Cephalometric X-rays films. Assessment of the malrelation of the apical bases in the transverse plane is done through the analyses of Postero-anterior Cephalometirc X-ray films. 8

Anteroposterior
Relationship of the maxilla or mandible relative to the skull: a. Orthognathic: When the maxilla or mandible is in normal position relative to the skull. b. Prognathic: When the maxilla or mandible is anterior relative to the skull. c. Retrognathic: When the maxilla or mandible is posterior relative to the skull. Relationship of the maxilla to the mandible: a. Skeletal Class I: when the maxilla and mandible are in normal anteroposterior relationship to each other. b. Skeletal Class II: when the mandible is in a posterior position relative to the maxilla. This may be due to a retrognathic mandible, prognathic maxilla or both. c. Skeletal Class III: when the mandible is an anterior position relative to the maxilla. This may be due to a prognathic mandible, retrognathic maxilla or both.

Vertical:
Malrelation of the apical base may be: Skeletal openbite: This may be caused by: i. Rotation of the maxillary apical base away from the mandibular. ii. Rotation of the mandibular apical base away from the maxillary. iii. Both Skeletal deepbite: This may be caused by: i. Rotation of the maxillary apical base toward the mandibular. ii. Rotation of the mandibular apical base toward the maxillary. iii. Both 9

Transverse:
Malrelation of the apical bases in the transverse plane results in: Skeletal Cross Bite: Skeletal cross bite may be: i. Lingual crossbite: Due to a small maxilla or a large mandible or both. ii. Buccal crossbite: Due to a large maxilla or a small mandible or both. iii. Bilateral crossbite iv. Unilateral crossbite: Due to asymmetry of the maxilla or the mandible. Deviations of the midline: It may be caused by right or left deviation of the upper or lower bony bases resulting in midline deviation. It may maxillary, mandibular or both.

Functional Malocclusion:
Premature contacts may necessitate a displacement of the mandible to obtain a position of maximum intercuspation of the teeth. When the mandible is displaced, the teeth are in maximum intercuspation but the condyles are not in their normal position relative to the glenoid fossa. Displacements may either be transverse or anteroposterior:

Transverse displacement:
They are frequently associated with unilateral crossbites. A premature contact in the buccal segments deviates the mandible to the right or the left resulting in a unilateral crossbite. "Occlusal interferences must be corrected" 10

Anteroposterior displacement:
This may be caused by a premature contact in the incisor region. Anterior Displacement: This is associated with False Class III (Pseudo Class III, Postural Prenormal Occlusion, Postural Class III). This may be due to: a. In a mild Class III case where the incisors meet edge-to-edge, the mandible may be displaced anteriorly to obtain a buccal occlusion. b. It may develop following early loss of primary molars, as a result of which the patient overcloses and the lower primary canines slide up the cusps of the uppers enforcing an anterior displacement of the mandible. Diagnosis is usually simple. Any patient with a mild reverse overjet and a positive overbite should be examined to determine whether they can with ease bring the incisors into an edge-to-edge relationship. In this circumstance, closure of the mandible to obtain a posterior occlusion is frequently associated with an anterior displacement. Posterior Displacement. This is usually seen in Class II division 2 cases with a deep overbite. There is true overclosure of the mandible with an increase in the free way space. The mandible closes at first forwards and upwards until the incisors occlude and then, owing to an abnormal sliding contact of these teeth in overcloses upwards and backwards due to continued contraction of the elevator muscles.

Classification of malocclusion
In order to acquire a better understanding of the many deviations from normal occlusion and to assist in diagnosis and treatment planning, it becomes necessary to group the varieties of malocclusion into order. Many methods of classifying malocclusion have been introduced: (1) Angle s classification (A) Dewey's modifications (B) Lischer s modifications (2) Bennetts classification (3) Simons classification (4) Ackerman and Proffit classification

Only Angle classification with Lischer modifications will be discussed. Angle classification: In 1899 Edward Angle published his classification of malocclusion. Angle based his classification upon the mesio distal relations of the mandibular teeth to the maxillary teeth, dental arches and jaws in anteroposterior plane. -ray in 1931 by Broadbent, it showed that the relation of the dental arches and the teeth doesnt necessarily reflect the relation of the basal bones in which they lie. not as a comprehensive picture of the whole dentofacial complex and skeletal pattern. is that providing all the teeth were present, the maxillary first permanent molars could be considered as fixed anatomical points or keys to occlusion. position in the jaws but they tend to move forwards during development (mesial drifting tendency). This mesial movement may become excessive by premature loss of deciduous molars. movement of the first permanent molars is suspected. whether I, II or III. N.B: The molars and canines positions are often not fully Class , , but rather in an intermediate relation. Molars and canines that fall between Class and Class are called end to end relationship, and those between Class and Class are called super Class . Angle Class malocclusion: "The lower dental arch is in normal anteroposterior relation to the upper dental arch" as evidenced by the occlusion of the mesiobuccal cusp of the maxillary first permanent molar in the buccal groove of the lower first permanent molar providing no drifting of these teeth has occurred. And if the deciduous molars are still present, allowance should be made for the wider mesiodistal width of the lower deciduous molars. the malocclusion exists elsewhere. Most cases fall into one of three categories: (1) Local abnormalities: a) Crowding of the upper and/or lower incisors, b) Labial inclination of the upper anterior teeth, c) Anterior cross bite, d) Posterior cross bite,

e) Local abnormalities due to premature loss of deciduous molars. 12

(2) Vertical malrelationships: Excessive overbite (deep bite) or deficient overbite (open bite). (3) Disproportions in the size between the basal bone and the teeth: The basal bone may be too large resulting in spacing of the teeth or too small resulting in crowding of the teeth with impaction of the third molars. Angle Class malocclusion: "The lower dental arch is in distal relation to the upper dental arch" as evidenced by the occlusion of the mesiobuccal cusp of the maxillary first permanent molar in the embrasure between the mandibular second premolar and first permanent molar. Class is measured in terms of units. The width of the premolar is considered to be one unit (or half the width of the molar). There are two divisions of class designated, division 1 and division 2: Division 1: This is usually characterized by: (1) proclination of the maxillary incisors (2) increased overjet (3) short upper lip and failure of the anterior lip seal (4) V- shaped upper arch (narrow in the canine and premolar region and broad between the molars) (5) deficient mandible and underdeveloped chin. Subdivision: A class division 1 subdivision malocclusion has a normal occlusal relation on one side of the arch and class occlusion on the other side Division 2: This is usually characterized by: (1) Lingual inclination of the maxillary central incisors and may be overlapped by the maxillary lateral incisors. (2) Broad maxillary arch (3) Deep overbite with the maxillary and mandibular incisors in apparent supraocclusion (4) Normal length upper lip contacting the lower lip but deep mental groove may be present. (5) The mandible is frequently of good size. Subdivision: Normal occlusal relation on one side of the arch and class occlusion on the other side. 13

Angle Class malocclusion: "The lower dental arch is in mesial relation to upper dental arch" as evidenced by the occlusion of the mesiobuccal cusp of the maxillary first permanent molar in the embrasure between the mandibular first and second molars. The maxillary incisors may occlude edge to edge to the mandibular incisors or anterior cross bite may be present or rarely the mandibular incisors occlude lingual to the maxillary incisors but show extreme degree of lingual tipping. This prenormal occlusion may result from excessively large mandible, lack of forward growth of the maxilla, or a combination of both. In true class malocclusion the mandible is in centric relation (most retruded position with the condyle in the glenoid fossa as evidenced by X-ray) and cant be retruded manually. Pseudo class (false or postural): This is not a true class malocclusion but its presentation is similar. Here the mandible shifts anteriorly during final stages of closure (acquiring a bite of accommodation) due to premature contact of the incisors or the canines. Such pseudo or postural class may tend, if left untreated, to become established by a further development of the whole occlusion in a class relation. Angle Class subdivision: Where normal occlusal relation exists on one side and class relation on the other side. Reliability and validity of Angle classification: Reliability is defined as "the extent to which an experiment, test, or measuring device yields the same results on repeated trials". Validity is "the conformity to accept biological principles". Angle classification is highly reliable as same results are obtained on repeated clinical examinations. But its validity is questionable due to: (1) The hypothesis on which it is based is invalid as the maxillary first permanent molars are not fixed points in the skull anatomy. (2) Cephalometric studies showed that it is possible to have the dental arches in one relation and the basal bone in another relation i.e. Class dental arches on skeletal Class . (3) In Class the classification doesnt differentiate between mandibular retrusion and maxillary prognathism and also in Class between the maxillary retrusion and mandibular protrusion. (4) The classification itself is incomplete as it classifies the anomalies in anteroposterior direction only ignoring both the vertical and the transverse directions. (5) Etiology of the malocclusion hasnt been elaborated upon.

Advantages and disadvantages of Angle's classification: The classification is greatly reliable, simple, and rapid and requires no specific instrumentation. These were the major advantages. The two main disadvantages are: 1. The hypothesis on which the classification is based in invalid. 2. The classification itself is incomplete because it dose not take into account: a. The vertical and transverse variations in the position of the dental arches. b. The skeletal pattern malrelationships. Lischer s modifications of Angle s classification: In 1933 Lischer introduced the following terms to clarify Angle classification: Neutroocclusion or Angle Class Distocclusion or Angle Class , Mesiocclusion or Angle Class .